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Consultative Cardiology Essentials
Teerapat Yingchoncharoen MD, FASE
Ramathibodi Hospital
Mahidol University
Review in Internal Medicine for R3 May 4th, 2019
Common Consultative Cardiology
Mahidol University
- Preoperative evaluation - ACLS - Common cardiac problems in pregnancy - Assessment of newly-detected or changing heart murmurs - Top 5 Cardio chief complaint : Chest pain, Dyspnea,
Syncope, Palpitation (+/- abnormal ECG), Edema - Evaluation of possible infectious endocarditis - Management of unstable ischemia outside CCU - Management of uncontrolled hypertension / arrhythmias
(esp. AF) in the hospitalized patients
Consultative Cardiology Essentials 2019
Quiz # 1
Mahidol University Consultative Cardiology Essentials 2019
A 23 years old otherwise healthy actress presented at ER at 5 pm
with acute abdominal pain which turned out to be twisted ovarian
tumor. You are asked to perform a preoperative evaluation for her.
She was scheduled for an operation in the next morning.
By standard guideline definition, the type of surgery is considered
A. Emergency
B. Urgency
C. Semi-urgency
D. Time-sensitive
E. Elective
DEFINITION➤ Emergency procedure
➤ Life or limb is threatened if not in OR
➤ No or very limited or minimal clinical evaluation, within < 6 hrs
➤ Urgent procedure
➤ Life or limb is threatened if not in OR
➤ Time for a limited clinical evaluation, within 6-24 hrs
➤ Time-sensitive procedure
➤ Delayed >1-6 wks to allow for an evaluation and significant changes in management will negatively affect outcome
➤ Elective procedure
➤ Procedure could be delayed for up to 1 year
Mahidol University
A 23 years old otherwise healthy actress presented at ER at 5 pm with
acute abdominal pain which turned out to be twisted ovarian tumor. You
are asked to perform a preoperative evaluation for her. On examination,
she was found to have a heart murmur. What is your opinion about this
heart murmur ?
Consultative Cardiology Essentials 2019
A. It’s an innocent murmur, keep
calm and continue watching
GOT
B. This is a pathologic murmur and
need further evaluation
Quiz # 2
Mahidol University Consultative Cardiology Essentials 2019
Mitral Stenosis Auscultatory findings
• Loud S1, Opening snap, Mid-diastolic rumbling murmur at apex - (left lateral position on expiration with bell) , Loud P2 (if PAH), Presystolic accentuation (in sinus rhythm)
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Mitral Stenosis Auscultatory findings
Severe MS = Long DRM, Short A2-OS, Loud P2, RVH
Pliability of valve Loud S1 OSPre-systolic accentuation
Elevated JVP in CHF Tapping apex (palpable S1) RV heaving Palpable P2
Inspection/Palpation
Mahidol University Consultative Cardiology Essentials 2019
Innocent (Still's) murmur
- Systolic ejection murmur - Short (duration <50% systole) - Soft, low-pitched - Single S2 during expiration while standing - Stable murmur intensity with maneuvers (Valsalva, standing, squatting)
George Frederic Still(1868-1941)
Pathologic Murmur
Mahidol University Consultative Cardiology Essentials 2019
- Diastolic murmur - Pansystolic murmur - Continuous murmur - Late systolic murmur - Systolic ejection murmur with 1. Other abnormal heart sounds eg. ejection click, gallop 2. Radiate to the neck or back 3. Louder than grade 2
Echo is recommended for patients with heart murmur and signs/symptoms of heart failure, MI, syncope, thromboembolism or IE ; abnormal CXR or ECG
Guide Short Case
• MS +/- TR • MR (+/- from MVP) • AS • AR • ASD with PAH • VSD • PS • Vascular hypertension (Takayasu, CoA, RAS ) • Ebstein’s anomaly (year 2009)
Step 2 : Active cardiac conditons
✤ Unstable angina✤ Acute heart failure✤ Significant cardiac arrhythmia✤ symptomatic valvular heart disease✤ Recent myocardial infarction and residual myocardial ischemia
within 6 mo.
