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Case report

Perioperative management of high-risk cardiovascular patients in abdominal surgery

Ana Anđelković1, Stefan Tanasić1
  • University Clinical Center of Serbia, Emergency Center, Department of Anesthesiology and Resuscitation, Belgrade, Serbia

ABSTRACT

Introduction: The preparation of cardiovascular patients for different types of surgical interventions represents a challenge in an anesthesiologist’s everyday practice. Its complexity depends on the severity of the underlying disease, the effects of the drug treatment, urgency, and the type of surgical intervention. Different types of scoring systems are available when it comes to the assessment of cardiovascular risk in patients during surgery. One of them, Revised Cardiac Risk Index (RCRI/Lee criteria), stands out due to its comprehensiveness and simplicity, and is thus applied most frequently. Using the example of two patients with cardiovascular disease, the aim of this paper is to show how the risk of perioperative complications can be reduced by applying a multidisciplinary approach, along with an individualized strategy and modern guidelines.

Case reports: In the first case, we presented a patient with acute appendicitis. Because of angina pectoris, one month prior to the planned abdominal surgery, Percutaneous Coronary Intervention was performed placing one stent, after which dual antiplatelet drugs were prescribed.

A patient with acute cholecystitis is presented in the second case. Coronary artery bypass grafting is planned within a month upon the abdominal surgery, due to a severe form of ischemic cardiomyopathy. Both patients are at high risk of myocardial damage during surgery, the first patient being at high risk of hemorrhage as well.

Conclusion: The appropriate balance in the perioperative care of such patients can be achieved by a multidisciplinary approach, as well as by adapting modern guidelines to patients’ individual needs.


INTRODUCTION

In everyday clinical practice, preparing a patient for surgical treatment is not an easy task. The presence of comorbidities, the urgency of surgical intervention, and the need for additional diagnostic procedures can affect the course of the treatment. There is a constant increase in the number of individuals suffering from cardiovascular disease worldwide due to lifestyle, chronic exposure to stressful situations, as well as aging populations. Achievements in pharmacotherapy follow the trend of an ever-increasing number of patients.

It is believed that around 5% of the world population undergoes some sort of surgical intervention every year, with a tendency of a constant increase in the number of patients [1],[2]. Of these, 85% of interventions do not belong to the field of cardiovascular surgery [2].

So, what should be done with a patient who suffers from cardiovascular disease, who is treated with the latest generation of anticoagulant drugs and who needs surgical intervention? Should a high-risk cardiovascular patient be additionally prepared for elective surgery?

Using two examples, we will try to present problems related to high-risk cardiovascular patients and their perioperative care, as well as the impact of adequate and timely risk assessment, adherence to guidelines and a multidisciplinary approach to such patients on reduced risk of perioperative complications. RCRI, a method for cardiac risk assessment, was used for patient evaluation, while the guide of the European Association of Anesthesiologists (Preoperative evaluation of adults undergoing elective noncardiac surgery) published in 2018 and the guide of the European Association of Cardiologists (ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery) published in 2022 were used as the basis of preoperative preparation of patients.

CASE PRESENTATION

Case 1

A 49-year-old male, BMI=25,7 kg/m2 , was admitted to the Emergency Room of the University Clinical Centre of Serbia for acute appendicitis. He denies any previous history of allergies and reports the following chronic diseases: arterial hypertension (HTA), angina pectoris (AP), hyperlipoproteinemia (HLP), and gout, which is why he is on regular therapy with ACE inhibitors, beta blockers, statins, and uricostatics. One month prior to admission, after coronary angiography, one stent (PCI LAD proximal Resolute Onyx 4,0x22mm) was placed, after which dual antiplatelet therapy with acetylsalicylic acid (ASA) and ticagrelor (P2Y12 ADP receptor platelet inhibitor) was introduced.

In preoperative laboratory analyses, high levels of inflammatory markers were present (WBC 16.0 x109 /L, CRP 142mg/L, PCT 0.12ng/ml), whereas the platelet count was 301x109 /L. The effect of the antiplatelet therapy was evaluated using point-of-care testing to examine platelet aggregation (the Multiplate test). The values of ASPI (947) and ADPHS (201) indicated a positive therapeutic effect of ticagrelor on platelet functions, whereas there was no effect of ASA. The RCRI score in this patient was 1.

As part of the preoperative preparation, the patient was examined by a cardiologist, and in cooperation with a clinical transfusion specialist a perioperative bleeding treatment strategy was developed including systemic and local antifibrinolytics, as well as platelet transfusion in case of acute bleeding.

