Basics of Cardiology for Surgical Residents

Practical ‘tidbits’ for dealing with common cardiac issues

in the surgical patient

Dr. Hatim Al Lawati MD, FRCPC, DABIM(CV), FACC, FSCAI

Senior Consultant | Interventional Cardiology
Sultan Qaboos University Hospital
 Objectives

At the end of this session the resident will be able to:

▪ To understand common cardiac conditions that need referral to the cardiology team
before surgery.

▪ To know basic investigations needed before initiating a request for cardiology

consultation.

▪ To review common ECG arrhythmias encountered on surgical wards.

▪ To describe the basic steps of preparing and optimizing a cardiac patient before surgery.
 Who should be referred to cardiology?
Common cardiac conditions that require referral to cardiology

1. Preoperative assessment of the risk of cardiovascular complications in cardiac

patients undergoing non-cardiac surgery

2. Management of acute cardiac complications perioperatively.

3. To help US help YOU with your patients:

– Initial approach to common cardiac symptoms in the postoperative patient
– Approach to common ECG tracings (even a medical student should know
how to read and manage these!)
 Basics of CARDIOLOGY for the surgical resident

Cardiac complications in non-cardiac surgery

Is it relevant to your practice?
 Scope of the problem
Data from an international multicenter cohort

4% 7-11%
Annual rate of
COMPLICATION
major operations RATE
42%
Of all the
mortalities are
30% 0.8-1.5% due to cardiac
Undergo extensive complications!!
surgical procedures
MORTALITY
in the presence of
cardiovascular
comorbidity
PJ Devereaux et al. JAMA 2012 (VISION Study)
AB Haynes et al. N Engl J Med 2009 (SSSL Study)
Scope of the problem
Data extrapolated to the Omani population

Total population 5,178,384

According to 2020 estimate
https://www.worldometers.info/world-population/oman-population/

Major surgery in 207,135 per year

Major cardiac complications seen in 14,500-22,785
Mortality in 1657-13,809
Cardiovascular mortality 696-5800 per year
Cardiovascular mortality ~ 2-16 per day
 Basics of CARDIOLOGY for the surgical resident

There is no such thing as ‘cardiac clearance’ for surgery!!

Preoperative cardiac risk assessment for
patients undergoing non-cardiac surgery
 Risk stratification in non-cardiac surgery
The risk from the proposed surgery

Surgical risk estimate according to the type of surgery or intervention

Surgical risk is a broad approximation of the 30-day risk of cardiovascular death and myocardial infarction that takes into
account only the specific surgical intervention, without considering the patient’s comorbidities

J Knuui et al. Eur Heart J 2014

LG Glance et al. Ann Surg 2012
 Risk stratification in non-cardiac surgery
The risk from the patient undergoing the procedure

Estimated energy requirements based Indices for the assessment of perioperative

on various activities risk of cardiovascular events

Risk Indices
Goldman et al 1977
Detsky et al 1986
Lee et al (revised cardiac index) 1999
ACS-NSQIP index 2008

J Knuui et al. Eur Heart J 2014

LG Glance et al. Ann Surg 2012
 Risk stratification in non-cardiac surgery
The risk from the patient undergoing the procedure
Revised Cardiac Risk Index (Revised Lee index) American College of Surgery – National Surgical Quality
High risk surgery Improvement Program (NSQIP); Gupta risk score

History of ischemic heart disease Type of Surgery

History of Congestive Heart Failure Functional status

History of cerebrovascular disease (CVA or TIA) Elevated Creatinine (>130 mol/L or >1.5 mg/dL)

Preoperative treatment with insulin ASA class; class I: healthy, class II: mild systemic disease,
class III: severe non-disabling systemic disease, class IV:
Preoperative serum Cr >117 µmol/L (> 2mg/dL) incapacitating disease with constant threat to life and class V:
Risk Factors Events (%) 95% CI moribund and not expected to live beyond 24 hours (with or
without surgery.
0 0.4 0.05-1.50
Age
1 0.9 0.30-2.10
Intraoperative, and postoperative MI and cardiac
2 6.6 3.90-10.30 arrest up to 30 days post surgery
>3 11.0 5.80-18.40
Predicts postoperative MI, pulmonary edema, VF, Gupta PK, et al. Circulation 2011
cardiac arrest and CHB Lee TH, et al. Circulation 1999
 Risk stratification in non-cardiac surgery
putting it all together