Mahidol University Consultative Cardiology Essentials 2019
Key Question For Patients with active cardiac condition
“How would you manage this patient in the absence of the surgical procedure”
Mahidol University 2017 ESC Guidelines for management of valvular heart disease
Active Cardiac Condition Valvular Heart Diseases
- Does the patient meet guideline-based indications for AV surgery or intervention irrespective of the upcoming non cardiac surgery (AVR, TAVR, BAV)
Aortic stenosis
Mitral stenosis- Non-cardiac surgery can be performed safely in patients with nonsignificant mitral stenosis (valve area >1.5 cm2 ) and in asymptomatic patients with significant mitral stenosis and a systolic pulmonary artery pressure <50 mmHg
Mahidol University
Active Cardiac Condition Valvular Heart Diseases
Patients with severe left-sided valve stenosis requiring emergency non cardiac surgery should be managed by a cardiovascular anesthesiologist with invasive hemodynamic or TEE imaging monitoring intraoperatively and remain in an intensive monitoring setting for 48-72 hours postoperatively
Mahidol University Congestive Heart Failure 2010;16(1):45.
Active Cardiac Condition CAD/HF
- History of MI is predictive of MACE - Recent MI : within 6 months - Try to wait at least 60 days after MI
Coronary artery disease
Heart failure- Presence of preoperative S3 and JVD—had strongest association with perioperative MACE - Absolute mortality rate is worse with LVEF≤ 30%
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Active Cardiac Condition Cardiomyopathy
- Hypertrophic obstructive cardiomyopathy : preload and heart rate
dependent. Avoid overdiuresis, vasodilators and use of inotropes
- Restrictive cardiomyopathy (amyloid, sarcoid, hemochromatosis) -
preload and heart rate dependent
- ARVC/D - monitor for VT, ? AICD
- Peripartum cardiomyopathy - delivery, ECMO, mechanical support,
transplant
Consultative Cardiology Essentials 2019
Mahidol University
Active Cardiac Condition Arrhythmias
Consultative Cardiology Essentials 2019
Cardio/EP Consults
- Tachyarrhythmias : Symptomatic ventricular
arrhythmia, Newly recognized VT, AF/SVT with
uncontrolled HR (>100 bpm)
- Bradyarrhythmias : Symptomatic bradycardia,
Mobitz II, high grade, third-degree AV block
Quiz # 3.1
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A. Extremely low risk
B. Low risk
C. Intermediate risk
D. High risk
E. Extremely high risk
Consultative Cardiology Essentials 2019
A 23 years old otherwise healthy actress presented at ER at 5 pm
with acute abdominal pain which turned out to be twisted ovarian
tumor. You are asked to perform a preoperative evaluation for her.
She was scheduled for an open exploratory laparotomy surgery in
the next morning. What is considered surgical risk category of this
procedure ?
Quiz # 3.2
Mahidol University
Which of the following are considered high risk procedure
(risk of 30-day CV death and MI >5%) EXCEPT ?
A. Liver transplantation
B. Renal transplantation
C. Lung transplantation
D. Lower limb amputation
E. Total cystectomy
Consultative Cardiology Essentials 2019
Step 1 : Urgent Sx
Step 2 : Active cardiac conditonsStep 3 : Risk of surgical procedure30 day CV death and MI
Step 4
2 Major Risk CalculatorsRevised Cardiac Risk Index
6 predictors - Cr>=2, HF, DM, CVA, CHD, Sx type
>=2 predictors = elevated risk
Am Col Surgeon NSQIP surgical risk calculator
21 patient-specific variables
best estimation but difficult to assess ‘Anaesthesiology Physical Status’