Six hours upon hospital admission, after preoperative preparation, appendectomy was performed using the laparoscopic surgical technique and balanced general anesthesia (BGA). Basic respiratory and hemodynamic monitoring (SpO2, EtCO2 , ECG, NIBP) was used and no hemodynamic instability was recorded during the operation. Shortly before surgery, tranexamic acid had been prescribed (TXA), in a dose of 30 mg/kg, and since blood loss during surgery was minimal, the proposal to apply local hemostatics (fibrin sealant, TXA) at the sites of surgical incisions was abandoned.

There were no complications during the laparoscopic surgery, and the patient who was extubated and hemodynamically stable was first transferred to the recovery room and then to the surgery department.

Following lab analyses, multiplate findings and monitoring of abdominal drains (which were empty), and in cooperation with a cardiologist, the patient was prescribed 100 mg of ASA per day 12 hours upon surgery, and 90 mg of ticagrelol twice a day 24h later. No episodes of hemodynamic instability or acute coronary events were recorded during the postoperative course. He was discharged from the hospital on the second postoperative day, after oral intake was introduced and normal peristalsis established.

Case 2

A 67-year-old male, BMI= 27,8 kg/m2 , was admitted to the Clinic for Emergency Surgery of the University Clinical Centre of Serbia for acute cholecystitis. Six days before the admission, the patient had been discharged from the Clinic for Cardiology where the Cardiosurgical council had found indications for surgical myocardial revascularization. During his stay at the Clinic for Cardiology, selective coronary angiography and echocardiography were performed as part of a cardiac evaluation.

The results of coronary angiography were as follows: RCA occluded proximally, Cx with 90-99% stenosis, 50% stenosis in the proximal LAD, and 50-70% in its mid portion. Echocardiography revealed EF of 40% with signs of left ventricular (LV) diastolic disfunction, hypokinesia/akinesia of ½ left ventricular inferior wall (LVIW) and scarring in the basal part of LVIW. The patient denies any previous history of allergies. He reports the following comorbidities: diabetes mellitus (he has been on oral antidiabetic therapy for 15 years), hypertension (HTA), and cardiomyopathy (CMP) treated with ACE inhibitors, beta blockers, diuretics, antianginal drugs (trimetazidine), and acetylsalicylic acid (ASA). Due to hyperlipoproteinemia (HLP), he has been on regular statin therapy, whereas he uses his therapy for chronic obstructive pulmonary disease (COPD) irregularly.

Considering the performed preoperative examinations and diagnostics, the greatest attention was focused on the risk of perioperative myocardial ischemia, so monitoring of cardiospecific enzymes was done during the patient’s hospitalization. The preoperative RCRI score was 3.

Classical cholecystectomy was performed in general endotracheal anesthesia (GETA), with basic respiratory and hemodynamic monitoring. The surgery was uneventful, with minimal blood loss, and intraoperative hypertension was controlled by intravenous glyceryl trinitrate solution. The patient was extubated after the surgery, he was hemodynamically stable and first transferred to the recovery room and then to the semi-intensive care unit. Pre-operative troponin level was 15ng/L, its trend was followed for 24h and 48h after surgery and it was 19 ng/L and 11 ng/L, respectively. The patient’s condition was good during the postoperative course, so he was discharged from the hospital on the sixth day upon surgery.

DISCUSSION

Revised Cardiac Risk Index (RCRI) is a simple method for cardiac risk assessment which relies on six parameters: 1) high-risk surgery, 2) history of ischemic heart disease, 3) congestive heart failure, 4) cerebrovascular diseases, 5) diabetes mellitus – insulin therapy, 6) renal failure (Cr ≥2.0mg/dL) (Table 1). Each parameter is worth one point, and it is considered that the overall value of all parameters ≥ 2 represents an increased risk of postoperative cardiac events [2],[3]. (Table 2). Although there are various scoring systems for cardiovascular risk assessment, we have decided on the RCRI as the most comprehensive system in assessing highrisk cardiovascular patients in abdominal surgery.

Table 1. Revised Cardiac Risk Index-Lee Criteria

Table 1. Revised Cardiac Risk Index-Lee Criteria

Table 2. Interpretation of risk score

Table 2. Interpretation of risk score

A number of factors influence an increase in cardiac risk during the surgical treatment of a patient – the urgency of surgical intervention, the type of surgical technique, drug therapy, the evaluated functional capacities of the patient, etc. When it comes to the category of noncardiac surgery, according to the type of surgical intervention, interventions can be classified as those with low, intermediate, and high risk of perioperative bleeding. Abdominal surgeries belong to the group of intermediate-risk procedures [2].

