You are asked to see a 78-year-old man who is due to have elective abdominal aortic aneurysm repair surgery in 6 weeks. He reports exertional angina.
In addition to managing vascular risk factors, including continuing beta-blocker, ACE inhibitor, and statin, which one of the following is most appropriate?
Abdominal vascular surgery is high risk, but patient-related factors will adjust the risk further. Assessment is indicated if it will change management. Confirming the presence of coronary disease may result in preoperative revascularization, and will enable perioperative management to be tailored appropriately. The best evidence base in this circumstance is nuclear perfusion imaging. Although cardiac MRI may give complementary and even additional information, it is not currently supported by ESC guidelines. Coronary angiography should be recommended for the same indications as in a non-operative setting, but would not be the most appropriate answer here.
A 56-year-old woman is assessed for knee replacement surgery. She has a history of angina and had elective coronary angioplasty to a lesion in the right coronary artery 2 years previously. She is limited by arthritis but can climb two flights of stairs without difficulty. She reports no angina.
Which one of the following would you recommend to assess perioperative risk?
Knee surgery is not high risk, but patient factors need to be considered. Although your patient has a history of IHD, her functional capacity is good (>4 METs indicated by ability to climb two flights of stairs) and she does not currently suffer from angina. Although there is good evidence that nuclear perfusion imaging can risk stratify preoperative patients, it is not necessary here. Other risk-stratification modalities may be useful, but are not recommended in ESC guidelines.
In which one of the following patients is carotid endarterectomy recommended?
The best evidence for revascularization is seen in patient E. A male with 50–69% stenosis and recent TIA might be recommended for revascularization. There is poor evidence to support revascularization in woman with previous TIA and <70% stenosis, or women with no previous TIA. Benefit is seen in men with no stroke/TIA where there is bilateral carotid stenosis >70%.
Which one of the following is used as a cardiac surgery risk score?
The other risk scores are used in cardiology, but not specifically in cardiac surgery.
Which one of the following factors does not add to the euroSCORE II risk?
Only CCS class 4 (rest) angina increases euroSCORE II risk. Presence of chronic lung disease (requiring long-term use of bronchodilators or steroids) and insulin-controlled diabetes contributes to risk. Myocardial infarction is considered recent and carries risk for up to 90 days. Even moderate pulmonary hypertension carries some risk.