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Perioperative Care of the Orthopedic Patient with Cardiac Disease

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Perioperative Care of the Orthopedic Patient

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Abstract

The goal of this chapter is to assist the cardiac care of a patient undergoing orthopedic surgery. The preoperative cardiac evaluation includes assessing the risk of the orthopedic procedure and determining the appropriate interventions to minimize that risk. The chapter discusses commonly encountered cardiac conditions and their management in the perioperative setting. A discussion of the more commonly encountered cardiac complications of orthopedic surgery is also included.

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References

  1. Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennereci MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid J, Sellevold OFM, Sicari R, den Berghe GV, Vermassen F. Guidelines for pre-operative cardiac risk assessment and peri-operative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30:2769–812.

    Article  PubMed  Google Scholar 

  2. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.

    Article  CAS  PubMed  Google Scholar 

  3. Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn JD, Baars HF, Yo TI, Trocino G, Vigna C, Roelandt JR, van Urk H. The effect of bisoprolol on peri-operative mortality and myocardial infarction in high risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluating Applying Stress Echo Study Group. N Engl J Med. 1999;341:1789–94.

    Article  CAS  PubMed  Google Scholar 

  4. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The prognostic value of exercise capacity: a review of the literature. Am Heart J. 1991;122:1423–31.

    Article  CAS  PubMed  Google Scholar 

  5. Biccard BM. Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery; implications for the preoperative assessment of functional capacity. Anesthesia. 2005;60:588–93.

    Article  CAS  Google Scholar 

  6. Wiklund RA, Stein HD, Rosenbaum SH. Activities of daily living and cardiovascular complications following elective, noncardiac surgery. Yale J Biol Med. 2001;74:75–87.

    CAS  PubMed Central  PubMed  Google Scholar 

  7. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB. A brief self administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651–4.

    Article  CAS  PubMed  Google Scholar 

  8. Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Pina IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104:1694–740.

    Article  CAS  PubMed  Google Scholar 

  9. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845.

    Article  CAS  PubMed  Google Scholar 

  10. Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, Schinkel AF, van Santen M, Simoons ML, Thomson IR, Klein J, van Urk H, Poldermans D. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med. 2005;118:1134–41.

    Article  PubMed  Google Scholar 

  11. Ackland GL, Harris S, Ziabari Y, Grocott M. Revised cardiac risk index and postoperative morbidity after elective orthopaedic surgery: a prospective cohort. Br J Anaesth. 2010;105:744–52.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  12. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel R, Robb JR. ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary. J Am Coll Cardiol. 2007;50:1707–32.

    Article  PubMed  Google Scholar 

  13. Noorzij PG, Boersma E, Bax JJ, Feringa HH, Schreiner F, Schouten O, Kertai MD, Klein J, van Urk H, Elhendy A, Poldermans D. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol. 2006;97:1103–6.

    Article  Google Scholar 

  14. Kertai MD, Boersma E, Bax JJ, Heijenbrok-Kal MH, Hunink MG, L’Talien GJ, et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart. 2003;89:1327–34.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Etchelis E, Meade M, Tomlinson G, et al. Semiquantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a metaanalysis. J Vasc Surg. 2002;36:534–40.

    Article  Google Scholar 

  16. Shaw LJ, Eagle KA, Gersh BJ, et al. Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery. J Am Coll Cardiol. 1996;27:787–98.

    Article  CAS  PubMed  Google Scholar 

  17. Elhendy A, Valkema R, van Domburg RT, et al. Safety of dobutamine-atropine stress myocardial perfusion scintigraphy. J Nucl Med. 1998;39:1662–6.

    CAS  PubMed  Google Scholar 

  18. Nandalur KR, Dwamena BA, Choudhri AF, et al. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2007;50:1343–53.

    Article  PubMed  Google Scholar 

  19. Rerkpattanapipat P, Morgan TM, Neagle CM, Link KM, et al. Assessment of perioperative cardiac risk with magnetic resonance imaging. Am J Cardiol. 2002;90:416–9.

    Article  PubMed  Google Scholar 

  20. Hamon M, Biondi-Zoccai GG, Malagutti P, et al. Diagnostic performance of multi-slice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol. 2006;48:1896–910.

    Article  PubMed  Google Scholar 

  21. Tsimikas S, Willerson JT, Ridker PM. C-reactive protein and other emerging blood biomarkers to optimize risk stratification in vulnerable patients. J Am Coll Cardiol. 2006;47(8 Suppl):C19–31.

