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Chapter 98: Perioperative Evaluation for Noncardiac Surgery

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As with most clinical cases, the cornerstone of perioperative management is a conscientious history and physical exam. Eliciting the patient’s functional status is of paramount importance in the stepwise algorithm for risk stratification; this is often quantified in terms of metabolic equivalents (METs) that the patient habitually performs. Which of the following activities falls short of the 4 MET cutoff used to define patients with acceptable functional capacity who may not need functional testing in the absence of acute decompensated cardiac conditions?

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A. Heavy housework

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B. Bicycling

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C. Doubles tennis

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D. Bowling

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E. Walking up a hill

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The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 98). Understanding a patient’s functional status is key in guiding management decisions. Excellent functional status, > 10 METs, includes activities such as boxing, judo, and cross-country skiing. Good functional status, 7 to 10 METs, includes bicycling, fencing, and kayaking. Moderate functional status, 4 to 6 METs, includes golf while carrying clubs, doubles tennis (option C), walking 7 kph, walking up a hill (option E), climbing a flight of stairs, or doing heavy housework (option A). Poor functional status, < 4 METs, includes light activities limited to driving, bowling (option D), and fishing from a bank.

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In patients who present with acute coronary syndromes (ACS), cardiac catheterization is generally recommended for defining coronary anatomy, stratifying risk, and devising the optimal treatment and revascularization strategy when appropriate. Which of the following statements about the perioperative management of a patient with ACS who is scheduled to undergo a noncardiac surgery is true?

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A. If noncardiac surgery must be performed within a matter of weeks, balloon angioplasty without stenting is preferred

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B. If noncardiac surgery is not essential but still time sensitive, drug-eluting stents (DESs) are preferred

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C. If DESs are implanted, noncardiac surgery should ideally be delayed for 2 years

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D. Noncardiac surgery may be considered at 30 days in the era of second- and third-generation DESs

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E. All of the above

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The answer is A. (Hurst’s the Heart, 14th Edition, Chap. 98). If noncardiac surgery must be performed within a matter of weeks, balloon angioplasty without stenting may be considered (option A). If surgery is not essential but still time sensitive, bare metal stenting (BMS) rather than drug-eluting stents (DESs) (option B) can be used if lesion parameters permit. If DESs are implanted, surgery should also ideally be delayed for 1 year, not 2 years (option C). However, surgery may be considered at 180 days, ...

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