Tag Archives: Cardiovascular Diseases

Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Posted on by
Reply

“Top Take-Home Messages

1.A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted.
2.Cardiovascular screening and treatment of patients undergoing noncardiac surgery should adhere to the same indications as nonsurgical patients, carefully timed to avoid delays in surgery and chosen in ways to avoid overscreening and overtreatment.
3.Stress testing should be performed judiciously in patients undergoing noncardiac surgery, especially those at lower risk, and only in patients in whom testing would be appropriate independent of planned surgery.
4.Team-based care should be emphasized when managing patients with complex anatomy or unstable cardiovascular disease.
5.New therapies for management of diabetes, heart failure, and obesity have significant perioperative implications. Sodium-glucose cotransporter 2 inhibitors should be discontinued 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis associated with their use.
6.Myocardial injury after noncardiac surgery is a newly identified disease process that should not be ignored because it portends real consequences for affected patients.
7.Patients with newly diagnosed atrial fibrillation identified during or after noncardiac surgery have an increased risk of stroke. These patients should be followed closely after surgery to treat reversible causes of arrhythmia and to assess the need for rhythm control and long-term anticoagulation.
8.Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications and is not recommended in the majority of cases.
9.In patients with unexplained hemodynamic instability and when clinical expertise is available, emergency focused cardiac ultrasound can be used for perioperative evaluation; however, focused cardiac ultrasound should not replace comprehensive transthoracic echocardiography.”
Stepwise Approach to Perioperative Cardiac Assessment
∗Cardiovascular risk factors: hypertension, smoking, high cholesterol, diabetes, women age >65 y, men age >55 y, obesity, family history of premature CAD. †Determining elevated calculated risk depends on the calculator used. Traditionally, RCRI >1 or a calculated risk of MACE with any perioperative risk calculator >1% is used as a threshold to identify patients at elevated risk. §Abnormal biomarker thresholds: troponin >99th percentile URL for the assay; BNP >92 ng/L, NT-proBNP ≥300 ng/L. ‡Conditions that pose additional risk for MACE. ‖Noninvasive stress testing or CCTA suggestive of LM or multivessel CAD. Colors correspond to Class of Recommendation in Table 3. BNP indicates B-type natriuretic peptide; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; CIED, cardiovascular implantable electronic device; CVD, cardiovascular disease; DASI, Duke Activity Status Index; ECG, electrocardiogram; GDMT, guideline-directed management and therapy; ICD, implantable cardioverter-defibrillator; LM, left main; MACE, major adverse cardiovascular event; METs, metabolic equivalents; NCS, noncardiac surgery; NT-proBNP, N-terminal pro b-type natriuretic peptide; RCRI, Revised Cardiac Risk Index; and URL, upper reference limit.
Continue reading →

An algorithm for preoperative cardiac risk assessment

Posted on by
Reply

One discussion last week involved cardiac arrest in the setting of hernia repair. The reference below was highlighted in the chief resident’s presentation.

Reference: Rafiq A, Skylar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgery. Health Services Insight. 2017 Feb 20; 9: 1178632916686074. doi: 10.1177/1178632916686074.

Summary: Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient’s medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks.

That being said, this review by Rafiq et al (2017) aims to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.

The ideal approach toward perioperative cardiac risk assessment requires a multidisciplinary team or a dedicated perioperative team of physicians. This leads expert physicians in this field to be involved in patient care with improved communications among primary physicians, anesthesiologist, surgeons, the patient, family members of the patient, cardiologist, and all other ancillary departments of health care involved.

Figure 1: Algorithm for perioperative cardiac risk assessment prior to noncardiac surgery (p.2)

algorithm cardiac

The authors state that it is important to stress the fact that a majority of these recommendations are based, to a large extent, on observational studies and clinical experience. There are only few RCTs that address this matter. It is prudent that more randomized trials are needed to improve on current recommendations, hence leading to further improvement in patient care and management in the perioperative period.

Mortality risk reduction associated with PTH reduction for Secondary Hyperparathyroidism

Posted on by
Reply

One discussion this week included parathyroid hormone (PTH) levels.

Reference: Komaba H, et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney International. 2015 Aug;88(2):350-359. doi: 10.1038/ki.2015.72

Summary: In a nationwide study of 114,064 hemodialysis patients, Komaba et al asked if PTx for severe SHPT improves survival of dialysis patients.  They compared patient outcomes by PTH levels, and by those with a history of parathyroidectomy (PTx) (6,6280) and those without PTx (107,436).

fig2

(p.353)

Excess PTH is shown to increase cardiac fibrosis; elevations in serum calcium, phophorus, and PTH levels are associated with death and cardiovascular events primarily due to vascular calcification (p.350).

fig4

(p.355)

For cardiovascular death, there was a significant increase in the multivariate-adjusted HR for patients with intact PTH levels < 60 pg/ml (HR, 1.11; 95% CI, 1.02–1.20) and those with intact PTH levels >500 pg/ml (HR, 1.41; 95% CI, 1.20–1.64). In contrast, such an increased risk of mortality was not observed in patients with a history of PTx, despite the fact that these patients had severe SHPT preoperatively.