    Article  CAS  PubMed  Google Scholar 

  22. Wang TJ, Larson MG, Levy D, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med. 2004;350:655–63.

    Article  CAS  PubMed  Google Scholar 

  23. Bibbins-Domingo K, Gupta R, Na B, et al. N-terminal fragment of the prohormone brain type natriuretic peptide (NT-proBNP), cardiovascular events, and mortality in patients with stable coronary heart disease. JAMA. 2007;297:169–76.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  24. Ferrringa HHH, Bax JJ, Elhendy A, et al. Association of plasma N-terminal pro-B-type natriuretic peptide with postoperative cardiac events in patients undergoing surgery for abdominal aortic aneurysm or leg bypass. Am J Cardiol. 2006;98:111–5.

    Article  Google Scholar 

  25. Dernellis J, Panaretou M. Assessment of cardiac risk in noncardiac surgery: brain natriuretic peptide in 1590 patients. Heart. 2006;92:1645–50.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  26. Cuthbertson BH, Card G, Croal BL, et al. The utility of B-type natriuretic peptide in predicting postoperative cardiac events and mortality in patients undergoing major emergency noncardiac surgery. Anaesthesia. 2007;62:875–81.

    Article  CAS  PubMed  Google Scholar 

  27. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371:1839–47.

    Article  CAS  PubMed  Google Scholar 

  28. van Lier F, Schouten O, Hoeks SE, et al. Impact of prophylactic beta-blocker therapy to prevent strokes after noncardiac surgery. Am J Cardiol. 2010;105:43–7.

    Article  PubMed  Google Scholar 

  29. Mnagano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996;335:1713–20.

    Article  Google Scholar 

  30. Brady AR, Gibbs JS, Greenhalgh RM, et al. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg. 2005;41:602–9.

    Article  CAS  PubMed  Google Scholar 

  31. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006;152:983–90.

    Article  CAS  PubMed  Google Scholar 

  32. Bangalore S, Wetterslev J, Pranesh S, et al. Perioperative B-blockers in patients having noncardiac surgery: a meta-analysis. Lancet. 2008;372:1962–76.

    Article  CAS  PubMed  Google Scholar 

  33. Beattie WS, Wijeysundera DN, Karkouti K, et al. Does tight heart rate control improve beta blocker efficacy? An updated analysis of the noncardiac surgical randomized trials. Anesth Analg. 2008;106:1039–48.

    Article  CAS  PubMed  Google Scholar 

  34. Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized controlled clinical trial. Br J Anaesth. 2010;104:305–12.

    Article  CAS  PubMed  Google Scholar 

  35. Burger W, Chemnitius JM, Kneissl GD, et al. Low dose aspirin for secondary cardiovascular protection-cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation-review and meta-analysis. J Intern Med. 2005;257:399–414.

    Article  CAS  PubMed  Google Scholar 

  36. POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370:1494–503.

    Article  Google Scholar 

  37. Costerga M, Voors AA, Pinto YM, et al. Effects of quinapril on outcome after coronary artery bypass grafting (the QUO VADIS Study). QUinapril on Vascular Ace and Determination of Ischemia. Am J Cardiol. 2001;87:542–6.

    Article  Google Scholar 

  38. Wijeysundera DN, Beattie WS. Calcium channel blockers for reducing cardiac morbidity after noncardiac surgery: a systematic review. Anesth Analg. 2003;97:634–41.

    Article  CAS  PubMed  Google Scholar 

  39. Coriat P, Daloz M, Bousseau D, et al. Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous nitroglycerine. Anesthesiology. 1984;61:193–6.

    Article  CAS  PubMed  Google Scholar 

  40. Oliver MF, Goldman L, Julian DG, et al. Effect of mivazerol on perioperative cardiac complications during noncardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT). Anesthesiology. 2004;101:284–93.

    Article  Google Scholar 

  41. Wijeysundera DN, Naik JS, Beattie WS, et al. Alpha-2 adrenergic agonists to prevent perioperative cardiac complications: a meta-analysis. Am J Med. 2003;114:742–52.

    Article  CAS  PubMed  Google Scholar 

  42. POISE-2 Investigators. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370:1504–13.

    Article  Google Scholar 

  43. Schouten O, Boersma E, Hoeks S, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361:980–9.

    Article  CAS  PubMed  Google Scholar 

  44. Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39:967–75.

    Article  PubMed  Google Scholar 

  45. Hindler K, Shaw AD, Samuels J, et al. Improved post-operative outcomes associated with preoperative statin therapy. Anesthesiology. 2006;105:1260–72.

    Article  CAS  PubMed  Google Scholar 

  46. McFalls EO, Ward HB, Moritz TE, et al. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795–804.

    Article  CAS  PubMed  Google Scholar 

  47. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a non-invasive approach in high risk patients undergoing major vascular surgery: the DECREASE V Pilot Study. J Am Coll Cardiol. 2007;49:1763–9.

    Article  PubMed  Google Scholar 

  48. Gottlieb A, Banoub M, Sprung J, et al. Perioperative cardiac morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty. J Cardiothorac Vasc Anesth. 1998;12:501.

