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Surgical Patients
RS Bumi Waras
Lampung
Questions
•
Which one should go
first?
•
Should we intervene
CAD problem or treat
it conservatively first?
•
How to balance
between ischemia and
bleeding risk during
surgery and or
revascularization?
Stepwise Approach
Conditions
•
•
Unstable angina •
Postpone the
pectoris procedure
•
Acute heart failure •
Treatment options
•
Significant cardiac should be discussed
arrhythmias in a multi-disciplinary
team involving all
•
Symptomatic valvular Surgery
peri-operative care
heart disease physicians
Eur Heart J 2014;35:2383-2431.
•
Recent myocardial
Step 3
Risk of Surgical Procedure
“30 day cardiovascular death & MI”
Without consideration of
patient’s comorbidity
Eur Heart J 2014;35:2383-2431.
Low Risk Surgical Procedure
•
Identify risk •
Initiation of titrated low
factors dose beta blocker before
•
Lifestyle & surgery (Class IIb/ Level B)
medical •
ACEi in patient with heart
treatment failure & systolic
based on dysfunction (Class IIa/
guidelines Level C)
•
Initiation of statin therapy
Eur Heart J 2014;35:2383-2431. for vascular
Surgery surgery (Class
IIa/ Level B)
Step 4
Intermediate/ High Risk Surgical Procedure
•
Additional functional capacity (METS):
ü
≥ 4 METS (good)
•
Initiation of titrated low dose beta blocker before
surgery (Class IIb/ Level B)
•
ACEi in patient with heart failure & systolic dysfunction
(Class IIa/ Level C)
•
Initiation of statin therapy for vascular surgery
(Class IIa/ Level B)
Surgery
Eur Heart J 2014;35:2383-2431.
Step 6
< 4 METS with High Risk Surgical Procedure
•
Cardiac Risk Factors
•
If cardiac risk factors
≤2 rest echo &
biomarkers of LV
function (Class IIb/
Level B-C) Surgery
SURGERY
Eur Heart J 2014;35:2383-2431.
Exercise Stress Testing
Class IIa
•
For patients with elevated risk and excellent
(>10 METs) functional capacity, it is
reasonable to forgo further exercise testing
with cardiac imaging and proceed to surgery.
(Level of Evidence: B)
Class IIb
1. For patients with elevated risk and unknown
functional capacity, it may be reasonable to
perform exercise testing to assess for
Circulation 2014;130:278-333.
Circulation 2014;130:278-333.
Pharmacological Stress Testing
Class IIa
•
It is reasonable for patients who are at an
elevated risk for noncardiac surgery and have
poor functional capacity (<4 METs) to
undergo noninvasive phar- macological stress
testing (either dobutamine stress
echocardiogram [DSE] or pharmacological
stress MPI) if it will change management.
(Level of Evidence: B)
Circulation 2014;130:278-333.
Class III: No Benefit
Circulation 2014;130:278-333.
Diagnostic Test
•
To assess medium to long term (≥ 1 year) outcomes:
q
SYNTAX, SYNTAX II, Logistic Clinical SYNTAX
Eur Heart J 2014;35:2541-2619.
q
ASCERT CABG, ASCERT PCI
Principal Therapy
Circulation 2014;130:278-333.
Indication for Revascularization in
Stable Angina or Silent Ischaemia
Circulation 2014;130:278-333.
Eur Heart J 2014;35:2541-2619.
Take Home Message
•
Use the simplest algorithm and risk scoring
•
Do balance the ischemia and bleeding risk in
each patient
•
Do optimize guideline-based medical therapy
•
Work as a team (Heart Team/ Jetty’s Team)
•
“Decision making” should be based on each
patient’s clinical condition
Thank you