Anestesia cardiovascular en cirugía no cardiaca / Cardiovascular anesthesia in noncardiac surgery

Clinical evaluation remains one of the main issues while considering anesthetic and surgical risk. Different scores for cardiac evaluation in non-cardiac surgery are traditionally based on the exclusion of active cardiac conditions, the risk of surgery, the functional capacity of the patient and the presence of specific cardiac risk factors. In recent decades, new guidelines incorporate an association between cardiac biomarkers and adverse cardiac events. For the management of coronary patients receiving double antiplatelet therapy, derived for non-cardiac surgery, the risk of stent thrombosis, the consequences of delaying the surgical procedure and the risk of bleeding must be considered. At this moment, there is no evidence regarding which is the best anesthetic management that decreased peri-operative cardiovascular complications in this group of patients. This article refers to the differences in preoperative assessment for non-cardiac surgery incorporated in the guidelines of the American College of Cardiology, the American Heart Association, the European Society of Cardiology and the Canadian Cardiovascular Society. Consideration are also given to the management of coronary patients on double antiplatelet therapy and its main complications as well as intraoperative management maneuvers that may decrease cardiovascular complications.

La valoración clínica sigue siendo uno de los pilares fundamentales en la evaluación del riesgo anestésico-quirúrgico. Los scores de riesgo para la evaluación cardiovascular y cirugía no cardíaca se basan tradicionalmente en la exclusión de condiciones cardíacas activas, la determinación del riesgo de cirugía, la capacidad funcional del paciente y la presencia de factores de riesgo cardíaco. En las últimas décadas, nuevas guías incorporan una asociación entre los biomarcadores cardiacos y los eventos cardiacos adversos. Para el manejo de pacientes coronarios en tratamiento antiagregante doble, derivados a cirugía no cardiaca, hay que considerar el riesgo de trombosis del stent, las consecuencias de retrasar el procedimiento quirúrgico y el aumento del riesgo de hemorragia. Hasta la fecha no existe evidencia acerca de cuál es el mejor manejo anestésico que disminuya las complicaciones cardiovasculares perioperatorias en este grupo de pacientes. Este artículo, hace referencia a las diferencias de la valoración preoperatoria para cirugía no cardiaca incorporados en las guías del American College of Cardiology, la American Heart Association, la European Society of Cardiology y la Canadian Cardiovascular Society. Algunas consideraciones acerca del manejo de pacientes coronarios, terapia antiplaquetaria dual y eventuales complicaciones. Se incluyen algunas estrategias farmacológicas, así como consideraciones específicas para el perioperatorio, con el fin de reducir morbilidad de origen cardiovascular.

Early oncological outcomes and accuracy of risk stratification and tailoring surgical staging based on preoperative histology, Ca125 and MRI in endometrial cancer: a prospective cohort study

Background: momentum to select patients who will benefit from the extensive procedures. However, the parameters used for risk stratification have variable accuracy outside of tertiary cancer centres. This study looks into the accuracy of risk stratification using preoperative histology, MRI and Ca 125 levels and the oncological outcomes after tailoring surgical staging based on the risk stratification by combining the three variables in a suburban centre with a growing cancer population.Methods: This prospective observational cohort study was undertaken in a suburban cancer center in Pushpagiri Medical College, Tiruvalla, Kerala between June 2014 and December 2018. All patients underwent surgical staging with hysterectomy and salpingo oophorectomy as the least procedure. Lymphadenectomy was tailored according to the preoperative risk grouping and changed only in the presence of gross findings at surgery. Adjuvant treatment and follow up data obtained and collected in Microsoft Excel and analysed using statistical software SPSS version 22.Results: Of 47 patients recruited for the study, 35 patients were available for final analysis. Preoperative histology was accurate in 73%. There was 20 % overestimation and 8% underestimation. Ca 125 levels were elevated in 15%.  MRI had an overall sensitivity of 74% and specificity of 60%. When MRI, Ca125 and histology were combined together, there was patients were deemed to be high risk. On final risk grouping, 9 patients were down staged and none were upstaged.Conclusions: Preoperative histology, MRI and ca 125 levels have moderate accuracy individually as preoperative risk determinates. The three parameters combined together show high specificity and PPV for preoperative risk stratification and the risk stratification has not been detrimental with respect to oncological outcomes of recurrence.

Coronary computed tomography angiography for risk stratification before noncardiac surgery.

Background: Currently, there are limited available data for coronary computed tomography angiography (CCTA) in the setting of the risk stratification before noncardiac surgery. The main purpose of this study is to investigate the role of CCTA in cardiac risk stratification before noncardiac surgery. Materials and Methods: Ninety‑three patients underwent CCTA in the assessment of cardiac risk before noncardiac surgery. Patients with normal or mildly abnormal CCTA (<50% stenosis) underwent surgery without any further testing (Group 1). Patients with abnormal CCTA (17 patients) (more than 50% stenosis) and nondiagnostic CCTA (5%) underwent either stress myocardial perfusion scintigraphy or conventional coronary angiography, Group 2. Results: Group one consists of 71 patients who went for surgery without any further testing. 59 of 71 (83%) patients had no complications in the postoperative period, 9 patients had noncardiac complications, 1 had a cardiac complication (new onset atrial fibrillation), and 2 patients died in the postoperative period due to noncardiac complications. Group 2 comprises 22 (26%) patients, 16 patients had no postoperative complications, 5 patients had noncardiac complications, and one patient developed postoperative acute heart failure. Conclusions: CCTA is diagnostic in up to 95% in the preoperative setting, and it provides a comprehensive cardiac examination in the risk stratification before intermediate and high‑risk noncardiac surgery. Therefore, CCTA may be considered as an alternative test for already established imaging techniques for preoperative cardiac risk stratification before noncardiac surgery.