    Article  CAS  PubMed  Google Scholar 

  49. Brilakis ES, Orford JL, Fasseas P, et al. Outcome of patients undergoing balloon angioplasty in the two months prior to noncardiac surgery. Am J Cardiol. 2005;96:512.

    Article  PubMed  Google Scholar 

  50. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing noncardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42:234.

    Article  PubMed  Google Scholar 

  51. van Kujik JP, Flu WJ, Schouten O, et al. Timing of noncardiac surgery after coronary artery stenting with bare metal or drug eluting stents. Am J Cardiol. 2009;104:1229–34.

    Article  Google Scholar 

  52. Eagle KA, Rihal CS, Mickel MC, et al. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. Circulation. 1997;96:1882–7.

    Article  CAS  PubMed  Google Scholar 

  53. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence Based Clinical Practice Guidelines. Chest. 2008;133(6 Suppl):299S–339.

    Article  CAS  PubMed  Google Scholar 

  54. Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, Klein J, Roelandt JR, Poldermans D. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004;116(1):8–13.

    Article  PubMed  Google Scholar 

  55. Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol. 1998;81(4):448–52.

    Article  CAS  PubMed  Google Scholar 

  56. Sohn GH, Dae Hee S, Byun KM, et al. The incidence and predictors of postoperative atrial fibrillation after non-cardiothoracic surgery. Korean Circ J. 2009;39:100–4.

    Article  PubMed Central  PubMed  Google Scholar 

  57. Kahn RL, Hargett MJ, Urquhart B, Sharrock NE, Peterson MG. Supraventricular tachyarrhythmias during total joint arthroplasty: incidence and risk. Clin Orthop Relat Res. 1993;296:265–9.

    PubMed  Google Scholar 

  58. Hollenberg SM, Dellinger RP. Noncardiac surgery: postoperative arrhythmias. Crit Care Med. 2000;28(Suppl):N145–50.

    Article  CAS  PubMed  Google Scholar 

  59. Mayson SE, Greenspan AJ, Adams S, et al. The changing face of postoperative atrial fibrillation prevention: a review of current medical therapy. Cardiol Rev. 2007;15:231–41.

    Article  PubMed  Google Scholar 

  60. Vaporciyan AA, Correa AM, Rice DC, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg. 2004;127:779–86.

    Article  PubMed  Google Scholar 

  61. Conwell C, Kamienski M, Memtsoudis S. Risk factors of new onset atrial fibrillation in the noncardiac orthopedic patient. 2011. Capstone Project Title.

    Google Scholar 

  62. Kowey PR, Stebbins D, Igidbashian L, et al. Clinical outcomes of patients who develop PAF after CABG surgery. Pacing Clin Electrophysiol. 2001;24:191–3.

    Article  CAS  PubMed  Google Scholar 

  63. Crystal E, Thorpe KE, Connolly SJ, et al. Metoprolol prophylaxis against postoperative atrial fibrillation increases length of hospital stay in patients not on preoperative beta blockers: the beta blocker length of stay (BLOS) trial. Heart. 2004;90:941–2.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  64. Chong CP, van Gaal WJ, Savige J, et al. Cardiac injury and troponin testing after orthopedic surgery. Injury. 2011;42:855–63.

    Article  PubMed  Google Scholar 

  65. Urban MK, Jules-Elysee K, Loughlin C, et al. The one year incidence of postoperative myocardial infarction in an orthopedic population. HSS J. 2008;4:76–80.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  66. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36:959–69.

    Article  CAS  PubMed  Google Scholar 

  67. Jules-Elysee K, Urban MK, Urquhart B, et al. Troponin I as a diagnostic marker of postoperative myocardial infarction in the orthopedic population. J Clin Anesth. 2001;8:556–60.

    Article  Google Scholar 

  68. Devereaux PJ, Goldman L, Yusuf S, et al. Surveillance and preservation of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ. 2005;173:779–88.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  69. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis of the hazards on discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27:2667–74.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Cardiovascular Disease, Hospital for Special Surgery, 407 East 70th Street, New York, NY, 10021, USA

    Lawrence F. Levin

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  1. Lawrence F. Levin
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Correspondence to Lawrence F. Levin .

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Editors and Affiliations

  1. Department of Medicine, Hospital for Special Surgery, New York, New York, USA

    C. Ronald MacKenzie

  2. Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA

    Charles N. Cornell

  3. Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA

    Stavros G. Memtsoudis

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Levin, L.F. (2014). Perioperative Care of the Orthopedic Patient with Cardiac Disease. In: MacKenzie, C., Cornell, C., Memtsoudis, S. (eds) Perioperative Care of the Orthopedic Patient. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-0100-1_11

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  • DOI: https://doi.org/10.1007/978-1-4614-0100-1_11

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