PIG Meeting: 8th April 2021

Referral letter from a general surgeon requesting an urgent perioperative consult for a 63-year-old man with ascending colon cancer.

Daily angina and history of PCI sometime in the last 10 years

Background

• PCI for coronary artery disease in last 10 years
• No regular cardiology follow-up
• No anti-platelet therapy and never been on DAPT
• Daily exertional angina after walking 20-30 metres and after meals
• IDDM
• Morbid obesity

Issues

• Urgent surgery
• Consult letter is concerning that patient is high risk and not optimally managed
• More information is required in order quantify perioperative risk

Discussion

• Patient should be referred for stress imaging
• Discussion around different modalities of stress imaging. Little evidence to suggest superiority, both nuclear imaging and stress echo have high NPV for post op cardiac events.
• Stress echo investigation of choice by cardiologists but not easy to obtain in our district, especially in an urgent setting
• CTCA discussed, non-invasive test, better predictive value in younger people with decreased calcium load
• CTA vision study showed that CTCA over-estimated risk of MACE compared with RCRI. (paper attached)
• Discussion around benefits vs risks of PCI in the setting of urgent surgery.
• May not be possible to delay surgery for 3- 6 months if coronary intervention required
• Newer DES require shorter duration of DAPT
• Need to consider that PCI may not confer a clinical benefit unless a LAD lesion with large areas of myocardium affected

Plan

• Urgent perioperative consult
• Sestamibi and resting echocardiogram
• Referral to rapid access cardiology clinic already underway from surgical team
• Can also be discussed at weekly cardiology meeting