What does 1 MET represent in terms of activities?
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Basic self-care activities like eating, dressing, or using the toilet.
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What does 1 MET represent in terms of activities?
Basic self-care activities like eating, dressing, or using the toilet.
What should be done 3-6 months after DES implantation regarding DAPT?
Discontinue DAPT; surgery may be considered.
What is the guideline for BMS surgery ≥30 days post-implantation?
Class I: Safe for non-cardiac surgery.
What factors can cause myocardial oxygen demand to increase?
Sympathetic hyperactivity, postoperative pain, withdrawal of β-blockers, hypovolemia, cardiac decompensation, systemic vasodilation, increased heart rate/arrhythmia.
What is a recent myocardial infarction (MI) timeframe that requires evaluation before non-cardiac surgery?
Recent MI within 90 days.
What is not counted in the RCRI unless other criteria for ischemic heart disease are present?
Prior coronary revascularization procedures.
What are the independent predictors of major cardiac complications in RCRI?
High-risk type of surgery and history of ischemic heart disease.
What should be considered for intermediate-risk surgery with one or more clinical risk factors?
Noninvasive stress testing.
What NYHA functional class indicates decompensated heart failure (HF) requiring evaluation?
NYHA functional class IV.
What should be done if pharmacologic stress testing is normal?
Proceed to surgery.
What is the risk percentage for low risk surgical procedures?
<1%.
What was the outcome of early intervention with CRT-D in the MADIT-CRT trial?
Associated with a significant long-term survival benefit in patients with mild heart-failure symptoms.
What is the recommendation for surgery <30 days after BMS implantation?
Class III: Delay surgery.
What factors affect subendocardial oxygen supply?
Hypotension, myocardial wall stress, coronary vasoconstriction, anemia, hypoxemia.
What should be done for patients according to GDMT or alternate strategies?
Proceed to surgery or consider noninvasive treatment and palliation.
What is done if the pharmacologic stress test is abnormal?
Coronary Angiography (CAG) is performed to delineate coronary anatomy and guide revascularization.
What does DSMM stand for?
Demand Supply Mismatch.
What defines a recent myocardial infarction (MI) according to ACC guidelines?
MI within 60 days.
What should be considered regarding aspirin discontinuation?
Discontinuation should be considered in patients where hemostasis is anticipated to be difficult to control during surgery.
What should be continued before coronary artery bypass grafting (CABG)?
Single antiplatelet therapy (SAPT).
What factors should be considered when managing aspirin in the perioperative period?
Perioperative bleeding risk versus thrombotic complications.
What types of surgery are classified as intermediate risk?
Intraperitoneal and intrathoracic surgery, Carotid endarterectomy, Head and neck surgery, Orthopedic surgery, Prostate surgery.
What is the mechanism behind Type 1 MI?
Rupture of a coronary plaque leads to platelet aggregation and thrombus formation.
What is the recommendation for patients with moderate or greater functional capacity?
No further testing required and proceed to surgery.
What should be done if noninvasive stress test results show no/mild/moderate stress-induced ischemia?
Proceed with planned surgery.
What physiological changes are associated with unstable coronary plaques?
Sympathetic hyperactivity, hemodynamic instability, and coronary vasoconstriction.
What should be considered for patients with heart failure and systolic dysfunction before surgery?
ACE inhibitors.
What are the two main causes of Acute Coronary Thrombosis?
Plaque rupture and plaque erosion.
Which surgeries are considered low risk (<1%)?
Superficial surgery, breast surgery, dental surgery, thyroid surgery, eye surgery, reconstructive surgery, carotid asymptomatic surgery, minor gynecological surgery, minor orthopedic surgery, minor urological surgery, endoscopic procedures, cataract surgery.
What is a current complaint that may indicate myocardial ischemia?
Chest pain considered secondary to myocardial ischemia.
What is the risk of intraperitoneal surgery according to Braunwald/ESC?
Intermediate risk.
What is the significance of the POISE-2 trial?
It supports the Class IIb recommendation for the continuation of aspirin.
What symptoms indicate a history of heart failure?
Dyspnea > II, pedal edema, orthopnea, JVP.
What types of surgeries are considered high-risk according to RCRI?
