A 75-year-old man is referred for elective preoperative assessment. He is a smoker with a 40 pack-year history and diet-controlled diabetes. Baseline blood tests including renal function are normal.
Which one of the following factors would make you consider that further investigation was needed to assess his cardiac risk?
Vascular surgery, especially suprainguinal surgery, carries a perioperative risk of a cardiac event of >5%. High-risk surgery in the elective setting would mandate further assessment of risk, which may include non-invasive stress testing. Orthopaedic surgery is considered intermediate risk surgery. In the presence of the other individual factors, further investigation is not required since optimal medical therapy should be given. Additional risk assessment would not alter this management.
You are asked to review a patient on a surgical ward who has been admitted for colonic surgery the next day to remove a tumour. You discover that she has a history of ischaemic heart disease and underwent elective PCI to the LAD 18 months previously. She is currently taking aspirin, ramipril, and simvastatin. She has a resting heart rate of 80 bpm in sinus rhythm. Her blood pressure is 105/80 mmHg. She is euvolaemic. The surgeon wishes to stop the aspirin prior to the surgery.
Which one of the following medication changes do you recommend?
An antiplatelet agent should be continued, especially where coronary intervention has taken place. The risks of bleeding do not outweigh the risks of a coronary event in this circumstance.
Beta-blockers are helpful in reducing risk in the perioperative period but should be uptitrated slowly to avoid hypotension.
Statins are not proven to be associated with cancer. Abrupt withdrawal in the perioperative period might be harmful. There is no evidence to support nitrates in this circumstance.
You review a 45-year-old man in clinic. He is due to have surgery on his knee ligaments in 4 weeks’ time. He is a smoker and has a strong family history of ischaemic heart disease. He is normotensive. He tells you that he is a keen swimmer and footballer, and injured his knee whilst training for a marathon recently. He currently finds it hard to walk unaided. Routine examination and resting ECG are normal.
Which one of the following statements best describes your approach?
In low-risk surgery, regardless of the patient’s risk factors, good functional status is an indicator of low cardiac risk. No specific investigation is needed but the opportunity should be taken to discuss future risk.
Which one of the following statements is not true regarding management of a pacemaker/implantable cardiac defibrillator during non-cardiac surgery?
Bipolar surgical diathermy/electrocautery is preferred. The other statements are all recommended measures. The device should always be checked before and after surgery to ensure appropriate functioning.
You are asked to review a 76-year-old man who has been admitted to a surgical ward with bowel obstruction. A CT scan suggests that a colonic malignancy is responsible. Urgent surgery is planned to relieve the obstruction. The anaesthetist has asked for your advice since the patient reports limiting angina and is not normally able to climb two flights of stairs without becoming breathless. He currently takes aspirin, ramipril, simvastatin, and bisoprolol. Your initial assessment concludes that he is currently free from angina and is euvolaemic with no signs of cardiac failure. His resting ECG demonstrates lateral T-wave inversion.
What would be your most likely response?
Decisions regarding non-cardiac surgery should be made jointly by the surgeon, anaesthetist, and patient, with input from specialist teams. There is always a balance of benefits against risks. In this circumstance, surgery should not be postponed since the consequences of doing so might be life threatening. The results of further tests would not change this decision, but the patient should continue on his current medication.
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