Pre-operative assessment

• Standard investigations: ECG, CXR, Bloods
• Risk stratification, based on
  • Exercise tolerance (METs – need at least 4 to tolerate GA)
  • History of recent cardiac ischaemia
  • Stability of cardiac symptoms
• HIGH risk patients
  • Exercise stress test (EST) – must pass before surgery
    • IF FAILED –> Sestamibi scan to check for reversible ischaemia (& then revascularise pre-op)
  • IF EST failed, and MIBI negative, cardiac risks make them a poor candidate for surgery – explore conservative options
• Pre-operative Echo (TTE) & optimisation of LV function

Pre-operative management

• Control HTn
• Control arrhythmias
• Management of antiplatelet agents for drug-eluting stents
  • Elective surgery: delay 4-6 weeks after bare metal stent insertion
    • If possible, delay a full 180 days
    • DEFINITELY delay 180 days after drug-eluting stent

Intraoperative management

• Invasive monitoring as a precaution (art line, PAC etc)
• Maintain normotension
• Consider epidural anaesthesia

Post-operative management

• ICU/HDU monitoring post-op
• consider delayed extubation
• post-operative support with vasopressors / inotropes
• Post-operative complication monitoring and management specific to the condition