Vascular surgery and any open intraperitoneal or intrathoracic procedures.
What does RCRI stand for?
Revised Cardiac Risk Index.
What types of significant arrhythmias require evaluation before non-cardiac surgery?
High-grade atrioventricular block, Mobitz II block, third-degree block, symptomatic ventricular arrhythmias, and uncontrolled supraventricular arrhythmias.
What are possible options if coronary artery intervention is needed?
Proceed for coronary artery intervention with dual antiplatelet therapy if the surgical procedure can be delayed, or proceed directly to operation with optimal medical therapy if delay is impossible.
What is the reported cardiac risk for intermediate-risk surgical procedures?
Generally 1%-5%.
What recommendations are made for low-risk surgical procedures?
Identify risk factors and provide recommendations on lifestyle and medical therapy according to ESC Guidelines.
What type of myocardial infarction is associated with Acute Coronary Thrombosis?
Type I MI.
Which surgeries fall under intermediate risk (1%-5%)?
Intraperitoneal surgery, splenectomy, hiatal hernia repair, cholecystectomy, carotid symptomatic surgery, peripheral arterial angioplasty, endovascular aneurysm repair, head and neck surgery, major neurological or orthopedic surgery, major urological or gynecological surgery, renal transplant, non-major intrathoracic surgery.
What does Class IIb recommendation for aspirin indicate?
Continuation of aspirin may be considered in the peri-operative period based on the risk of bleeding and thrombosis.
What underlying conditions are associated with Atrial Fibrillation with Fast Ventricular Rate (AF with FVR)?
Rheumatic Heart Disease (RHD) and Mitral Stenosis (MS).
What are the three risk groups identified by the AUB-HAS2 index for patients undergoing noncardiac surgery?
Low risk (score 0-1), Intermediate risk (score 2-3), High risk (score >3).
When is the most common time for perioperative myocardial infarction (MI) to occur in non-cardiac surgery?
24-48 hours after surgery.
What is the most common type of MI during the perioperative period?
Type 2 MI (demand supply mismatch).
What is the recommendation for patients already on aspirin?
Peri-operative continuation of aspirin may be considered. (Class IIb)
What is the rate of cardiac death with no risk factors according to RCRI?
0.4%.
What symptoms indicate symptomatic mitral stenosis that requires evaluation?
Progressive dyspnea on exertion, exertional presyncope, or heart failure.
What is the next step if further testing is deemed necessary for patients with poor functional capacity?
Conduct pharmacologic stress testing.
What is the recommendation for surgery within <3 months after Drug-Eluting Stent (DES) implantation?
Class III: Harm — Delay surgery.
What is recommended for patients with poor or unknown functional capacity unable to do physiological stress testing?
Pharmacologic stress testing (MPI) is recommended.
What is the recommendation for surgery ≥6 months after DES implantation?
Discontinue DAPT; Class I: Proceed with surgery.
What activities can be performed at 4 METs?
Light housework, climbing stairs, walking at 4 mph, and moderate recreational activities.
What therapy is mentioned for managing myocardial ischemia?
Nitrate therapy.
What can prolonged ST-depression ischemia lead to?
Type II MI.
What is the recommendation for surgery >6 months after DES implantation?
Preferable for surgery.
What is the recommendation for low-risk patients (<1%) in perioperative cardiac assessment?
No further testing and proceed to surgery.
What types of surgery are classified as high risk according to the risk stratification?
Aortic and other major vascular surgery, Peripheral vascular surgery.
What causes Type 1 myocardial infarction (MI)?
Plaque rupture (spontaneous MI).
What is the functional capacity threshold for further testing in elevated-risk patients?
Moderate or greater (≥4 METs).
When should noninvasive testing be considered?
Prior to any surgical procedure for patient counseling or change of perioperative management.
How long after balloon angioplasty can surgery be performed?
2 weeks after intervention.
What should be done after coronary angiography if indicated?
Coronary revascularization according to existing guidelines.
What is the recommendation class for aspirin administration before surgery?
Class 2a.
What was the outcome of spironolactone in the TOPCAT trial?
Significantly reduced the incidence of the primary composite in patients with heart failure and preserved ejection fraction.
What does ACS stand for?
