A 68-year-old woman is referred for perioperative risk evaluation prior to breast implant removal. The patient was diagnosed with breast cancer 16 years ago and underwent left mastectomy, chemotherapy, and radiation, followed by breast reconstruction surgery. Recently, hardening developed around the implant, and she would like to have the implant removed. The patient has a history of a mild reduction in cardiac function that was first identified after she completed chemotherapy. Five years ago, she developed chest pain while walking on the golf course and was diagnosed with coronary artery disease requiring drug-eluting stent placement to the left anterior descending artery. Two years ago, she experienced an episode of facial droop and garbled speech that she was told may have been a transient ischemic attack. The patient's last echocardiogram was 6 months ago and showed a mildly dilated left ventricle with an ejection fraction of 40%-45% and mild mitral regurgitation. She walks up the stairs at a slow pace and sometimes stops to rest on the landing, but she thinks this may be because she has been sedentary and gained weight over the last couple of years. The patient has noticed no recent change in symptoms. She has a 20-pack-year smoking history but quit at the time of her breast cancer diagnosis. Blood pressure is 134/78 mm Hg and pulse is 65/min. BMI is 36 kg/m². Physical examination shows a normal jugular venous pressure. There is a soft pansystolic murmur at the apex. Lung fields are clear on auscultation. No peripheral edema is present. Basic preoperative laboratory studies are significant only for a creatinine of 1.2 mg/dL. ECG shows sinus rhythm and nonspecific T-wave changes. Which of the following is the best preoperative management for this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_be59_a846_8f63_6504bd0e7408_MD0005_00 Determining perioperative cardiovascular risk requires consideration of the type of surgery being performed as well as the clinical comorbidities and functional status of the patient. The level of risk associated with the particular noncardiac surgery should be considered first; patients undergoing low-risk surgeries (eg, breast or cataract surgery) have <1% risk of experiencing cardiac death or nonfatal myocardial infarction (MI). In the absence of acutely active cardiac disease (eg, decompensated heart failure, unstable angina), patients undergoing these low-risk surgeries require no further cardiac workup regardless of underlying comorbidities. For intermediate- or high-risk surgeries, patients should be evaluated using a validated prediction model such as the Revised Cardiac Risk Index (RCRI). Moderate- or high-risk patients (ie, with an estimated risk of cardiac death, nonfatal cardiac arrest, or nonfatal MI >1%) may need additional evaluation depending on their functional status: Those able to perform >4 metabolic equivalents (METs) of activity (eg, brisk walking, climbing 2 flights of stairs) generally do not require additional evaluation, but those with poor functional status (exercise capacity <4 METs) are recommended to undergo further evaluation prior to surgery. Revised Cardiac Risk Index (RCRI) (Choice B) A recommendation for nonoperative management may be appropriate for proposed high-risk surgery in a patient with extensive comorbidities (eg, coronary artery disease, insulin-dependent diabetes, renal insufficiency). However, low-risk surgeries are associated with low risk of significant cardiac events regardless of underlying comorbidity. (Choices C, D, and E) This patient has left ventricular systolic dysfunction with mild mitral regurgitation and a history of ischemic heart disease, leading to an estimated cardiac risk of 2.4% based on the RCRI. She also has a reduced exercise capacity of <4 METs (sometimes unable to climb 2 flights of stairs). Therefore, stress testing (eg, exercise ECG, myocardial perfusion imaging) or repeat echocardiogram to assess for a cause of her reduced exercise capacity would be appropriate if she were planning to undergo intermediate- or high-risk surgery. These tests are not necessary for low-risk surgery. Educational objective: Assessment of a patient's perioperative cardiac risk depends on the risk associated with the proposed surgery as well as the patient's underlying comorbidities and functional capacity. Low-risk surgeries (eg, breast or cataract surgery) carry <1% risk of significant cardiac events and, in the absence of acutely active cardiac disease (eg, decompensated heart failure, unstable angina), do not require preoperative cardiac workup regardless of underlying comorbidities. References: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/25091544)

A 68-Year-Old Woman Is Referred for Perioperative Risk Evaluation Prior