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery JACC. VOL. 64, NO. 22, 2014
(Intraperitoneal, intrathoracic suprainguinal vascular reconstruction)
Better predictive performance, more updated, more surgery specifichttp://www.riskcalculator.facs.org
Echocardiography
In pt with dyspnea of unknown origin (IIa)
In pt with unstable HF (IIa)
In pt with documented LV dysfunction with last echo > 1 year (IIb)
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery JACC. VOL. 64, NO. 22, 2014
Step 1 : Urgent SxStep 2 : Active cardiac conditonsStep 3 : Risk of surgical procedure
Step 4 : Functional capacity
Step 5 : METs < 4 : Risk of Sx
Step 7 : Cardiac stress test
✤ No or moderate stress induced ischemia Sx
✤ Extensive ischemia
Revascularization Sx
Balloon angioplasty > 2 wk
Bare-metal stent > 4 wk
Old generation DES ≥ 12 mo
New generation DES ≥ 6 mo
CABG
Risk Sx Clinical risk factor + METs < 4 Class
High > 2 I
High 1-2 IIb
Intermediate 1-2 IIb
Imaging stress test
General consideration
Abnormal resting ECGs (e.g. strain) Exercise stress Echo / stress MPI
LBBB Pharmacologic stress MPI
Unable to exercise Pharmacologic stress MPI, DSE
Heart block/ Bronchospasm/ Carotid disease
Avoid adenosine / dipyridamole
Serious arrhythmia/ Severe HTN Avoid dobutamine
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery JACC. VOL. 64, NO. 22, 2014
สรุป
Mahidol University
1. ถ้าเป็น Emergency surgery ลุยเลย
2. Low risk ไม่ว่า METS เท่าไหร่ก็ผ่า
3. METS 4 ขึ้นไป จะทำอะไรก็ทำไป 4. Non-invasive test ทำถ้ามี CAD risk ต้องคิดว่าถ้าเจอ CAD แล้ว
ตัวโรคสามารถรอ 1-6 เดือน หลัง coronary revascularization ได้
5. Beta-blocker ไม่จำเป็นต้องพยายามให้ใหม่อีกต่อไป เว้นแต่กินอยู่แล้วก็ให้ต่อไป
6. ยาที่ควรหยุดก่อนผ่าตัด : antiplatelets, anti-hypertensive โดยเฉพาะ diuretics และ ACEi/ARB เช้าวันผ่า
Consultative Cardiology Essentials 2019
Quiz # 4
Mahidol University
ชาย 54 ปี stable ischemic heart disease S/P PCI to LAD เมื่อ 3 เดือนก่อน with BMS now on ASA+Plavix ต้องการผ่า cholecystectomy จะทำยังงัย ?
1. ผ่าตัดได้ on ASA ตัวเดียว
2. ผ่าตัดได้ on Plavix ตัวเดียว
3. Delay การผ่าตัดไปก่อน
4. ผ่าตัดได้ off Dual antiplatelets
5. ผ่าตัดได้ bridging ด้วย LMWH
Consultative Cardiology Essentials 2019
Quiz # 5
Mahidol University
ชาย 85 ปี CKD, STEMI S/P PCI to LAD เมื่อ 1 เดือนก่อน with DES now on ASA+Plavix ต้องการผ่า TKA จะทำยังงัย ?
1. ผ่าตัดได้ on ASA ตัวเดียว
2. ผ่าตัดได้ on Plavix ตัวเดียว
3. Delay การผ่าตัดไปก่อน
4. ผ่าตัดได้ off Dual antiplatelets
5. ผ่าตัดได้ bridging ด้วย LMWH
Consultative Cardiology Essentials 2019
Consideration in preexisting DAPT
Risk of stent thrombosis
Consequence of delaying surgery
Perioperative bleeding risk
✤Vascular reconstruction✤ Complex visceral procedure✤ Neurosurgery✤ Transbronchial procedure
Continue ASA in low and intermediate bleeding risk Sx
Resume P2Y12i as soon as possible ( within 48 h )
High risk MI / high ischemic risk features
-> postpone Sx up to 6 mo
TIMING FOR ELECTIVE NON-CARDIAC SURGERY IN PREEXISTING DAPT
Quiz # 6
Mahidol University
ผู้ป่วย post MI ทำ PCI with DES at LM on ASA + Prasugrel มา 6 เดือน จะไปทำ elective hernia repair จะแนะนำให้ผู้ป่วยหยุดยา prasugrel กี่วันก่อนผ่าตัด ?
1. 3 วัน
2. 5 วัน
3. 7 วัน
4. 9 วัน
5. 11 วัน
Consultative Cardiology Essentials 2018
60 years old male with old CVA, AF, on Rivaroxaban 20 mg. OD. He has a schedule for ERCP with sphincterotomy next 2 weeks. His renal function is normal.
What is your suggestion?
