Perioperative management of cardiac ischemia: Difference between revisions
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| + | == Background == |
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+ | ===Epidemiology=== |
| − | * |
+ | *Represents 1-6% of cardiac events |
| − | == |
+ | ===Etiology=== |
| − | * |
+ | *Bleeding (35%) |
| − | * |
+ | *Cardiac cause (44%), including MI, AV block, arrhythmias |
| − | * |
+ | *Other (21%), including PE, anaphylaxis, and hypoxemia |
| − | == |
+ | ===Pathophysiology=== |
| − | * |
+ | *Thrombosis |
| − | * |
+ | *Catecholamine surges from stress state |
| − | * |
+ | *Obstruction |
| − | * |
+ | *Infection or inflammation |
| − | * |
+ | *Increased demand, from tachycardia, fever, hypotension, anemia, and hypoxemia |
| − | == |
+ | ==Clinical Manifestations== |
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| − | * |
+ | *[[Myocardial infarction after non-cardiac surgery]] (MINS) |
| − | * |
+ | *[[STEMI]] is rare |
| − | == |
+ | ==Diagnosis== |
| − | * |
+ | *Increased troponin with typical pattern |
| − | * |
+ | *Signs of ischemia, including Q waves on ECG or wall motion abnormalities on echocardiography |
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+ | ==Management== |
| − | * |
+ | *Treat underlying cause |
| − | * |
+ | *Add ASA and beta blocker, consider ACE inhibitor or nitrates |
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+ | ==Preoperative assessment== |
| − | * |
+ | *If surgery is emergent, proceed to OR |
| − | * |
+ | *If not emergent, then rule out ACS and treat this first |
| − | * |
+ | *If not having ACS, then risk stratify with AHA class or RCRI or NSQuIP |
| − | * |
+ | *Elective surgery should be delayed for: |
| − | ** |
+ | **Anticoagulation/antiplatelets |
| − | ** |
+ | **Electrolyte abnormalities |
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+ | **Infection, especially pneumonia |
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+ | **Obstructions in the vasculature (ACS or PE within the past month) |
| − | ** |
+ | **Unstable vitals |
| − | == |
+ | ==Prognosis== |
| − | * |
+ | *15-25% in-hospital mortality |
| − | * |
+ | *Outcomes are related to peak troponin (per VISION study) |
[[Category:Perioperative medicine]] |
[[Category:Perioperative medicine]] |
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Latest revision as of 08:19, 2 August 2020
Background
Epidemiology
- Represents 1-6% of cardiac events
Etiology
- Bleeding (35%)
- Cardiac cause (44%), including MI, AV block, arrhythmias
- Other (21%), including PE, anaphylaxis, and hypoxemia
Pathophysiology
- Thrombosis
- Catecholamine surges from stress state
- Obstruction
- Infection or inflammation
- Increased demand, from tachycardia, fever, hypotension, anemia, and hypoxemia
Clinical Manifestations
- Highest risk period for MI is post-op day 3
- Myocardial infarction after non-cardiac surgery (MINS)
- STEMI is rare
Diagnosis
- Increased troponin with typical pattern
- Signs of ischemia, including Q waves on ECG or wall motion abnormalities on echocardiography
Management
- Treat underlying cause
- Add ASA and beta blocker, consider ACE inhibitor or nitrates
Preoperative assessment
- If surgery is emergent, proceed to OR
- If not emergent, then rule out ACS and treat this first
- If not having ACS, then risk stratify with AHA class or RCRI or NSQuIP
- Elective surgery should be delayed for:
- Anticoagulation/antiplatelets
- Electrolyte abnormalities
- Infection, especially pneumonia
- Obstructions in the vasculature (ACS or PE within the past month)
- Unstable vitals
Prognosis
- 15-25% in-hospital mortality
- Outcomes are related to peak troponin (per VISION study)