Treatment should be initiated optimally between

30 days and at least 2 days before surgery and
should be continued postoperatively aiming at a
target resting HR of 60-70 beats per minute and
a systolic BP >100 mmHg
 Aspirin in patients undergoing non-cardiac surgery
The POISE-II trial | primary efficacy outcome
Kaplan-Meier estimates of the primary composited Subgroup analysis of the primary outcome measure
outcome of death or non-fatal myocardial infarction
at 30 days

PJ Devereaux, et al. N Engl J Med 2014

Aspirin in patients undergoing non-cardiac surgery
The POISE-II trial | Safety outcomes

Effect of aspirin on 30 day outcomes | Safety Outcomes

PJ Devereaux, et al. N Engl J Med 2014

 Aspirin in patients undergoing non-cardiac surgery
The POISE-II trial | Safety outcomes
Absolute increase in the risk of a composite of life-threatening or major bleeding with aspirin therapy on each of
the 10 postoperative days until 30 days after surgery

PJ Devereaux, et al. N Engl J Med 2014

 Extended release metoprolol before non-cardiac surgery
The POISE Trial | where β-blockers win!

Primary outcome; cardiovascular death, non-fatal

myocardial infarction and non-fatal cardiac arrest Myocardial infarction

Events rates 5.8% vs. 6.9% Events rates 4.2% vs. 5.7%
HR= 0.84, 95% CI 0.70-0.99 HR= 0.73, 95% CI 0.60-0.89
P=0.0399 P=0.0017
ARR= 1.1% ARR= 1.5%
NNT~ 91 NNT~ 67

PJ Devereaux, et al. Lancet 2008

Extended release metoprolol before non-cardiac surgery
The POISE Trial | where β-blockers lose!

Stroke Death

Events rates 3.1% vs. 2.3%

HR= 1.33, 95% CI 1.03-1.74
P=0.0317
ARI= 0.8%
NNT= 125

Events rates 1% vs. 0.5%

HR= 2.17, 95% CI 1.26-3.74
P=0.0053
ARI= 0.5%
NNT= 200

PJ Devereaux, et al. Lancet 2008

Risk stratification in non-cardiac surgery
putting it all together
 Risk stratification in non-cardiac surgery
putting it all together

Treatment with β-blockers should be initiated optimally between 30 days and at least 2 days before surgery and should
be continued postoperatively aiming at target resting heart rate of 60-70 beats per minute and systolic BP >100 mmHg
 Recommendations for preoperative evaluation
Summary of recommendations on preoperative cardiac evaluation

Requesting preoperative cardiac investigations in urgent surgery/unstable patients

 Recommendations for preoperative evaluation
Summary of recommendations on preoperative cardiac evaluation

Requesting preoperative cardiac investigations in urgent surgery/unstable patients

 Recommendations for preoperative evaluation
Summary of recommendations on preoperative cardiac evaluation

Requesting preoperative cardiac investigations in urgent surgery/unstable patients

 Basics of CARDIOLOGY for the surgical resident

Initial approach to diagnosis and management

Common cardiac issues in the immediate
post-operative phase
 - Case # 1 -

• 74-M admitted for an elective hernia repair. He is post op day 2. He has been on IV fluids
due to post operative ileus. All his medications are on hold because he is unable to tolerate
oral intake (aspirin, atenolol, lisinopril, atorvastatin, furosemide)

• You were called at 09:00 p.m. because the patient is dyspneic. On examination, he’s
tachypneic (RR 30) and hypoxic (SPO2 87% on RA). BP 150/90 mmHg. HR 120/min. Lung
fields are filled with fine crackles bilaterally. HS were regular. JVP is difficult to assess.

