Preoperative Evaluation of the Cardiac Patient
Consult Medicine 2011-2012
1. An 83 year old woman is admitted with a hip fracture and referred to you for
preoperative evaluation. Her medical illnesses are hypertension and chronic atrial
fibrillation. She takes hydrochlorothiazide/triamterene – one daily, amlodipine – 5 mg
daily, and digoxin – 0.125 mg daily. On physical examination her BP is 140/100, heart
rate 90 with an irregular rhythm, and respirations 20. She is obese, has JVD to the angle
of her jaw at 30 degrees, and basilar crackles. There is a faint S3. Her BMP is normal
except for a potassium of 2.8 and a calcium of 11.0 (albumin is 4.0). EKG shows LVH
and atrial fibrillation with a ventricular response of 90. Assuming optimal perioperative
care, what is this patient’s serious perioperative morbidity and mortality from the
cardiovascular standpoint?
A. 0.4%
B. 0.9%
C. 7%
D. 11%
2. Besides replacing this elderly patient’s potassium, what else should be done to improve
this patient’s prognosis at surgery?
A. Advising non-operative treatment because of the high operative risks
B. Delay of 1-2 days before surgery to optimize medical condition
C. Admission to a monitored bed with placement of a pulmonary artery catheter
D. Use of a beta blocker to decrease operative mortality
E. Increase in amlodipine to more effectively control hypertension
3. A 60 year old man is seen in preoperative clinic for medical evaluation prior to a right
femoral-popliteal bypass surgery. He denies any chest discomfort but says his right leg
now hurts at rest, and he cannot walk more than 50 feet without stopping because of the
pain. Up until two months ago he could walk up two flights of stairs slowly but without
pain. He has a history of well-controlled type 2 diabetes mellitus requiring 35 units of
70/30 insulin twice a day, a myocardial infarction three years ago with cardiac
catheterization showing right coronary stenosis of 75%, congestive heart failure with an
echo done two months ago showing 30% ejection fraction and mild mitral regurgitation,
hypertension, a chronic left bundle branch block, and Stage 3 chronic renal insufficiency.
His medications include insulin, aspirin, lisinopril, furosemide, and metoprolol. His
physical examination is remarkable only for normal vital signs, clear lung fields, a
cardiac examination with a II/VI holosystolic murmur at the apex, and trace pedal edema.
BMP reveals blood urea nitrogen of 35 and a creatinine of 2.9 which are stable. CBC
shows only an hematocrit of 34, MCV of 82, and normal white blood count and platelet
count. Previous iron studies were compatible with chronic disease. EKG shows the
continued presence of a LBBB. What additional testing should be done before approving
this patient for surgery.
A. No additional testing is needed
B. Dipyridamole/sestamibi scan
C. Cardiac catheterization
D. Implantation of a cardiac defibrillator and AV sequential pacemaker
4. A 75 year old patient is referred to you one evening from the observation unit for
general medical evaluation prior to a TURP the following morning. He is asymptomatic
except for urinary retention. On physical examination you detect a III/VI late-peaking
systolic ejection murmur at the right second interspace with radiation to the clavicles.
The murmur changes in pitch as you trace it down the left sternal border. There is a
carotid-radial delay. S2 is diminished, carotid upstroke is slow, and there is an S4. LVH
is present on EKG. Surgery under spinal anesthesia is planned for the following
morning. What is the best set of recommendations to make to the surgeon at this time?
A. Delay surgery for at least one day to obtain an echo with Doppler
B. Proceed with surgery but recommend endocarditis prophylaxis
C. Proceed with surgery but recommend general anesthesia
D. Proceed with surgery but recommend continuous IV fluids at 150 cc/hour
5. A 40 year old man is referred to you for preoperative evaluation prior to a left inguinal
hernia repair. He has no symptoms other than occasional bulging and pain at the hernia
site. He has a II/VI systolic ejection murmur best heard at the left lower sternal border
which increases with valsalva and decreases with handgrip. An EKG shows LVH. What
is the one correct observation about this patient’s cardiac condition?
