| NEEDS STATEMENT
As the population ages and elderly patients and their families
seek to improve the quality and length of life via surgery, the
prevalence of heart disease in surgical patients will likely
increase. Improvements in the medical therapy of patients with
chronic coronary artery disease and congestive heart failure may
mean that such patients come to surgery better prepared than in
the past. Recent guidelines from the American College of
Cardiology/American Heart Association (ACC/AHA) address preventive
measures, including the management of antiplatelet medications and
pharmacologic protection with β-blockers,
statins, and aspirin. Anesthesiologists are critically involved in
the preanesthetic preparation of such patients and the
implementation of these therapies, and thus they should be aware
of the current thinking.
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| CASE HISTORY A
63-year-old woman presented for left femoral–popliteal
bypass surgery. Her medical history was significant for
peripheral vascular disease, poorly controlled
insulin-dependent diabetes, and end-stage renal disease
requiring hemodialysis. Ambulation had been difficult for
the past 3 months, and she was unable to climb stairs or
walk more than half a block. A stress test 18 months
earlier showed no ischemic changes and an absence of
arrhythmias, in addition to normal wall motion with an
ejection fraction of 74%. She denied symptoms of coronary
ischemia. Results of preoperative laboratory tests
included hemoglobin, 8.6 g/dL; hematocrit, 25.1%;
potassium, 4.5 mEq/L; blood urea nitrogen, 22 mg/dL;
creatinine, 5.9 mg/dL; and normal coagulation. She was
receiving antibiotics, insulin (both regular and lente,
dosed on a sliding scale), furosemide, and
hydrochlorothiazide. Vital sign measurements were blood
pressure, 139/60 mm Hg; pulse, 72 beats per minute;
respiratory rate, 36 breaths per minute; and SpO2, 95% on
room air. She weighed 98 kg; physical examination findings
were otherwise unremarkable.
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LEARNING OBJECTIVES
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At the end of this activity, the participant should be able to:
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Stratify
patients according to their risk for perioperative
cardiovascular events by using appropriate risk factors.
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Estimate the
risk of surgical patients for perioperative cardiovascular
events.
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Stratify
patients based on their functional status.
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Use the
ACC/AHA algorithm to determine which patients may require
noninvasive testing before surgery.
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Appropriately
schedule patients for elective noncardiac surgery following
the placement of bare- metal/drug-eluting stents.
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Review the
indications for coronary revascularization via percutaneous
coronary intervention (PCI) or coronary artery bypass graft
(CABG) surgery.
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Review the
risks and benefits of coronary revascularization before
noncardiac surgery.
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Discuss
current findings regarding cardiac outcomes after
noninvasive stress testing versus preoperative evaluation.
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Discuss why
the assessment of cardiac patients may differ nationally.
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Describe the
pathophysiology of perioperative and nonsurgery-related
cardiac ischemic events.
TARGET AUDIENCE: Anesthesiologists
INSTRUCTIONS FOR COMPLETING THIS COURSE
The estimated time to complete this activity is 2 hours. There
are two options for completing this CME activity.
Option 1: Exam Only. This option can only be
exercised by subscribers to Anesthesiology News who possess
a material copy of the course. Participants who select this
option must read the article in the journal, reflect on the information
presented, and then register to complete the exam and course evaluation
online before December 31, 2008. (CME credit is not valid past this
date.)
To register for the exam only, click on the Register For Exam link
located at the bottom of this page. DO NOT select this option if you
do not possess a material copy of the CME course material.
There are ten questions in the examination and you must achieve
a score of 80% or better to earn CME credit. Following successful
completion, your certificate will be immediately available online.
In addition, a historical record of completed CME courses is
maintained online in an individualized profile. This includes
copies of course certificates which can be printed at any time.
Option 2: Course Material and Exam. All participants
are eligible for this option.
You must first register for this course by clicking the "Register
for Course" link located at the bottom of this page. Course
material is presented in small digestible sections followed by exam
questions pertaining to the information in the segment covered.
As you read through the material on the course pages, you will occasionally
be prompted to answer exam questions.
There are several short pages of information and 10 multiple choice
questions presented in this course. You must achieve a minimum
grade of 80% (8 correct answers) to receive CME credit. The exam and
course evaluation must be completed before December 31, 2008. (CME
credit is not valid past this date.)
The course software does not permit you to page back from the exam
questions. You must be sure that you understand the material
presented on each page before proceeding.
When you have answered the last exam question, the Course Results
page will display. This page will contain your final grade and allow
you to immediately view/print your Certificate if you have achieved
the minimum passing score of 80%.
Upon successful completion, your Certificate will be available
at all times from your Student Control Panel. In addition,
a historical record of completed CME courses is maintained online
in an individualized profile. This includes copies of course
certificates which can be printed at any time.
The course does not need to be completed in a single online session.
You can log off at any point and return to the course at your convenience.
If you wish to obtain more information regarding the features of this
site, you may visit the Orientation page.
Click here to view Orientation.
REGISTRATION
The registration fee for this course is $15.00
Physicians are provided with two opportunities to complete the
course presented here.
Accreditation Statement
Mount Sinai School of Medicine is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Credit Designation: The Mount Sinai School of Medicine designates
each educational activity for a maximum of 2 AMA PRA Category 1 CreditsTM.
Physicians should only claim credit commensurate with the extent of
their participation in the activity.
It is the policy of Mount Sinai School of Medicine to ensure objectivity,
balance, independence, and scientific rigor in all CME-sponsored educational
activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any
relevant financial relationships and to assist in resolving any conflict
of interest that may arise from the relationship. Presenters must
also make a meaningful disclosure to the audience of their discussions
of unlabeled or unapproved drugs or devices.
Disclosures
The authors, reviewer, and editor have no relationships with
pharmaceutical companies or manufacturers of products to disclose.
This educational activity may contain discussion of published
and/or investigational uses of agents for the treatment of
disease. Some uses of these agents have not been approved by the
FDA. Please refer to the official prescribing information for each
product for approved indications, contraindications, and warnings.
CONTACT INFORMATION
Questions regarding course content may be directed to Dr. Elizabeth
Frost: ElzFrost@aol.com.
If you require technical assistance with completing this
course, please contact Continuing Education Online Customer Service
at 718-648-8080 or send e-mail to
CEO.support6@proceo.com.
All other requests for administrative assistance should be directed
to Josephine Greene in the CME office at the Mount Sinai School of
Medicine : 212-241-4441 or send email to
Josephine.Greene@msnyuhealth.org
CALL FOR WRITERS
If you would like to write a CME lesson in Anesthesiology News,
please send an e-mail to Elizabeth A.M. Frost, MD, at
ElzFrost@aol.com
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This option is for the examination
ONLY. No course material is provided. This option
is available for subscribers of Anesthesiology News who
possess a material copy of the course material. DO NOT select
this option if you do not have the course material. |
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This option is available for all participants. This option
includes a full online text version of the course material and
exam. |
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