Cardiac Patient for Non Cardiac

Surgery

Moderator: Dr Bharti Wadhwa

Panelists: Dr Jyotsna Goswami

Dr Niranjan Waje
Dr Madhavi Buddhi
• Worldwide Non cardiac surgeries have
overall complication rate of 7-11%

• Mortality rate of 0.8-1.5%

• 42% cardiac complications

 Case 1
45 year old man H/o Hypertension since last 8years,
anterior wall MI 2 months back presents for inguinal
hernia repair. Angiography done at that time: Single
vessel block 98%

• Rx Amlodepine , Atenolol , Atorvas . Monotrate,

ecosprin and sublingual nitrate SOS
• ECG : Q waves with ST segment depression in V4-6
• ECHO: RWMA ,LVEF 45%, Mild MR, Type I diastolic
dysfuntion
• S Creatinine: 0.8mg/dl
• Non diabetic
• METS: >4
 Should we take up this patient for surgery
or defer?

If defer, then till when?

Dr Jyotsana Goswami
 What all tools / various methods of risk
stratification are you using for predicting peri-
operative cardiac morbidity in your clinical
practice ?

Dr Niranjan Waje
 Which of the following would you
consider as best for preoperative risk
stratification?

MICA calculator / NSQIP/RCRI

Dr Niranjan Waje
What are the Preoperative risk reduction
strategies that you follow as a routine?
Drugs , intervention etc......

When would you like to go for a PCI to reduce

cardiac morbidity in a patient for non cardiac
surgery? (Both for elective and time sensitive
procedures)
Dr Jyotsana Goswami
 Case 1
45 year old man H/o Hypertension since last 8years,
anterior wall MI 8 months back presents for inguinal
hernia repair. Angiography done at that time: triple vessel
block 98%

• Rx Amlodepine , cardevilol , Atorvas, ecosprin, lasix and

sublingual nitrate SOS
• ECG : Q waves with ST segment depression in V4-6
• ECHO: RWMA ,LVEF 20-25%, Mild MR, Type II diastolic
dysfuntion
• S Creatinine: 0.8mg/dl
• Non diabetic
• METS: >4
How would you optimize this patient and
what would be the goals of management
in this case?

Dr Niranjan Waje
Pre-operative counseling in a patient with
high cardiac risk

Keeping a cardiologist on stand by for high

risk cardiac cases ??
Dr Jyotsana Goswami
 Case 2

65year old, H/o CAD, two stents DES placed 3

months back presented for cataract surgery

• ECHO : RWMA + , inferior wall, septum jerky,

LVEF 30-35%, grade I diastolic dysfunction
• DAPT ( Ecosprin+ clopidrogel)
• Vitals stable
What are the main anesthetics concerns in
this patient?

How would you address these concerns

and optimize your patient pre-
operatively ?

Dr Madhavi Buddhi
 Case 3

65year old, H/o CAD, two stents DES placed 3

months back presented with sub-trochanteric
fracture femur

• ECHO : RWMA + , inferior wall, septum jerky y,

LVEF 30-35%, grade I diastolic dysfunction
• DAPT ( Ecosprin+ clopidrogel)
• Vitals stable
Now what shall be your plan of
action?

Dr Madhavi Buddhi
What are indications of newer drugs like
prasugrel and what the anesthesiologist
needs to keep in mind when the patient
is taking these drugs?

Dr Jyotsna Goswami
what are the Problems with preoperative
aspirin withdrawal ?

Dr Niranjan Waje
 Case 4

65year old, H/o CAD, two stents DES placed 2

weeks back presented with sub-trochanteric
fracture femur

• ECHO : RWMA + , inferior wall, septum jerky y,

LVEF 30-35%, grade I diastolic dysfunction
• DAPT ( Ecosprin+ clopedrogel)
• Vitals stable
Which is a better choice for bridging Rx in
patients on DAPT: Platelet inhibitors or
LNWH ?

Dr Madhavi Buddhi
What is the recent update on use of
bridging Rx for patients on DAPT?

Dr Jyotsna Goswami
 CASE 5

65year old man presents with RTA , crush injury, #

pelvis, suspected splenic injury. Relatives inform that
patient had stent placement 8months back and is on
DAPT.

• Hct : 27%
• S Creatinine : 1.2mg/dl, Rest Investigations WNL
• Vitals : HR 120/min, rest stable
• ECG : Old anterior wall MI
• ECHO: not available

Patient is to be taken up for emergency laparotomy stat

 No time to withdraw DAPT...

Role of Platelet transfusion to reduce the

risk of bleeding....

Any other modalities??

Dr Niranjan Waje
 Case 6

77 year old woman with history of DES stent

placement 8 months back is posted for lap
cholecystectomy.

• Rx: She is on Ramipril , cardivas, atorvas,

Ecosprin, clopedrogil, lasix
• ECG: non specific ST –T wave changes
• ECHO: done 4months back: No RWMA, Mild MR,
LVEF 40%, Type I diastolic dysfunction
What will be Preoperative investigations
and orders for this patient?

ECHO as a Routine ?

Dr Madhavi Buddhi
 Intra-operative monitoring
Would you use a pulmonary artery catheter
(PAC)?

Would you monitor transesophageal

echocardiography (TEE)?

Best ECG lead for monitoring of ischaemia?

Dr Jyotsna Goswami
 Anesthetic goals for intraoperative
management
• RA vs GA ?
• Induction agent of choice ?
• Inhalation agent of choice ?
• Role of nitroglycerin prophylaxis ?

Dr Madhavi Buddhi
• Significant depression of ST segment was
noticed intraoperatively. How would you treat
it?

• Would you give prophylactic intravenous

nitroglycerin to prevent myocardial ischemia?

• Vasopressor of choice in case of hypotension?

Dr Niranjan Waje
 Myocardial injury after noncardiac
surgery (MINS)
• What is the significance of MINS?

• How important is cardiac surveillance in non

cardiac surgery ?

• What is the role of Cardiac biomarkers: High

sensitivity Troponin T and Pro BNP
Dr Jyotsna Goswami
 Case 7

A 28yr old woman, known case of Mitral Stenosis

presents for Rhinoplasty. She is on digoxin, lasix
and antibiotic prophylaxis.

O/E: vitals stable, chest clear

METS > 4
ECG: NSR
ECHO: done 6 months back, not available
CXR: WNL
• How would you mange this case?

• What all to look for in the ECHO?

• Intra-operative monitoring tools in this patient?

• Status of pulmonary vasodilators in the peri-

operative period ?
 Take home message
• These patients are prone for myocardial ischaemia, infarction and
arrhythmias during peri-operative period
• Thorough evaluation has to be done regarding history and tests.
• Any modifiable risk factors have to be corrected
• Team effort: involve cardiologists, surgeons, treating physicians and
patients
• Anti-failure medications, beta-blockers and statins have to be
continued throughout peri-operative period
• For regional anaesthesia, guidelines have to be followed regarding
anticoagulant medications.
• Factors which alter myocardial oxygen supply-demand ratio are to
be taken care of.
• Monitoring is important to detect early ischaemia and rhythm
disturbances.
• Post-operative pain management is other important aspect.
Thank you