A. An echo is unnecessary because the diagnosis is obvious clinically
B. Use dopamine if hypotension occurs intraoperatively
C. Myocardial infarction is the commonest cardiac complication perioperatively
D. Family members should be evaluated for this patient’s heart condition
E. A pulmonary artery catheter should be placed if general anesthesia is used
6. What are the indications for use of a pulmonary artery catheter in patients undergoing
surgery?
A. CHF with an EF of less than 35%
B. Severe valvular heart disease
C. Myocardial infarction within the last month
D. All of the above
E. None of the above
7. A 55 year old man who needs to undergo lumbar disk surgery is referred for evaluation
of an irregular heartbeat noted on physical examination. He has no symptoms other than
back pain with sciatica. A 24 hour Holter monitor reveals 10,000 PVCs with some
couplets, triplets, and non-sustained ventricular tachycardia. Cardiac physical
examination, TSH, echocardiogram, and dipyridamole-sestamibi testing are normal.
What is the appropriate perioperative management of this patient?
A. Initiation of a continuous esmolol infusion preoperatively and critical care
monitoring for 24 hours postoperatively.
B. Coronary arteriography to detect possible ischemic heart disease.
C. Advise the surgeon there is no increased cardiac risk and to proceed with
surgery.
D. Advise postoperative telemetry for at least 24 hours.
E. Place on oral beta blockers to suppress the palpitations.
8.A. A 74 year old man with hypertension and three-vessel coronary artery disease
undergoes a total knee arthroplasty. He was advised two months ago to have CABS, but
refused. He did agree at that time to having a bare metal stent placed in his 90% stenosed
LAD. His medications include aspirin, metoprolol, amlodipine, and trazodone. His
surgery is uneventful, and he is placed on telemetry because of his precarious cardiac
status. What if anything should be done postoperatively to evaluate for myocardial
injury?
A. No cardiac evaluation should be done unless symptoms occur.
B. Measure troponins in the recovery room and daily times two.
C. Obtain EKG in the recovery room and daily times two.
D. Obtain both troponins and EKGs as noted above.
8B. You elect to check troponins and an EKG, and the initial troponin returns at 3.5 and
the EKG shows only non-specific ST-T wave changes. What is the proper management
at this time (more than one answer is correct) - 12 hours after surgery.
A. Cardiology consultation
B. Cardiac catheterization
C. Fibrinolytic therapy
D. Low molecular weight heparin
E. Unfractionated heparin
F. Aspirin
G. Beta blocker
H. ACE inhibitor
I. Statin
J. Clopidogrel
K. Echocardiogram
L. Dip/Sesta scan
9. Which of the following antihypertensives should be held the morning of surgery to
avoid perioperative hypotension assuming the blood pressure is normal that morning?
A. ACE inhibitors
B. Alpha-blockers
C. Beta blockers
D. Calcium channel blockers
E. None of the above
10. Surgeries are usually delayed in patients whose systolic blood pressure is greater than
180 or diastolic pressure greater than 110. However, surgery may proceed with use of a
quick-acting antihypertensive in what group of patients?
A. Patients with a history of well-controlled hypertension
B. Patients who have no cardiovascular comorbidities
C. Patients younger than age 50
D. Patients with a normal EKG
11. Hypertension and congestive heart failure both occur in the perioperative setting.
What are the two perioperative periods when these complications are most likely to
occur?
A. Induction
B. Intraoperatively
C. Recovery room
D. Two days postoperatively
12. A 50 year old woman with a prosthetic metallic aortic valve must undergo an
abdominal hysterectomy. There is no history of hypertension, diabetes mellitus, CHF, or
stroke. She is currently on 5 mg daily warfarin therapy with an INR of 2.6. How should
her anticoagulation be managed perioperatively? Assume in every case that DVT
prophylaxis will be administered.