A. Continue Rivaroxaban and go on surgeryB. Off Rivaroxaban 24 h and go on surgeryC. Off Rivaroxaban 48 h and go on surgeryD. Off Rivaroxaban 5 days and go on surgeryE. Off Rivaroxaban and go on surgery if PTT within
normal range
Quiz # 7
Mahidol University Consultative Cardiology Essentials 2019
Unplanned surgery
Cardiac,vascular,neurosurgical emergency procedure
Threaten the survival of limb or organ, fixation of Fx, relief of pain,
or other distressing symptoms
• Specific antidote for direct thrombin inhibitor (Dabigatran)
• REVERSE-AD trial
• Idarucizumab normalized the test results in 88 to 98% of the patients, an effect that was evident within minutes
Idarucizumab 5 g IV in two doses a 2.5 g IV no more than 15 min apart
No patients requiring urgent surgical interventions
ANNEXA-4 : Prospective open-label Phase III trial
Mahidol University
ชาย 50 ปี AF, Rheumatic MS S/P MVR 5 ปีก่อน on warfarin INR 2.5 ล้มกระดูกสะโพกหัก อาการอื่นปกติ ทาง Ortho plan elective hip surgery สัปดาห์หน้า
ทำยังไงดี
1. ผ่าตัดได้ไม่ต้องหยุด Warfarin
2. หยุด warfarin 2-3 วัน แล้ว go on surgery
3. หยุด warfarin ให้ heparin bridging
4. ขอทำ echo ดู valvular function ดูก่อน
5. Delay การผ่าตัดไปก่อน
Quiz # 8
Bridging protocolINR
Time
1
2
3
4
VKA stopped
Surgery
2-4 days
Bridge!!! (48 hr before Sx)UFH - stop 4-6 hr before Sx
LMWH - stop 12 hr before Sx
12-24 hr
Resume VKA
Mahidol University
Mahidol University
ควรให้ IE prophylaxis ใน case ?
General Cardiology Tutorial For Residents
A. ASD secundum ถอนฟัน B. ASD primum ทำ TEE C. S/P TOF repair ทำ Colonoscopy D. PDA ligate แล้ว 3 เดือน ถอนฟัน E. MVP with severe MR ถอนฟัน
Mahidol University
Medical student, 22 years old man, history of previous IE, history of penicillin allergy จะถอนฟัน. Best management ?
General Cardiology Tutorial For Residents
A. Amoxicillin 2 gm PO B. Vancomycin 1 mg IV C. Erythromycin 2 mg PO D. Clindamycin 600 mg PO E. Ceftriaxone 2 mg IV
Mahidol University
Which of the following is a contraindication of pregnancy EXCEPT?
A. 24 y - Marfan with 5-cm aortic root B. 30 y - HOCM with resting gradient 50 mmHg
C. 20 y - Idiopathic pulmonary hypertension D. 33 y - History of peripartum cardiomyopathy EF40% E. 30 y - Severe rheumatic MS, FC III
mWHO classification of maternal cardiovascular risk
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
mWHO I Risk No detectable increased risk of maternal mortality and no/mild increased risk in
morbidity
Small/mild PS Marternal cardiac event rate
2.5 - 5 %
Small/mild PDA Counseling Yes
Mitral valve prolapse Care during pregnancy Local hospital
Successfully repaired simple lesion
Minimal follow-up visits during pregnancy
Once or twice
Atrial or ventricular ectopic beats, isolated
Location of delivery Local hospital
mWHO classification of maternal cardiovascular risk
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
Risk Small increased risk of maternal
mortality or moderate increased in morbidity
Marternal cardiac event rate
5.7%-10.5%
Counseling Yes
Care during pregnancy Local hospital
Minimal follow-up visits during pregnancy
Once per trimester
Location of delivery Local hospital
mWHO II
Unoperated ASD or VSD
Repaired TOF
Most arrhythmias (supraventricular)
Turner syndrome without aortic
dilatation
mWHO classification of maternal cardiovascular risk
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
mWHO II - III Risk Intermediate increased risk of
maternal mortality or moderate to severe increased
in morbidityMild impaired LVEF
(EF>45%)
Aorta < 45 mm in bicuspid AV pathology
Marternal cardiac event rate
10-19%
HCM Repaired coarctation Counseling Yes
Marfan or orther HTAD without
dilatation
AVSD Care during pregnancy
Referral hospital
Native or tissue valve disease not
considered WHO I or IV
Minimal follow-up visits during pregnancy
Bimonthly
Location of delivery Referral hospital
