What is the primary recommendation for managing cardiovascular abnormalities in an adult-gerontology or acute complex chronic patient with perioperative risk factors?

Management of Cardiovascular Abnormalities in Perioperative Adult-Gerontology Patients

The primary recommendation for managing cardiovascular abnormalities in adult-gerontology or acute complex chronic patients with perioperative risk factors is to conduct a thorough preoperative risk assessment, including identification of major risk indicators such as unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease. 1

Risk Assessment and Stratification

• Major perioperative risk indicators include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease 1
• Clinical risk factors that increase perioperative cardiovascular risk include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, and high-risk surgery 1, 2
• The American College of Cardiology recommends a stepwise approach to risk assessment for patients with known or suspected coronary artery disease, using tools like the Revised Cardiac Risk Index 1, 3
• Risk increases in a stepwise fashion with additional cardiovascular risk factors (hypertension, diabetes mellitus, current smoking), with odds of perioperative myocardial infarction significantly higher in patients with multiple risk factors 4

Preoperative Evaluation

• Preoperative assessment should include systemic arterial oximetry, ECG, chest x-ray, transthoracic echocardiography, complete blood count, and coagulation screening 1
• B-type natriuretic peptide level before surgery serves as an additional risk stratification factor 2
• Functional capacity assessment in metabolic equivalent tasks (METs) is crucial, with patients having ≥4 METs generally able to proceed with planned surgery without further cardiac testing 5, 3
• Patients unable to climb ≥2 flights of stairs (<4 METs) may require additional stress testing if results would change perioperative management 3

High-Risk Patient Populations

• Certain populations require specialized management at centers for adult congenital heart disease or cardiovascular care, including patients with:
  • Prior Fontan procedure
  • Severe pulmonary arterial hypertension
  • Cyanotic congenital heart disease
  • Complex congenital heart disease
  • Left ventricular assist devices 1
• Adults aged 75 years or older and patients with coronary stents have significantly higher risk of perioperative myocardial infarction and major adverse cardiovascular events 3

Perioperative Monitoring and Management

• ECGs should be obtained at baseline, immediately after surgery, and on the first two postoperative days for high-risk procedures 1
• Cardiac biomarker monitoring is recommended in high-risk patients and those with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction 1
• Echocardiography and pulmonary artery catheterization are recommended for assessing heart function, especially in patients with right heart dysfunction 1
• The distinction between cardiogenic shock and transient postoperative cardiac stunning is important as they are associated with different hospital paths and outcomes 2

Pharmacological Management

• For myocardial dysfunction, consider:
  • Low-to-moderate doses of dobutamine and epinephrine
  • Milrinone
  • Levosimendan, either alone or in combination 1
• For vasoplegia-induced hypotension, norepinephrine is recommended to maintain adequate perfusion pressure 1
• For perioperative ST-segment elevation MI, consider aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors 1
• Routine use of high-dose β-blockers (e.g., 100 mg of metoprolol succinate) 2-4 hours prior to surgery should be avoided as they are associated with higher risk of stroke and mortality 3
• Statins should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery, as they are associated with fewer postoperative cardiovascular complications and lower mortality 3

Mechanical Support Considerations

• For heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended 1
• Ventricular assist devices should be considered before end-organ dysfunction becomes evident 1

Common Pitfalls and Caveats

• Perioperative MI carries a 40-70% mortality rate and high risk for future cardiac events 1
• Long operations with hemodynamic instability requiring large-volume fluid replacement increase perioperative mortality in patients with congenital heart disease 1
• Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but increases surgical bleeding 3
• Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 3
• Postoperative cardiovascular dysfunction may be characterized by unexpectedly low systemic vascular resistance (vasodilatory shock), which requires specific management approaches 2