• Past medical history: What’s

1. Hypertension
2. Type II Diabetes Next?
3. Dyslipidemia
4. CAD post CABG in 2010
5. Echo (2018) LVEF 35%.
 Acute Dyspnea in the post-operative patient
Differential diagnosis

• Acute Heart Failure

• Acute pulmonary embolism
• Pulmonary atelectasis
• Acute myocardial ischemia (either demand-supply mis-match or acute
coronary plaque rupture)
• Pneumonia (hospital acquired, aspiration … etc)
 - Case # 1 -

What information do I need to be able to help you manage your patient?

1. Vital signs (BP, pulse rate, RR, T, O2 saturation)

2. 12-lead electrocardiogram
3. Chest x-ray (PA and lateral)
4. Lab investigations:
– CBC, renal function tests
– Tn-T (serial measurements)
– + BNP or NT-pro-BNP (let me decide!)
 - Case # 1 -

Chest x-ray
12-lead ECG
 - Case # 2 -

• 65-M admitted for exploratory laparotomy for acute peritonitis. He is post op day 5. He was
operated for a perforated gastric ulcer. He has been tolerating orally now and able to
ambulate in the ward.

• You were called at 09:00 a.m. because the patient is complaining of chest pain. On
examination, he’s tachypneic (RR 30) and normoxemic (SPO2 97% on RA). BP 110/70
mmHg. HR 120/min (irregular). Lung fields are clear to asucultation. HS were irregular. JVP
was not raised.

• Past medical history:

1. Type II Diabetes
2. Dyslipidemia
3. CAD post PCI to the RCA 6 months ago
4. Echo (2019) LVEF 55%. Moderate mitral regurgitation (myxomatous mitral valve). Normal PA pressure.
 Acute chest pain in the post-operative patient
Differential diagnosis

• Acute myocardial ischemia

– Type 1 MI (acute coronary plaque ruptue)
– Type 2 MI (demand-supply mismatch)
• Acute pulmonary embolism
• New arrhythmia with rapid ventricular rate (AF, AFL with variable AV
block, Multifocal AT, sinus tachycardia with ectopic beats)
• Acute pleurisy
• Acute pericarditis
 - Case # 2 -

What information do I need to be able to help you manage your patient?

1. Vital signs (BP, pulse rate, RR, T, O2 saturation)

2. 12-lead electrocardiogram
3. Chest x-ray (PA and lateral)
4. Lab investigations:
– CBC, renal function tests
– Tn-T (serial measurements)
– Electrolytes including serum Mg2+ level
 Cardiac Biomarkers
The value of serial measurements

Operating characteristics of some commonly used biochemical markers of myocardial injury

Elevated c-Tn-T
Definition of acute myocardial infarction

C Thygesen et al. Circulation 2018

 Elevated c-Tn-T
It’s not always due to an acute coronary syndrome

Reasons for the Elevation of Cardiac Troponin Values Because of Myocardial Injury
Myocardial injury related to acute myocardial ischemia Other causes of myocardial injury
Atherosclerotic plaque disruption with thrombosis Cardiac Conditions
Myocardial injury related to acute myocardia ischemia because of O2 Heart failure
supply/demand mismatch Myocarditis
Cardiomyopathy (any type)
Related to myocardial perfusion
Coronary revascularization procedures
Coronary artery spasm, microvascular dysfunction Catheter ablation
Coronary embolism Defibrillator shocks
Cardiac contusion
Coronary artery dissection Severe hypertension (hypertensive crisis)
Sustained bradyarrhythmia Systemic conditions
Hypotension or shock Sepsis, infectious disease
Chronic kidney disease
Respiratory failure
Stroke, subarachnoid hemorrhage
Severe anemia Pulmonary embolism, pulmonary hypertension
Increased myocardial O2 demands Infiltrative diseases e.g. amyloidosis, sarcoidosis
Chemotherapeutic agents
Sustained tachyarrhythmias Critically ill patients
Severe hypertension with or without LVH Strenuous exercise
 Elevated c-Tn-T
It’s not always due to an acute coronary syndrome

Early cardiac Tn kinetics in patients after acute Timing of blood draws and clinical decisions when using
myocardial injury including acute myocardial infarction the ESC 0hr/1hr and 0hr/3hr algorithms
Cardiac biomarkers
Timelines for early detection, peak levels and clearance

