Focusing Focusing on the Surgical Patient with on the Surgical Patient with

Cardiac ProblemsCardiac ProblemsBy Kate J. Morse, RN, ACNP-BC, CCRNBy Kate J. Morse, RN, ACNP-BC, CCRN

Nursing2009,Nursing2009, March 2009 March 2009

2.1 ANCC contact hours2.1 ANCC contact hoursOnline: www.nursingcenter.comOnline: www.nursingcenter.com

© 2009 Lippincott Williams & Wilkins. All world rights reserved.© 2009 Lippincott Williams & Wilkins. All world rights reserved.

SignificanceSignificance

Baby boomers born 1946-1964 will be Baby boomers born 1946-1964 will be increasingly greater consumers of healthcare in increasingly greater consumers of healthcare in the coming decadesthe coming decades

39% of these patients will have cardiovascular 39% of these patients will have cardiovascular diseasedisease

American College of Cardiology/American Heart American College of Cardiology/American Heart Association (ACC/AHA) have established Association (ACC/AHA) have established guidelines for perioperative cardiovascular guidelines for perioperative cardiovascular evaluationevaluation

Preoperative evaluationPreoperative evaluation

Determines cardiovascular riskDetermines cardiovascular risk

Additional testing may be doneAdditional testing may be done

Surgeon and anesthesiologist will examine Surgeon and anesthesiologist will examine patientpatient

Nurse can perform health history and physical Nurse can perform health history and physical assessmentassessment

Questions to ask patientQuestions to ask patient

Do you experience chest pain?Do you experience chest pain? Do you take nitroglycerin?Do you take nitroglycerin? Do you need to rest between taking a shower Do you need to rest between taking a shower

and dressing?and dressing? Can you walk up a flight of stairs?Can you walk up a flight of stairs? Have you stopped an activity due to symptoms?Have you stopped an activity due to symptoms? Do you have swelling or pain in your feet, legs?Do you have swelling or pain in your feet, legs? Does anyone in your family have heart trouble?Does anyone in your family have heart trouble?

Physical assessmentPhysical assessment

Take BP in both arms, checking for artery Take BP in both arms, checking for artery stenosisstenosis

Assess carotid pulses for bruitsAssess carotid pulses for bruits

Auscultate lungs and heart soundsAuscultate lungs and heart sounds

Examine extremities for edema and signs of Examine extremities for edema and signs of peripheral vascular diseaseperipheral vascular disease

Conditions to treatConditions to treatActive cardiac conditions, which should be treated

before noncardiac surgery, include: acute coronary syndromes decompensated heart failure significant dysrhythmias (high-grade atrioventricular

blocks and symptomatic ventricular dysrhythmias), supraventricular dysrhythmias (poorly controlled atrial fibrillation, symptomatic bradycardia, ventricular tachycardia)

severe valvular heart diseases (severe aortic stenosis or symptomatic mitral stenosis)

GuidelinesGuidelines

Make a distinction between:Make a distinction between:- history of myocardial infarction (MI)- history of myocardial infarction (MI)

- abnormal Q waves on a 12-lead ECG- abnormal Q waves on a 12-lead ECG- an acute MI- an acute MI

Irreversible myocardial necrosis (history of MI or Irreversible myocardial necrosis (history of MI or abnormal Q waves) is considered a clinical risk abnormal Q waves) is considered a clinical risk factorfactor

GuidelinesGuidelines

Active cardiac condition is defined as:Active cardiac condition is defined as:

- an acute MI 7 days or less before the exam- an acute MI 7 days or less before the exam

- a recent MI occurring more than 7 days ago- a recent MI occurring more than 7 days ago

but less than or equal to a month ago with but less than or equal to a month ago with evidence of ischemic risk by clinical symptoms evidence of ischemic risk by clinical symptoms or noninvasive studyor noninvasive study

Low cardiac riskLow cardiac risk

Patient with recent MI but no further risk with Patient with recent MI but no further risk with stress teststress test

Elective surgery may still be postponed 4 to 6 Elective surgery may still be postponed 4 to 6 weeks after the MIweeks after the MI

Body systems linked to Body systems linked to increased cardiac riskincreased cardiac risk

Pulmonary: lung disease increases patient risk Pulmonary: lung disease increases patient risk of complicationsof complications

Evaluate risk with:Evaluate risk with: - accurate smoking history- accurate smoking history - pulmonary function tests (PFTs)- pulmonary function tests (PFTs) - arterial blood gas analysis- arterial blood gas analysis - chest X-ray- chest X-ray

DiabetesDiabetes

Most common metabolic diseaseMost common metabolic disease

Can complicate surgery Can complicate surgery

These patients often have undiagnosed These patients often have undiagnosed coronary artery disease (CAD)coronary artery disease (CAD)

Tight glycemic control is key - glucose below Tight glycemic control is key - glucose below 200 is target200 is target

Kidney diseaseKidney disease

Can be associated with cardiac diseaseCan be associated with cardiac disease

Preoperatively patient’s renal function will be Preoperatively patient’s renal function will be assessed with lab tests:assessed with lab tests:

- blood urea nitrogen- blood urea nitrogen - creatinine clearance- creatinine clearance - glomerular filtration rate- glomerular filtration rate

Fluid and electrolyte levels will be monitored and Fluid and electrolyte levels will be monitored and balanced in someone who’s renally impairedbalanced in someone who’s renally impaired

Hematologic disordersHematologic disorders

Anemia places stress on cardiovascular systemAnemia places stress on cardiovascular system