A. Hold warfarin until INR falls to < 1.5, operate, and resume oral warfarin dose.
B. Hold warfarin until the INR begins to fall, begin IV heparin to maintain APTT
at 1.5-2.5 times control, and stop the heparin 6 hours preoperatively. Resume IV
heparin along with oral warfarin at 12-24 hours after surgery and continue IV
heparin until the INR is above 2.5.
C. Hold the warfarin until the INR falls to < 1.5 and operate. Start IV heparin 1224 hours postoperatively along with oral warfarin. Stop heparin when the INR is
above 2.5.
D. Hold warfarin until the INR begins to fall, begin therapeutic low
molecular weight heparin, and give the last dose of LMWH 12-16 hours
preoperatively. Resume therapeutic LMWH 12-24 hours postoperatively along
with oral warfarin. Stop LMHW when the INR is therapeutic.
E. Continue the patient on warfarin and perform the procedure laparoscopically so
that anticoagulation will not need interruption.
13. You are called to the recovery room to evaluate a 70 year old woman with new-onset
atrial fibrillation and a ventricular response of 170. Her surgical procedure was resection
of a lung nodule. She is lethargic but does not appear to have chest pain, and her blood
pressure is 110/70. EKG shows no ischemia or infarction. Preoperatively she was on an
ACEI for her hypertension and an SSRI for depression. What are correct statements
about this patient?
A. CABS would predispose to this arrhythmia.
B. Immediate cardioversion should be performed.
C. IV beta blocker is the most appropriate therapy for rate control.
D. IV digoxin is the most appropriate therapy for rate control.
E. IV heparin should be given immediately.
F. IV adenosine triphosphate should be given immediately.
G. Advanced age increases the risk for this arrhythmia
perioperatively.
H. If this patient had been undergoing cardiac surgery, a beta blocker or
amiodarone preoperatively might have prevented this arrhythmia.
I. ACE inhibitor use perioperatively reduces the incidence of this arrhythmia.
14. A 56 year old man with a near obstructing colonic adenocarcinoma is referred for
preoperative evaluation. He admits to dyspnea on exertion after walking about one
block, and on cardiac examination he has a III/VI crescendo-decrescendo murmur best
heard at the right second interspace with radiation to his neck. Carotid upstroke is slow.
Echocardiogram shows severe aortic stenosis with a gradient of 70 mm. What is the best
course of action?
A. Proceed with colonic resection
B. Proceed with aortic valve replacement
C. Perform balloon aortic valvuloplasty and then the colonic surgery
D. Do not perform any surgical procedure and arrange hospice care
E. Perform simultaneous aortic valve replacement and colonic surgery
15. A 38 year old woman with a cholecystectomy planned in one week for symptomatic
gallstones is referred for preoperative evaluation because of a cardiac murmur. She notes
mild dypsnea when doing housework. On examination she has a loud S1, a rumbling
diastolic murmur over the apex, and a harsh third heart sound. What is the most common
perioperative complication?
A. Hypotension
B. Congestive heart failure
C. Atrial fibrillation
D. Systemic embolization
E. Myocardial infarction
16. A 68 year old patient with an AV sequential pacemaker undergoes a right total knee
arthroplasty. During electrocautery use near end of procedure, his heart rate suddenly
accelerates to about 120, and you as the internist performing his preoperative evaluation
are contacted for advice. There has been no excessive blood loss and a stat EKG shows
only a paced tachycardia. What is the most likely explanation?
A.
B.
C.
D.
Reprogramming of the pacemaker induced by the cautery
An anesthesia error resulting in too little sedation
Adaptation of the pacemaker to perceived increased activity
Shutdown of the pacemaker with resumption of the patient’s underlying
rhythm
17. A 45 year old woman with type 2 diabetes mellitus and hypertension is admitted
through the emergency room with a gluteal abscess. She takes hydrocholorothiazide 25
mg daily and atenolol – 50 mg daily along with bid 70/30 insulin. During surgery a fluid
bolus is required to maintain her systolic blood pressure in the 90-100 range. You see her
in the recovery room where her BP is 85/60, RR-16, T-98.8, and heart rate 60. She is
mildly lethargic. Her heart and lung examinations are normal. SaO2 is 99% on 2 liters
BNC. In addition to a fluid bolus and CBC what else is indicated at this time?