For example, it is typical that patients who have undergone percutaneous coronary intervention (PCI) with stent placement are prescribed dual antiplatelet therapy. In case of a necessary surgical intervention, such a patient is at an increased risk of adverse coronary events in the first month upon the performed PCI [2],[4]. The gold standard in evaluating the effect of antiplatelet therapy is reflected in the application of standard laboratory analyses, and following the time profile from the last taken dose of the drug to the time of the surgical intervention. ASA’s plasma half-life is only 20 minutes, but the effect of the medication is present for 7-10 days after the last dose. When it comes to ticagrelol, which is one of our patient’s prescribed medications, its plasma half-life is 6-12h, and its effect is present for 3 to 5 days after the last dose [2]. In conditions where the inflammatory response of the organism is activated, the effect of a drug on platelet functions may be impaired. This is when the point-of-care method, Multiplate test, can be of help in the assessment. By combining standard laboratory tests and the pointof-care method, a good assessment of perioperative bleeding can be obtained, as well as the residual effect of the applied therapy. Nowadays, Multiplate test is routinely applied, but in cases where it is not available, clinicians most often rely on standard laboratory analyses and the "therapeutic window" since the last dose of the drug. In cases of urgent surgical interventions, according to the assessment of the degree of perioperative bleeding and guided by the available data on how often regular therapy is used, we are governed by the application of transfusion therapy, as well as the available range of hemostatic drugs (desmopressin, antifibrinolytics, recombinant activated factor VII, fibrinogen concentrate, prothrombin complex concentrate, activated prothrombin complex, etc.).

Myocardial injury during noncardiac surgery (MINS) is perioperative myocardial ischemia caused by an imbalance between myocardial oxygen needs and the delivery of oxygen to the myocardium, i.e., type 2 myocardial damage [2],[5],[6].

The degree of damage correlates with an increase in high-sensitive (hs) serum troponin-T. The VISION study showed that an increase in the levels of hsT >20ng/L, i.e., a 5ng/L-increase compared to preoperative levels followed for three days upon surgery, was a good predictor of 30-day mortality after noncardiac surgery [2],[7].

The type of surgical technique (classical open surgery or laparoscopic surgery), and the type of anesthesia (GETA or regional anesthesia) affect the cardiovascular status during the perioperative period. Laparoscopic surgery is related to frequent changes in the patient’s position on the operating table, and the technique itself involves "creating" the pneumoperitoneum by CO2 insufflation. Due to transient iatrogenic Abdominal Compartment Syndrome, during laparoscopy, there is a decrease of blood flow to the heart (pre-load), an increase in systemic vascular resistance, and central venous pressure, which can affect reduced perfusion through the coronary blood vessels [8]. Therefore, this is not the most popular technique in a patient with previously verified coronary artery disease.

CONCLUSION

Treating a surgical patient who suffers from cardiovascular disease may be highly challenging for a clinician. The risk of potential bleeding, cardiac risk assessment, and the strategy of applying cardiovascular therapy during the postoperative period are some of the problems an anesthesiologist faces on a daily basis.

A real balance may be achieved by a multidisciplinary approach of a surgeon, a cardiologist, a clinical transfusion specialist, and an anesthesiologist, and nowadays a great emphasis is also placed on adapting modern guidelines to individual patient needs.

  • Conflict of interest:
    None declared.

Informations

March 2024

Pages 89-95
  • Keywords:
    cardiovascular patient, abdominal surgery, Lee Criteria, myocardial injury
  • Received:
    10 January 2024
  • Revised:
    01 February 2024
  • Accepted:
    27 February 2024
  • Online first:
    25 March 2024
  • DOI:
  • Cite this article:
    Anđelković A, Tanasić S. Perioperative management of high-risk cardiovascular patients in abdominal surgery. Serbian Journal of the Medical Chamber. 2024;5(1):89-95. doi: 10.5937/smclk5-48642
Corresponding author

Ana Anđelković
Department of Anesthesiology and Resuscitation, Emergency Center, University Clinical Center of Serbia
2 Pasterova Street, 11000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015 Apr 27;385 Suppl 2:S11. doi: 10.1016/S0140-6736(15)60806-6. [CROSSREF]

2. Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, et al; ESC Scientific Document Group. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022 Oct 14;43(39):3826-924. doi: 10.1093/eurheartj/ehac270. [CROSSREF]

3. Roshanov PS, Walsh M, Devereaux PJ, MacNeil SD, Lam NN, Hildebrand AM, et al. External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study. BMJ Open. 2017 Jan 9;7(1):e013510. doi: 10.1136/bmjopen-2016-013510. [CROSSREF]