Acute Coronary Syndrome.
What activities are associated with >10 METs?
Strenuous sports such as swimming, singles tennis, football, basketball, or skiing.
What does the ACC National Database Registry define as recent MI?
Occurs within 7 days to 1 month.
What is the most common scoring method for risk stratification in non-cardiac surgery?
Revised Cardiac Risk Index (RCRI).
What MET level indicates poor functional capacity?
<4 METs.
What are the unstable coronary syndromes that require evaluation before non-cardiac surgery?
Unstable or severe angina (CCS class III or IV) and recent MI <60 days.
What does the consultant provide recommendations on?
Perioperative medical management, surveillance for cardiac events, and continuation of chronic cardiovascular medical therapy.
What type of inhibitor is Ticagrelor?
A reversible inhibitor of the P2Y12 receptor.
What is the reported cardiac risk for high-risk surgical procedures?
Often >5%.
What does the 'H' in AUB-HAS2 Cardiovascular Risk Index stand for?
Heart Disease.
What is the reported cardiac risk for low-risk surgical procedures?
Generally <1%.
What type of inhibitor is Prasugrel?
An irreversible inhibitor.
What is the next step if pharmacologic stress testing is abnormal?
Coronary angiography (CAG) to delineate coronary anatomy.
What is the functional capacity threshold to proceed with surgery?
≥4 METs.
What was the outcome of administering aspirin before surgery according to the POISE-2 trial?
Had no significant effect on the rate of death or nonfatal myocardial infarction.
What was the outcome of renal artery denervation in the SIMPLICITY HTN-3 trial?
Did not show a significant reduction of systolic blood pressure in patients with resistant hypertension.
What is the recommendation for peri-operative continuation of statins?
It is recommended to continue statins, favoring those with a long half-life or extended-release formulation. (Class I)
What surgeries are classified as high risk (>5%)?
Aortic and major vascular surgery, open lower limb revascularization or amputation, duodeno-pancreatic surgery, liver resection, bile duct surgery, esophagectomy.
What should be done if Acute Coronary Syndrome (ACS) is present?
Evaluate and treat according to GDMT.
What velocity indicates a risk of sudden cardiac death (SCD) in asymptomatic severe aortic stenosis (AS)?
Velocity > 5 m/s.
What symptom indicates a patient with symptomatic severe mitral stenosis (MS) may not be able to undergo non-cardiac surgery?
Patient is not able to lie down.
What dictates the strategy for perioperative cardiac management?
Patient- or surgical-specific factors.
When should Ticagrelor be stopped before surgery?
3 days prior to surgery.
What types of surgery are classified as low risk?
Endoscopic procedures, Superficial procedures, Cataract surgery, Breast surgery, Ambulatory surgery.
What primarily causes Type 2 myocardial infarction (MI)?
Prolonged imbalance between myocardial oxygen supply and demand in the setting of coronary artery disease (CAD).
What should be done if a patient has poor or unknown functional capacity (<4 METs)?
Determine if further testing will impact decision making or perioperative care.
What are the common events occurring in patients undergoing non-cardiac surgery?
Atrial fibrillation (AF) and perioperative myocardial infarction (MI).
How can the AUB-HAS2 cardiovascular risk index be utilized?
By busy physicians in clinic or nurses in preadmission units to quickly stratify cardiovascular risk.
When can surgery be performed after bare-metal stent placement?
≥4 weeks after stent placement.
What should be done if it is 30 days or more since BMS implantation?
Proceed with surgery (Class I).
What is the risk percentage for intermediate risk surgical procedures?
1-5%.
What type of surgery is classified as high risk according to RCRI criteria?
Intraperitoneal/intrathoracic surgery.
What should be discontinued before surgery?
Clopidogrel and Ticagrelor.
What ECG finding is associated with myocardial infarction?
Pathological Q waves.
How does the performance of the AUB-HAS2 index compare to the Revised Cardiac Risk Index?
The AUB-HAS2 index is superior to the Revised Cardiac Risk Index.
What should be done for elevated-risk patients?
Further clinical management based on risk stratification.
What factors should be considered for non-cardiac surgery?
Emergency vs. elective surgery.
What is the classification for beta blockers and statins according to the guidelines?