A.
B.
C.
D.
E.
Chest X-ray
IV Narcan
Blood cultures
EKG
CT Chest – PE protocol
18. An 82 year old man undergoes emergent surgery for ischemic bowel with about 25
cm of small bowel removed at surgery. He has known congestive heart failure with an
ejection fraction of 35% and takes an lisinopril, furosemide, and spironolactone. He
received several liters of IV fluid in the OR. On examination his blood pressure is now
241/139, pulse is 115, respiratory rate is 28, temperature 99.2, and SaO2 – 91% on 4L
BNC. On examination he is mildly lethargic but is in some discomfort. He has bilateral
crackles to mid- scapulae. Cardiac exam reveals an S3, S4, and tachycardia. In addition
to a stat BMP, EKG, troponins, morphine, and 40 mg furosemide, what other medication
would you consider at this time?
A.
B.
C.
D.
IV enalaprilat
IV diltiazem
IV esmolol
IV hydralazine
19. A 72 year old man comes to you for preoperative evaluation prior to
scheduling a partial colectomy for adenocarcinoma of the colon. He has type 2 diabetes
mellitus requiring insulin therapy. Functional capacity is poor because of osteoarthritis.
There is no history of chest pain, dyspnea, pedal edema, or arrhythmia, but on EKG there
are q waves present in II, III, and AFV. His CXR is normal. What is the best approach?
A.
B.
C.
D.
E.
No further cardiac evaluation prior to surgery
Exercise treadmill testing
Dipyridamole-sesamibi scan and echocardiogram
Initiation of a beta blocker and approval for surgery
Cardiac catheterization
20. If an exercise treadmill test indicates no residual ischemia, how soon is it safe to
perform non-cardiac surgery on a patient with a recent myocardial infarction?
A.
B.
C.
D.
One week
Four to six weeks
Two months
Six months
E. One year
21. A 55 year old man comes for preoperative evaluation prior to a laryngectomy. Four
years ago he had CABG for left main disease. He denies chest pain, dyspnea, or any
palpitations. He is able to climb 2 flights of stairs without a problem. Physical
examination is unremarkable. An EKG unchanged from one year ago shows a LBBB.
What additional testing should be done to evaluate his cardiac status?
A. Echocardiogram
B. Exercise treadmill test
C. Dipyridimole/sestamibi scan
D. Exercise treadmill test with radiopharmaceutical imaging
E. No further cardiac evaluation needed
22. A 75 y.o. man is hospitalized for treatment of a hip fracture incurred when he
fell over his dog. He has known hypertension and coronary disease and had two stents
placed over a year ago. His medications are aspirin, metoprolol, rosuvastatin, and
lisinopril. His hematocrit upon admission was 33.8 with an MCV of 83. His TIBC was
325, serum iron 60, and serum ferritin 197. Stool hemoccult is negative. He goes to
surgery, and a CBC is now pending from the Recovery Room. In the Recovery Room he
denies dyspnea, his BP is 115/75, and his heart rate 82. At what threshold of hemoglobin
should he be transfused?
A. Transfuse now given the expected hemoglobin drop
B. <10
C. <9
D. <8
E. <7
23. A. A 55 y.o. man is referred to preoperative clinic prior to inguinal hernia
repair. His small hernia which was discovered recently causes him occasional discomfort,
but is thus far reducible. He has hypertension, insulin-requiring diabetes,
hyperlipidemia and Class III angina. He is currently on a beta blocker, statin, sustained
release NTG, aspirin, HCTZ, and an ACEI. An EKG is unremarkable. You refer the
patient to Cardiology, and a catheterization is performed. Which one of the following
cath reports would allow you to send the patient to surgery without CABS or PCI.