4. De Hert S, Staender S, Fritsch G, Hinkelbein J, Afshari A, Bettelli G, et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2018 Jun;35(6):407-65. doi: 10.1097/EJA.0000000000000817. [CROSSREF]

5. Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, et al. Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association. Circulation. 2021 Nov 9;144(19):e287-e305. doi: 10.1161/ CIR.0000000000001024. [CROSSREF]

6. Ellenberger C, Schorer R, Diaper J, Jeleff A, Luise S, Hagermann A, et al. Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial. Surgery. 2022 Jun;171(6):1626-34. doi: 10.1016/j. surg.2021.10.029. [CROSSREF]

7. Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, et al; Writing Committee for the VISION Study Investigators. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30- day mortality among patients undergoing noncardiac surgery. JAMA. 2017 Apr 25;317(16):1642-51. doi: 10.1001/jama.2017.4360. [CROSSREF]

8. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascular and ventilatory consequences of laparoscopic surgery. Circulation. 2017 Feb 14;135(7):700-10. doi: 10.1161/CIRCULATIONAHA.116.023262. [CROSSREF]


REFERENCES

1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015 Apr 27;385 Suppl 2:S11. doi: 10.1016/S0140-6736(15)60806-6. [CROSSREF]

2. Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, et al; ESC Scientific Document Group. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022 Oct 14;43(39):3826-924. doi: 10.1093/eurheartj/ehac270. [CROSSREF]

3. Roshanov PS, Walsh M, Devereaux PJ, MacNeil SD, Lam NN, Hildebrand AM, et al. External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study. BMJ Open. 2017 Jan 9;7(1):e013510. doi: 10.1136/bmjopen-2016-013510. [CROSSREF]

4. De Hert S, Staender S, Fritsch G, Hinkelbein J, Afshari A, Bettelli G, et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2018 Jun;35(6):407-65. doi: 10.1097/EJA.0000000000000817. [CROSSREF]

5. Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, et al. Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association. Circulation. 2021 Nov 9;144(19):e287-e305. doi: 10.1161/ CIR.0000000000001024. [CROSSREF]

6. Ellenberger C, Schorer R, Diaper J, Jeleff A, Luise S, Hagermann A, et al. Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial. Surgery. 2022 Jun;171(6):1626-34. doi: 10.1016/j. surg.2021.10.029. [CROSSREF]

7. Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, et al; Writing Committee for the VISION Study Investigators. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30- day mortality among patients undergoing noncardiac surgery. JAMA. 2017 Apr 25;317(16):1642-51. doi: 10.1001/jama.2017.4360. [CROSSREF]

8. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascular and ventilatory consequences of laparoscopic surgery. Circulation. 2017 Feb 14;135(7):700-10. doi: 10.1161/CIRCULATIONAHA.116.023262. [CROSSREF]

1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015 Apr 27;385 Suppl 2:S11. doi: 10.1016/S0140-6736(15)60806-6. [CROSSREF]

2. Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, et al; ESC Scientific Document Group. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022 Oct 14;43(39):3826-924. doi: 10.1093/eurheartj/ehac270. [CROSSREF]

3. Roshanov PS, Walsh M, Devereaux PJ, MacNeil SD, Lam NN, Hildebrand AM, et al. External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study. BMJ Open. 2017 Jan 9;7(1):e013510. doi: 10.1136/bmjopen-2016-013510. [CROSSREF]

4. De Hert S, Staender S, Fritsch G, Hinkelbein J, Afshari A, Bettelli G, et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2018 Jun;35(6):407-65. doi: 10.1097/EJA.0000000000000817. [CROSSREF]

5. Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, et al. Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association. Circulation. 2021 Nov 9;144(19):e287-e305. doi: 10.1161/ CIR.0000000000001024. [CROSSREF]

6. Ellenberger C, Schorer R, Diaper J, Jeleff A, Luise S, Hagermann A, et al. Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial. Surgery. 2022 Jun;171(6):1626-34. doi: 10.1016/j. surg.2021.10.029. [CROSSREF]

7. Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, et al; Writing Committee for the VISION Study Investigators. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30- day mortality among patients undergoing noncardiac surgery. JAMA. 2017 Apr 25;317(16):1642-51. doi: 10.1001/jama.2017.4360. [CROSSREF]

8. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascular and ventilatory consequences of laparoscopic surgery. Circulation. 2017 Feb 14;135(7):700-10. doi: 10.1161/CIRCULATIONAHA.116.023262. [CROSSREF]


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