- Myoglobin rises within <2 hours

- Troponin rises <4 hours, peaks 14-24 hours and
normalize by 7-10 days (assuming normal renal
function)
- CK-MB rises 24-48 hours, peaks 12-24 hours and
normalizes within 48-72 hours
 - Case # 2 –
What does the ECG show?
 - Case # 2 –
What does the ECG show?
 - Case # 2 –
What does the ECG show?
 - Case # 2 –
What does the ECG show?
 - Case # 2 –
What does the ECG show?
 - Case # 2 –
The patient’s actual ECG!!
 - Case # 2 -

Initial management:

1. Supplemental O2 if ++ distress
2. SEND me the ECG – I will need right sided and posterior leads
3. Shift the patient to a high dependency unit + attach to a cardiac monitor + attached to
defibrillator
4. Aspirin 300 mg PO/NG/IV
5. Clopidogrel 600 mg PO/NG
6. DO NOT GIVE Morphine or GTN if evidence of RV extension – risk of refractory
hypotension
7. If hypotensive; IV fluids + Synchronized DC cardioversion (ICU, Cardiology)
 - Case # 3 -

• 58-F admitted for laparoscopic cholecystectomy which is scheduled for the next day.
She’s a known hypertensive on atenolol 25 mg, amlodipine 5 mg, and irbesartan 150
mg. She’s now NPO.

• You were called at 05:00 a.m. the day of the surgery because the patient’s BP
measured repeatedly was high with values up 190/100 mmHg. The patient is
asymptomatic.

• Other past medical history:

1. Dyslipidemia
2. OA knees.
 - Case # 3 -

Do you need to consult cardiology for this patient?

NO!
1. Give the patient her usual medications
2. Patient may be anxious. Consider oral sedation/anxiolytics
3. Up-titrate medications until you get an optimal BP response to allow her to undergo surgery
safely.
4. YOU CAN LOOK UP THE MEDICATIONS YOUSELF!
Resources on Drug Information
Doses, indications, side-effects, monitoring, contraindications
 - Case # 4 -

• 49-F admitted for total thyroidectomy. She’s postop day 3. She’s a known
hypertensive on atenolol 25 mg and amlodipine 5 mg.

• You were called at 07:00 p.m. because the nurse is worried about a slow heart rate.
When checking her vital parameters, the pulse rate is 45/min. The patient is
asymptomatic.
 - Case # 2 -

What information do I need to be able to help you manage your patient?

1. Vital signs (BP, pulse rate, RR, T, O2 saturation)

2. 12-lead electrocardiogram
3. Lab investigations (but let’s decide after we see the ECG!)
 - Case # 4 –
What does the ECG show?
 - Case # 4 –
What does the ECG show?
 - Case # 4 –
What does the ECG show?
 - Case # 4 –
The patient’s actual ECG?
 - Case # 4 -

Initial management:

1. Send lab investigations

– TFT
– Electrolytes including K, Mg
2. Correct electrolyte abnormalities if any
3. Start/Adjust dose of thyroxine if needed
4. May need to increase β-blockers if needed!
 - Case # 5 -

• 79-F admitted after a fall and was diagnosed with a displaced hip fracture. She’s
awaiting ORIF. The surgeon and the anesthesiologist are concerned about the
patient’s bleeding risk. She is known to have permanent Atrial Fibrillation and is on
Rivaroxaban for thromboprophylaxis.

• Now she’s ready for discharge. You, being the senior house officer in charge of the
patient, are wondering if she really needs to be on Rivaroxaban. She has never had a
stroke before

• Past medical history:

1. Hypertension
2. Osteoporosis
Why do we anticoagulated patients with AF?
Assessment of risk of systemic embolism in confirmed AF

CHA2DS2-VASC Score for calculating stroke risk in atrial fibrillation

D Sellers, et al. Anaesthesia 2018

Other situations where omitting antithrombotic
medications can be catastrophic?

Acute mechanical valve Acute coronary stent

thrombosis thrombosis

15% 25-40%
 Basics of Cardiology for Surgical Residents
Practical ‘tidbits’ for dealing with common cardiac issues
in the surgical patient

Thank you!
Questions/Comments?
References