1. Focusing on the Surgical Patient with Cardiac Problems By Kate J. Morse, RN, ACNP-BC, CCRN Nursing2009, March 2009 2.1 ANCC contact hours Online: www.nursingcenter.com © 2009 Lippincott Williams & Wilkins. All world rights reserved.

2. Significance  Baby boomers born 1946-1964 will be increasingly greater consumers of healthcare in the coming decades  39% of these patients will have cardiovascular disease  American College of Cardiology/American Heart Association (ACC/AHA) have established guidelines for perioperative cardiovascular evaluation

3. Preoperative evaluation  Determines cardiovascular risk  Additional testing may be done  Surgeon and anesthesiologist will examine patient  Nurse can perform health history and physical assessment

4. Questions to ask patient  Do you experience chest pain?  Do you take nitroglycerin?  Do you need to rest between taking a shower and dressing?  Can you walk up a flight of stairs?  Have you stopped an activity due to symptoms?  Do you have swelling or pain in your feet, legs?  Does anyone in your family have heart trouble?

5. Physical assessment  Take BP in both arms, checking for artery stenosis  Assess carotid pulses for bruits  Auscultate lungs and heart sounds  Examine extremities for edema and signs of peripheral vascular disease

6. Conditions to treat Active cardiac conditions, which should be treated before noncardiac surgery, include:   acute coronary syndromes   decompensated heart failure   significant dysrhythmias (high-grade atrioventricular blocks and symptomatic ventricular dysrhythmias), supraventricular dysrhythmias (poorly controlled atrial fibrillation, symptomatic bradycardia, ventricular tachycardia)   severe valvular heart diseases (severe aortic stenosis or symptomatic mitral stenosis)

7. Guidelines  Make a distinction between: - history of myocardial infarction (MI) - abnormal Q waves on a 12-lead ECG - abnormal Q waves on a 12-lead ECG - an acute MI  Irreversible myocardial necrosis (history of MI or abnormal Q waves) is considered a clinical risk factor

8. Guidelines  Active cardiac condition is defined as: - an acute MI 7 days or less before the exam - an acute MI 7 days or less before the exam - a recent MI occurring more than 7 days ago - a recent MI occurring more than 7 days ago but less than or equal to a month ago with evidence of ischemic risk by clinical symptoms or noninvasive study but less than or equal to a month ago with evidence of ischemic risk by clinical symptoms or noninvasive study

9. Low cardiac risk  Patient with recent MI but no further risk with stress test  Elective surgery may still be postponed 4 to 6 weeks after the MI

10. Body systems linked to increased cardiac risk  Pulmonary: lung disease increases patient risk of complications  Evaluate risk with: - accurate smoking history - accurate smoking history - pulmonary function tests (PFTs) - pulmonary function tests (PFTs) - arterial blood gas analysis - arterial blood gas analysis - chest X-ray - chest X-ray

11. Diabetes  Most common metabolic disease  Can complicate surgery  These patients often have undiagnosed coronary artery disease (CAD)  Tight glycemic control is key - glucose below 200 is target

12. Kidney disease  Can be associated with cardiac disease  Preoperatively patient’s renal function will be assessed with lab tests: - blood urea nitrogen - blood urea nitrogen - creatinine clearance - creatinine clearance - glomerular filtration rate - glomerular filtration rate  Fluid and electrolyte levels will be monitored and balanced in someone who’s renally impaired

13. Hematologic disorders  Anemia places stress on cardiovascular system  If complete blood cell count reveals anemia, blood transfusion risk will be assessed by surgeon  Hypercoagulability conditions (polycythemia, thrombocytopenia) put patient at risk for clotting and should be addressed preoperatively

14. Step-by-step approach for surgical risk  Determine urgency of surgery - emergent surgery, cardiologist will make - emergent surgery, cardiologist will make recommendations recommendations - if elective, may be delayed or postponed - if elective, may be delayed or postponed  Evaluate patient for active cardiac conditions

15. Step-by-step approach for surgical risk  Evaluate surgical risk - is the procedure low, intermediate, or high risk?  Evaluate patient’s functional capacity - done subjectively by asking patient questions regarding activities of daily living - done subjectively by asking patient questions regarding activities of daily living - stress test - stress test

16. Step-by-step approach for surgical risk  Evaluate clinical risk factors - patient has symptoms - patient has symptoms - unknown functional capacity - unknown functional capacity  Clinical risk factors include - history ischemic heart disease - history ischemic heart disease - history heart failure - history heart failure - history cerebral vascular disease - history cerebral vascular disease - diabetes - diabetes - renal disease - renal disease

17. Recommendations  If no clinical risk factors, surgery can proceed  If one or two clinical risk factors, surgery can proceed with beta-blocker therapy; additional testing should be considered  If three or more clinical risk factors, consider cardiac risk; additional testing shouldn’t be done if it won’t change plan of care

18. Cardiac risks in noncardiac surgery The The guidelines stratify surgical risk according to three levels:   Vascular (cardiac risk greater than 5%) - Major vascular procedures such as aortic repair - Peripheral vascular surgery

19. Cardiac risks in noncardiac surgery   Intermediate risk (1% to 5%) - Intraperitoneal and intrathoracic surgery - Head and neck surgery - Carotid endarterectomy - Orthopedic surgery - Prostate surgery

20. Cardiac risks in noncardiac surgery   Low risk (less than 1%) - Endoscopic procedures - Superficial procedures - Cataract surgery - Breast surgery - Ambulatory surgery

21. Diagnostic tests  Exercise stress test is first choice unless contraindicated  Pharmacologic stress test if unable to walk or exercise  Coronary arteriograph - invasive test evaluates coronary anatomy

22. Cardiac revascularization  May be done prior to elective noncardiac surgery  For severe multivessel disease or significant left main CAD  Two options - coronary artery bypass graft or percutaneous coronary intervention (PCI) with bare-metal or drug-eluting stents

23. Surgery post PCI  Elective surgery should be delayed 4 to 6 weeks after PCI with bare-metal stents  Delay 12 months after drug-eluting stents  Medications post PCI (aspirin, Plavix) put patient at risk for bleeding  If patient underwent balloon angioplasty, elective noncardiac surgery isn’t recommended for 4 weeks

24. Medications and surgery  Aspirin and Plavix therapy increase risk of bleeding  Beta-blockers should be continued  If patient has one or more clinical risk factors, beta-blockers should be started preoperatively if not taking already

25. Medications and surgery  A patient having vascular surgery should be started on a statin  Statins may also be considered in patients in patients with one clinical risk factor having an intermediate risk procedure  Uncontrolled hypertension or CAD patients may need a alpha-agonist

26. Other presurgical considerations  Patients with implanted pacemakers or cardioverters should alert anesthesiologist/ surgeon so appropriate safety precautions are taken