A. RCA, circumflex, and LAD all have > 70% stenosis
B. Left main artery has > 50% stenosis
C. Two vessel disease with proximal LAD stenosis > 70% and EF < 50%
D. Tight LAD disease alone
E. All of the above require procedural intervention
23. B. The patient is found to have an 80% RCA lesion that proves
symptomatically refractory to an increase in medical therapy. He is interested in having
stent placement. What would be the best recommendation to make?
A. Place drug eluting stent and then approve for hernia repair
B. Place bare metal stent and then approve for hernia repair
C. Perform angioplasy alone and then approve for hernia repair
D. Perform hernia repair and then place drug eluting stent
24. A 63 y.o. man is referred for evaluation of chest discomfort prior to
undergoing a colon resection for adenocarcinoma. His pain is pressure-like, substernal,
related to activity, and is relieved by rest. He has the pain two times per week, and there
is no recent change in severity or frequency. His only other medical illness is poorly
controlled hypertension for which he takes HCTZ, amlodipine, and lisinopril. An EKG
shows LBBB. What is the best non-invasive imaging modality to assess this patient's
chest pain?
A. Dobutamine stress echocardiography
B. Dobutamine myocardial scan
C. Dipyridamole/sestamibi scan
D. Exercise myocardial perfusion imaging
25. Identify the patients who may be sent to surgery without further cardiac
preoperative evaluation or treatment:
A. 82 y.o. with hypertension, Stage III chronic renal disease, T2DM requiring
insulin, congestive heart failure by history, and a remote stroke undergoing cataract
extraction.
B. 68 y.o. with Stage II angina, hypertension, and insulin-requiring diabetes
undergoing open repair of an abdominal aortic aneurysm. He walks a half mile to church
every weekend.
C. 73 y.o. with hypertension, peripheral vascular disease, and a III/VI holosystolic
murmur at the apex radiating to the axilla along with a soft S3. Lungs are clear. She is
able to walk through a large supermarket doing her own shopping. She will undergo a
femoral/popliteal bypass.
D. 81 y.o. with iron deficiency anemia, Class III CHF with known diastolic
dysfunction, Class II angina, and a positive stool hemoccult referred by GI prior to
colonoscopy.
25. The POISE trial discouraged use of beta blockers acutely perioperatively
because of increased mortality rates. The DECREASE IV trial suggested that bisoprolol
might be used safely if started one month preoperatively with heart rate titration to 50-70
beats per minute. According to the revised 2009 ACC/AHA guidelines in which of the
following scenarios can beta blockade be used with potential perioperative mortality
benefit (Class I or IIA)?
A. A 67 y.o. man with a planned open abdominal aortic aneurysm repair. He is
on metoprolol daily for Class II angina.
B. A 72 y.o. woman undergoing femoral/popliteal bypass surgery. She was
experiencing some substernal chest discomfort with ambulation less than one block. She
also has T2 diabetes mellitus and Class III chronic renal disease. Dobutamine stress echo
shows reversible ischemia involving the RCA distribution.
C. A 76 y.o. man who will undergo an elective total hip arthroplasty for DJD. He
has well-controlled hypertension, congestive heart failure with an ejection fraction of
30%, and a history of stroke with minimal residual left hemiparesis.
D. A 67 y.o. man undergoing endovascular repair of an abdominal aortic
aneurysm. He is a heavy smoker (100 pack years) and has well-controlled hypertension.
He does not have DM, stroke, known CAD, or CHF. However, his creatinine is 2.2
attributed to previously uncontrolled hypertension.
E. A 78 y.o. woman with hypertension, Stage III chronic renal disease, history of
stroke, T2DM requiring insulin, and CHF - diastolic dysfunction admitted with a hip
fracture due to a fall at home.