Cardiovascular Problems (Perioperative Course 2014)

PERIOPERATIVE COURSE FOR THE RESIDENTS
CARDIOVASCULAR DISEASE
TIM PERIOPERATIF
DEPARTEMEN OBSTETRI-GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
2013
Objective
• To understand physiological cardiovascular changes
during pregnancy
• To understand perioperative management on
cardiovascular
• To understand Pregnancy-associated maternal
mortality in cardiac disease
Introduction
• Centers for Disease Control and Prevention  heart disease is
the leading cause of death in women who are 25 to 44 years
old (Kung and colleagues, 2008)
• Cardiac disorders of varying severity complicate

approximately 1 percent of pregnancies and contribute
significantly to maternal morbidity and mortality rates
• The data for maternal mortality in 2000–2002 show that

cardiac disease is now the most common cause of maternal
mortality in the UK.
FG Cunningham, KJ Leveno, et all (editors). Williams Obstetrics 23 rd ed: Cardiovascular Disease. USA: The McGraw-Hill Companies, 2010.
RH Swanton, S Banerjee (editors). Swanton’s Cardiology: A concise guide to clinical practice 6 th ed: Pregnancy and Heart Disease. USA:
Blackwell Science Ltd, 2008; p. 526-30.
Introduction
RH Swanton, S Banerjee (editors). Swanton’s Cardiology: A concise guide to clinical practice 6 th ed: Pregnancy and Heart Disease.
USA: Blackwell Science Ltd, 2008; p. 526-30.
Introduction
RH Swanton, S Banerjee (editors). Swanton’s Cardiology: A concise guide to clinical practice 6 th ed: Pregnancy and Heart Disease.
USA: Blackwell Science Ltd, 2008; p. 526-30.
Physiological changes in pregnancy
Goals of cardiovascular system
1.Transport and delivery of oxygen and nutrients for metabolic use
2.Removal of metabolic waste products
Cardiovascular adaptations during pregnancy
Clinical Classification of Heart Disease (functional
status)  New York Heart Association (NYHA)
Class I Uncompromised—no limitation of physical activity: These
women do not have symptoms of cardiac insufficiency or
experience anginal pain.
Class II Slight limitation of physical activity: These women are

comfortable at rest, but if ordinary physical activity is
undertaken, discomfort in the form of excessive fatigue,
palpitation, dyspnea, or anginal pain results.
Class III Marked limitation of physical activity: These women are

comfortable at rest, but less than ordinary activity causes
excessive fatigue, palpitation, dyspnea, or anginal pain.
Class IV Severely compromised—inability to perform any physical

activity without discomfort: Symptoms of cardiac insufficiency
or angina may develop even at rest. If any physical activity is
undertaken, discomfort is increased.
FG Cunningham, KJ Leveno, et all (editors). Williams Obstetrics 23 rd ed: Cardiovascular Disease. USA: The McGraw-Hill Companies, 2010.
Perioperative Management
• Assessment of cardiovascular disease can be broadly
divided into 
– Ischemic heart disease

– Hypertension,
– Cardiac failure
– Cardiac arrhythmias and pacemakers
– Valvular disease.
J McNamara. Core Topics in Perioperative Medicine: Perioperative Management of Cardiovascular Disease. USA: Cambridge
University Press, 2004; p. 1-11.
FRBG Galas, LA Hajjar, JOC Auler JR. Perioperative Critical Care Cardiology 2 nd ed: Perioperative Cardiac Risk Stratification. Italy:
Springer, 2007; p. 109-15.
Perioperative Management
The objectives of preoperative evaluation are:
(a)performing an evaluation of the patient’s current medical
status;
(b)Making recommendations concerning the evaluation,
management, and risk of cardiac problems over the entire
perioperative period; and
(c)providing a clinical risk profile that the patient, primary
physician, anesthesiologist, and surgeon can use in making
treatment decisions that may influence short- and long-term
outcomes.
J McNamara. Core Topics in Perioperative Medicine: Perioperative Management of Cardiovascular Disease. USA: Cambridge University Press,
2004; p. 1-11.
FRBG Galas, LA Hajjar, JOC Auler JR. Perioperative Critical Care Cardiology 2 nd ed: Perioperative Cardiac Risk Stratification. Italy: Springer, 2007;
p. 109-15.
Evaluation of Patient’s Medical Status
• Assessment via history should particularly focus on
the patient’s functional ability.
• The American College of Cardiology and American

Heart Foundation have devised a method of
assessing function by means of simple questions
about activity, and quantified the physiological
reserve required to attain certain levels of activity
using ‘metabolic equivalent tasks (METs)’.
Estimated energy requirements for various activities
MET indicates metabolic equivalent.