Class I.
What is the rate of myocardial infarction with three or more risk factors?
9.1%.
Should asymptomatic severe aortic stenosis or symptomatic mitral stenosis undergo extensive evaluation before non-cardiac surgery?
No, they should be sent for non-cardiac surgery without much evaluation.
What age is considered a risk factor in the AUB-HAS2 Cardiovascular Risk Index?
Age ≥ 75 years.
What hemoglobin level indicates anemia in the AUB-HAS2 Cardiovascular Risk Index?
Hemoglobin < 12 mg/dL.
When can antiplatelet therapy be restarted after surgery?
Day 1–4 after surgery.
What happens if the functional capacity is <4 METs?
Continue to Step 5.
When should pre-operative initiation of statin therapy be considered?
In patients undergoing vascular surgery, ideally at least 2 weeks before surgery. (Class IIa)
What is the first step in preoperative cardiac risk evaluation?
Determine if the surgery is urgent.
What is the next step if ACS is not present?
Estimate perioperative risk of MACE based on combined clinical/surgical risk.
What is the first step in the 2014 ACC/AHA guideline for perioperative cardiac assessment?
Identify if the patient has known risk factors for CAD.
What conditions are included in the history of cerebrovascular disease?
Transient Ischemic Attack (TIA) or Stroke.
What type of diabetes is considered a risk factor in RCRI?
Diabetes mellitus requiring treatment with insulin.
What should be done if a patient has 3 or more cardiac risk factors?
Proceed to Step 7.
What defines severe aortic stenosis that requires evaluation?
Mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm², or symptomatic.
What type of inhibitor is Clopidogrel?
An irreversible inhibitor.
What is recommended for extensive stress-induced ischemia?
Individualized perioperative management considering the potential benefits and adverse outcomes.
What is the significance of the AUB-HAS2 index in surgical settings?
It provides a simple and comprehensive measure for cardiovascular risk stratification.
What is the recommendation for surgery if it is less than 30 days since Bare-Metal Stent (BMS) implantation?
Delay surgery (Class III: Harm).
What is the risk associated with surgery 3-6 months after DES implantation?
Delayed surgery risk is greater than stent thrombosis risk.
What methods are used for risk assessment in perioperative cardiac evaluation?
RCRI (Revised Cardiac Risk Index) and AUB-HAS2 Score.
What should be done if emergency surgery is required?
Proceed with clinical risk stratification and then proceed to surgery.
What is the recommendation for patients already on statins?
Peri-operative continuation of statin therapy is recommended. (Class I)
What serum creatinine level is a risk factor in RCRI?
Preoperative serum creatinine > 2.0 mg/dL.
What additional evaluations may be considered for patients with 2 or fewer cardiac risk factors?
Rest echocardiography and biomarkers for LV function.
What should be determined in Step 3 of the evaluation?
The risk of the surgical procedure.
What should be considered for patients with known ischemic heart disease before surgery?
Initiation of a titrated low-dose beta blocker regimen.
What is the minimum duration for dual antiplatelet therapy after bare-metal stent placement?
At least 4 weeks.
What should be done if active or unstable cardiac conditions are present?
Discuss treatment options in a multidisciplinary team.
When should Clopidogrel be stopped before surgery?
5 days prior to surgery.
What percentage of perioperative MIs are due to plaque rupture?
About 50%.
When should Prasugrel be stopped before surgery?
7 days prior to surgery.
What may be considered for patients with one or more clinical risk factors?
Preoperative baseline ECG to monitor changes during the perioperative period.
What is the predominant type of perioperative myocardial infarction?
Type 2 MI.
When can surgery be performed after old-generation drug-eluting stents?
Within 12 months after intervention.
What is the mnemonic for stopping antiplatelet medications before surgery?
TCP (Ticagrelor, Clopidogrel, Prasugrel) - 3, 5, 7 days.
What should be considered for patients undergoing vascular surgery?
Initiation of statin therapy.
What are the hemodynamic instabilities associated with unstable coronary plaques?
Tachycardia and hypertension.
How long is a single dose of aspirin required after BMS implantation?
At least 4 weeks.
When can surgery be performed after new-generation drug-eluting stents?
Within 6 months after intervention.