mWHO classification of maternal cardiovascular risk
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
mWHO III Risk Significant increase risk of
maternal mortality or severe morbidity
Mod impaired LVEF (EF 30-45%)
Systemic RV/ good or mild decreased
function
Marternal cardiac event rate
19-27 %
Mechanical valve Severe asymptomatic AS
Counseling Expert counselling required
Previous postpartum cardiomyopathy without
any residual LV impairment
Unrepaired cyanotic heart disease
Care during pregnancy
Expert center
Moderate MS Fontan circulation/ patient well cardiac condition not
complicated
Minimal follow-up visits during pregnancy
Montly or bimonthly
Moderate aortic root dilatation
Ventricular tachycardia
Location of delivery Expert center
mWHO classification of maternal cardiovascular risk
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
mWHO IV Risk Extremely high risk of maternal mortality or severe morbidity
Severe impaired LVEF (EF 30-45%)
Systemic RV/ mod to severe decreased
function
Marternal cardiac event rate 40-100%
PAHSevere symptomatic
AS Counseling Contraindicate; termination
discussed
Previous postpartum cardiomyopathy with any
residual LV impairment Severe (re)coarctation Care during pregnancy Expert center
Severe MSFontan with any
complication Minimal follow-up visits
during pregnancy Montly
Severe aortic dilatation
Vascular Ehlers-Danlos
Location of delivery Expert center
Mahidol University
A 32-year-old woman with a mechanical bileaflet aortic valve prosthesis presents 8 weeks after her last menstrual period. A pregnancy test is positive. She is now taking warfarin 3 mg daily to maintain her INR between 2 and 3.
• According to 2018 ESC guidelines for management of valvular heart disease, which is the most appropriate therapy in this patient during her first trimester of pregnancy ?
Mahidol University
A. Continue warfarin to maintain an INR of 2 to 3 B. Replace warfarin with aspirin 325 mg daily C. Replace warfarin with unfractionated heparin
infusion D. Replace warfarin with subcutaneous LMWH
twice daily E. Increase warfarin to maintain an INR of 3 to 4
Anticoagulant in pregnancy• Warfarin → Cross the placenta
–Warfarin associated embryopathy– Intracranial hemorrhage (3-12%)
• UFH → Not cross the placenta–High incidence of thromboembolism–HIT, osteopenia
• LMWH → Not cross the placenta–May higher incidence of thromboembolism–Less HIT, less osteopenia
Mahidol University
Fetal Warfarin Syndrome
J Med Assoc Thai 2005; 88(Suppl 8): S246-50 Obstet Gynecol 2002;99:35-40
Nasal abnormality, small nose with markedly depressed nasal bridge
Brachydactyly, hypoplasia of all distal phalanges, stippled epiphyses
Skull defect Cerebellar atrophyOptic atrophy MicropthalmiaMicrocephaly Scoliosis
Mahidol University
Incidence : 2.6 % if Warfarin dose < 5mg/day 8 % if Warfarin doss > 5 mg/day
PREGNANCY AND HEART DISEASE
ESC 2018 guidelines for the management of cardiovascular disease during pregnancy
Sepsis
High fever
Pain
Inotrope agent
Hypovolemia Thyroid storm
Hypoxia
Q 1 : AF/AT with rapid VR leads to hypotension or hypotension is the cause of AF/AT with rapid VR?
Q 2 : If AF/AT leads to hypotension. Which one is the major contributor : rhythm or rate?
Rate
Rate เร็วแค่ไหนที่น่าจะอธิบาย hypotension และต้องคุม rate ลงมาเท่าไร?
Common Consultative Cardiology
Mahidol University
- Preoperative evaluation - ACLS - Common cardiac problems in pregnancy - Assessment of newly-detected or changing heart murmurs - Top 5 Cardio chief complaint : Chest pain, Dyspnea,
Syncope, Palpitation (+/- abnormal ECG), Edema - Evaluation of possible infectious endocarditis - Management of unstable ischemia outside CCU - Management of uncontrolled hypertension / arrhythmias
(esp. AF) in the hospitalized patients
Consultative Cardiology Essentials 2019
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