If complete blood cell count reveals anemia, If complete blood cell count reveals anemia, blood transfusion risk will be assessed by blood transfusion risk will be assessed by surgeonsurgeon

Hypercoagulability conditions (polycythemia, Hypercoagulability conditions (polycythemia, thrombocytopenia) put patient at risk for clotting thrombocytopenia) put patient at risk for clotting and should be addressed preoperativelyand should be addressed preoperatively

Step-by-step approach for Step-by-step approach for surgical risksurgical risk

Determine urgency of surgeryDetermine urgency of surgery

- emergent surgery, cardiologist will make- emergent surgery, cardiologist will make

recommendationsrecommendations

- if elective, may be delayed or postponed- if elective, may be delayed or postponed

Evaluate patient for active cardiac conditionsEvaluate patient for active cardiac conditions

Step-by-step approach for Step-by-step approach for surgical risksurgical risk

Evaluate surgical risk - is the procedure low, Evaluate surgical risk - is the procedure low, intermediate, or high risk?intermediate, or high risk?

Evaluate patient’s functional capacityEvaluate patient’s functional capacity

- done subjectively by asking patient questions - done subjectively by asking patient questions regarding activities of daily livingregarding activities of daily living

- stress test- stress test

Step-by-step approach for Step-by-step approach for surgical risksurgical risk

Evaluate clinical risk factorsEvaluate clinical risk factors - patient has symptoms- patient has symptoms - unknown functional capacity- unknown functional capacity

Clinical risk factors includeClinical risk factors include - history ischemic heart disease- history ischemic heart disease - history heart failure- history heart failure - history cerebral vascular disease- history cerebral vascular disease - diabetes- diabetes - renal disease- renal disease

RecommendationsRecommendations

If no clinical risk factors, surgery can proceedIf no clinical risk factors, surgery can proceed

If one or two clinical risk factors, surgery can If one or two clinical risk factors, surgery can proceed with beta-blocker therapy; additional proceed with beta-blocker therapy; additional testing should be consideredtesting should be considered

If three or more clinical risk factors, consider If three or more clinical risk factors, consider cardiac risk; additional testing shouldn’t be done cardiac risk; additional testing shouldn’t be done if it won’t change plan of careif it won’t change plan of care

Cardiac risks in noncardiac Cardiac risks in noncardiac surgerysurgery

The The guidelines stratify surgical risk according to three levels:

Vascular

(cardiac risk greater than 5%)

- Major vascular procedures such as aortic repair

- Peripheral vascular surgery

Cardiac risks in noncardiac Cardiac risks in noncardiac surgerysurgery

Intermediate risk

(1% to 5%)

- Intraperitoneal and intrathoracic surgery

- Head and neck surgery

- Carotid endarterectomy

- Orthopedic surgery

- Prostate surgery

Cardiac risks in noncardiac Cardiac risks in noncardiac surgerysurgery

Low risk

(less than 1%)

- Endoscopic procedures

- Superficial procedures

- Cataract surgery

- Breast surgery

- Ambulatory surgery

Diagnostic testsDiagnostic tests

Exercise stress test is first choice unless Exercise stress test is first choice unless contraindicatedcontraindicated

Pharmacologic stress test if unable to walk or Pharmacologic stress test if unable to walk or exerciseexercise

Coronary arteriograph - invasive test evaluates Coronary arteriograph - invasive test evaluates coronary anatomycoronary anatomy

Cardiac revascularizationCardiac revascularization

May be done prior to elective noncardiac May be done prior to elective noncardiac surgerysurgery

For severe multivessel disease or significant left For severe multivessel disease or significant left main CADmain CAD

Two options - coronary artery bypass graft or Two options - coronary artery bypass graft or percutaneous coronary intervention (PCI) with percutaneous coronary intervention (PCI) with bare-metal or drug-eluting stentsbare-metal or drug-eluting stents

Surgery post PCISurgery post PCI

Elective surgery should be delayed 4 to 6 weeks Elective surgery should be delayed 4 to 6 weeks after PCI with bare-metal stentsafter PCI with bare-metal stents

Delay 12 months after drug-eluting stentsDelay 12 months after drug-eluting stents

Medications post PCI (aspirin, Plavix) put patient Medications post PCI (aspirin, Plavix) put patient at risk for bleedingat risk for bleeding

If patient underwent balloon angioplasty, elective If patient underwent balloon angioplasty, elective noncardiac surgery isn’t recommended for 4 noncardiac surgery isn’t recommended for 4 weeksweeks

Medications and surgeryMedications and surgery

Aspirin and Plavix therapy increase risk of Aspirin and Plavix therapy increase risk of bleedingbleeding

Beta-blockers should be continuedBeta-blockers should be continued

If patient has one or more clinical risk factors, If patient has one or more clinical risk factors, beta-blockers should be started preoperatively if beta-blockers should be started preoperatively if not taking alreadynot taking already

Medications and surgeryMedications and surgery

A patient having vascular surgery should be A patient having vascular surgery should be started on a statinstarted on a statin

Statins may also be considered in patients in Statins may also be considered in patients in patients with one clinical risk factor having an patients with one clinical risk factor having an intermediate risk procedureintermediate risk procedure

Uncontrolled hypertension or CAD patients may Uncontrolled hypertension or CAD patients may need a alpha-agonistneed a alpha-agonist

Other presurgical Other presurgical considerationsconsiderations

Patients with implanted pacemakers or Patients with implanted pacemakers or cardioverters should alert anesthesiologist/ cardioverters should alert anesthesiologist/ surgeon so appropriate safety precautions are surgeon so appropriate safety precautions are takentaken