Consultative Cardiology Essentialsreviews.berlinpharm.com/20190504/Common_consultative...2019/05/04 · Consultative Cardiology Essentials 2019 A. It’s an innocent murmur, keep

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

Pre-op Guidelines in a nutshell

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 ?


A. It’s an innocent murmur, keep

calm and continue watching

GOT

B. This is a pathologic murmur and

need further evaluation

Quiz # 2


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)

Mahidol University

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


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


- 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)

Cardiac auscultation location





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.


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%

Mahidol University

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


Mahidol University

Active Cardiac Condition Arrhythmias


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

Recent interrogate CIED fn ✤ PPM : within 12 mo.✤ ICD : within 6 mo.✤ CRT : within 3-6 mo.

CIED

Quiz # 3.1

Mahidol University

A. Extremely low risk

B. Low risk

C. Intermediate risk

D. High risk

E. Extremely high risk


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


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

http://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)


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


Pre-op Guidelines in a nutshell

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


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


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


4. ผ่าตัดได้ off Dual antiplatelets

5. ผ่าตัดได้ bridging ด้วย LMWH


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


MINIMAL DISCONTINUATION AND RE-IMPLEMENTATION TIME FRAMES OF DAPT

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


Interventions and bleeding risk

No bridging with LMWH/UFH

Elective intervention

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


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

PREGNANCY AND HEART DISEASE

mWHO classification of maternal cardiovascular risk


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




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


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 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


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


Bimonthly

Location of delivery Referral hospital




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


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


Montly or bimonthly

Moderate aortic root dilatation

Ventricular tachycardia

Location of delivery Expert center




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



15:30

Digoxin 0.25 mg IV

ชาย 18 ปี ไม่มี underlying ปกติ Fc I .ใจสั่น 2-3 ชม.ก่อนมารพ.

BP = 118/76

00:30

Repeat Digoxin 0.25 mg IV

10:40

Repeat Digoxin 0.25 mg IV

16:40

Severe hypotension : patient died

Digoxin 0.25 mg IV

BP = 75/63

ผป.เป็น AF with WPW syndrome เสียชีวิตจาก too fast ventricular rate & hypotension

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?

Mahidol University

Mahidol University

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


THANK YOU FOR YOUR ATTENTIONEMAIL : [email protected]

Consultative Cardiology Essentialsreviews.berlinpharm.com/20190504/Common_consultative...2019/05/04 · Consultative Cardiology Essentials 2019 A. It’s an innocent murmur, keep

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