Adapted from the Duke Activity Status Index (Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Proyr DB. A brief self-administered
questionnaire to determine functional capacity [the Duke Activity Status Index]. Am J Cardiol 1989; 64: 651–654) and AHA Exercise Standards (Fletcher GF, Balady G,
Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise standards: A statement for healthcare professionals from the American Heart Association. Circulation 1995; 91:
580–615).
• Assessment via examination should include a full
cardiovascular assessment and blood pressure.
• Assessment via investigations will follow local

guidelines:
– ECG  for any patient with cardiovascular disease
– chest X-ray  for any patient with cardiac related
respiratory symptoms
– echocardiogram  for patients with murmurs and to
assess moderate to severe heart failure.
Predicting adverse cardiac events during pregnancy
• Four predictors/risk of maternal complications:
1. A history of heart failure, transient ischemic attack, stroke, or

arrhythmia;
2. Pre-pregnancy NYHA class II or above;
3. Left heart obstruction (mitral valve area <2 cm2, aortic valve
area <1.5 cm2, peak left outflow gradient >30 mmHg); and
4. Ejection fraction less than 40%.
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation
2001;104:515–21.
Pregnancy-associated maternal
mortality in cardiac disease
Group 1 - Mortality <1% (minimal risk of complications)
• Atrial septal defect*
• Ventricular septal defect*
• Patent ductus arteriosus*
• Mitral stenosis: NYHA class I & II
• Pulmonic/tricuspid valve disease
• Corrected tetralogy of Fallot
• Bioprosthetic valve
* = If unassociated with pulmonary hypertension

Clark SL. Structural cardiac disease in pregnancy. In: Clark SL, Cotton DB, Phelan JP, eds. Critical Care Obstetrics. Oradell, N.J.: Medical
Economics Books, 1987; 92.
Group 2 - Mortality 5 -15% (moderate risk of complications)
Group 2A
• Mitral stenosis: NYHA class III & IV†
• Aortic stenosis
• Coarctation of aorta without valvular involvement
• Uncorrected tetralogy of Fallot
• Previous myocardial infarction
• Marfan syndrome with normal aorta
Group 2B
• Mitral stenosis with atrial fibrillation
• Artificial valve*†
* = If unassociated with pulmonary hypertension
† = If anticoagulation with heparin, rather than coumadin, is elected
Group 3 - Mortality 25-50% (major risk of
complication or death)
• Pulmonary hypertension Primary, Eisenmenger
• Coarctation of aorta with valvular involvement
• Marfan syndrome with aortic involvement
• Peripartum cardiomyopathy with persistent left
ventricular dysfunction
Ischaemic Heart Disease and Angina
• The severity of angina can be estimated from the
history
• Severe symptoms  investigated with an exercise

tolerance test if they are able to walk
• Those who for any reason cannot walk (exp.

osteoarthritis or peripheral vascular disease of the
lower limb)  investigated with dobutamine stress
testing or thallium scanning to identify areas of
myocardial ischemia
• Severe angina  coronary angiography,
angioplasty or even coronary
artery bypass grafting.
 optimise the angina with

nitrates, calcium channel
blockers or -blockers.
• Unstable angina suggests acute myocardial ischaemia

and should be controlled prior to surgery.
Hypertension
• Uncontrolled hypertension is associated with
increased perioperative morbidity.
• Many anesthetists will anaesthetize patients with

hypertension up to 115mmHg diastolic, however
most will be concerned with any pressures above
200 mmHg systolic or 100 mmHg diastolic.
Cardiac Failure
• A history of cardiac failure is the single best predictor
for poor outcome after surgery.
• Patients with cardiac failure will require admission to

the Intensive Care Unit (ICU) for specialized invasive
monitoring and are likely to require inotropic drugs if
surgery cannot be postponed.
Cardiac Dysrhythmias
• AF patient with a ventricular response rate 100/min
should be referred to the cardiologists or general
physicians
• Digoxin, or cardioversion - return to sinus rhythm.
• All patients with AF should be considered for

anticoagulation postoperatively, especially those who
have left atrial hypertrophy documented by
echocardiography.
Valvular Heart Disease
• All patients with known valve dysfunction should
have a recent echocardiogram (ideally 6 months) and
all newly diagnosed murmurs should have an
echocardiogram.
• Symptomatic valvular disease carries a very high risk
with surgery.
• Patients with prosthetic heart valves or heart valve
defects will always require prophylactic antibiotics,
whether the valve replacement is mechanical or
tissue.
Management of Specific Cardiac Lesions
in Pregnancy
KD Wenstrom. Protocols for High-Risk Pregnancies, 5th ed: Cardiac Disease. USA: Blackwell Publishing Ltd, 2010; p. 195-201.
Conclusion
Perioperative management:
• Identify and then optimize cardiovascular
disease.
• Plan the required investigations well and liaise

with senior anesthetic staff early.
• Risks of cardiovascular complications can be

substantially reduced with sensible planning and
appropriate perioperative care.

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PERIOPERATIVE COURSE FOR THE RESIDENTS

• Cardiac disorders of varying severity complicate

• The data for maternal mortality in 2000–2002 show that

Class II Slight limitation of physical activity: These women are

Class III Marked limitation of physical activity: These women are

Class IV Severely compromised—inability to perform any physical

– Ischemic heart disease

• The American College of Cardiology and American

MET indicates metabolic equivalent.

• Assessment via investigations will follow local

1. A history of heart failure, transient ischemic attack, stroke, or

* = If unassociated with pulmonary hypertension

• Severe symptoms  investigated with an exercise

• Those who for any reason cannot walk (exp.

 optimise the angina with

• Unstable angina suggests acute myocardial ischaemia

• Many anesthetists will anaesthetize patients with

• Patients with cardiac failure will require admission to

• Digoxin, or cardioversion - return to sinus rhythm.

• All patients with AF should be considered for

• Plan the required investigations well and liaise

• Risks of cardiovascular complications can be

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