<style> .reveal h1, .reveal h2, .reveal h3, .reveal h4, .reveal h5, .reveal h6 { font-family: Arial; font-weight:bold; } .reveal .slides { text-align: left; padding-right:50px; font-size: 50px; } </style> # Perioperative # Assessment ### in non-CV surgery --- Presenter: R2林協霆 Supervisor: 王詠醫師 --- ## Goal: * characterize risk of Pt & procedure → * appropriate testing (ie, results will Δ management) and interventions * ie, reasonable probability of ↓ risk of MACE --- ## REVISED CARDIAC RISK INDEX (RCRI)  --- ### CARDIAC RISK ASSOCIATED WITH SURGERY  ---  ---  --- ## Additional preoperative testing ### (Circ 2014;130:e278) * ECG if known cardiac disease and possibly reasonable in all, * except if low-risk surgery * TTE if any of following & prior TTE >12 month ago or prior to Δ in sx: * dyspnea of unknown origin; * hx of HF w/ ↑ dyspnea; * suspect (eg, murmur) or known ≥ moderate valvular disease --- ## Coronary artery disease * If possible, wait ~60 day after MI in the absence of revascularization before elective surgery * Coronary revasc guided by standard indications. * Has not been shown to Δ risk of death or postop MI when done prior to elective vasc. surgery (NEJM 2004;351:2795). --- ## Heart failure (JACC 2014;64:e77) * Decompensated HF should be optimally treated prior to elective surgery * 30-d CV event rate: * symptomatic HF > asx HFrEF > asx HFpEF > no HF --- ## Valvular heart disease * If meet criteria for valve intervention, do so before elective surgery (postpone if necessary) * If severe valve disease and surgery urgent, intra- & postoperative hemodynamic monitoring reasonable (espec for AS, because at ↑ risk even if sx not severe; be careful to maintain preload, avoid hypotension, and watch for atrial fibrillation) --- ## Cardiac implantable electronic devices * Discuss w/ surgical team need for device (eg, complete heart block) & consequences if interference w/ fxn, and likelihood of electromagnetic interference * Consider reprogramming, magnet use, etc. as needed --- # Pre- & perioperative pharmacologic management --- ### Anticoagulants  --- ### Wafarin  --- ### Antiplates  --- ### Aspirin  * continue in Pts w/ existing indication. * Initiation prior to surgery does not ↓ 30-d ischemic events and ↑ bleeding (NEJM 2014;370:1494), but Pts w/ recent stents excluded. * Hold 5-7 d: Neurosurgery, prostate, posterior eye chamber procedures --- ### DAPT  --- ### POST-PCI SURGERY AND DUAL ANTIPLATELET THERAPY * ==Post-PTCA==: wait 2-4 weeks (then operate under ASA) * ==Post-BMS==: dual antiplatelet therapy for a minimum of 2-4 weeks (then operate under ASA) * Discontinue Clopidogrel 5-7 days preoperatively * ==Post-DES==: dual antiplatelet therapy for a strict minimum of 3 to 6 months with new generation stents * consider bridging with IV tirofiban / eptifibatide / cangrelor if surgery required before this time then operate under ASA --- ## β-blockers (JAMA 2015;313:2486) * Continue βB in Pts on them chronically. Do not stop βB abruptly postop (may cause reflex sympathetic activation). Use IV if Pt unable to take PO. * Reasonable to initiate if intermed- or high-risk ⊕ stress test, or RCRI ≥3, espec if vasc surgery. * Initiate ≥1 wk prior to surgery (not day of), use low-dose, shortacting βB, and titrate to achieve HR and BP goal (?HR ~55–65). Avoid bradycardia and HoTN. --- ## High risk of thomboembolism  --- ## Moderate to low risk of thomboembolism