75 yo with oesophageal cancer

Background:

• HTN
• AF – CHADS-VASC 4
• Binge drinker
• Ex-smoker
• NIDDM
• Epilepsy – absence seizures

Discussion:

• BP in clinic – 192/70
• Discussed at CPET group – not taking medications as has no regular GP
• Spirometry: Mild airflow obstruction, post BD change 28%. Consistent with asthma.
• CPET – Peak VO2 low at 15.2ml/kg, AT 7.7ml/kg/min. T depression inferolaterally towards peak exercise.
• Maximal stress test: HRmax – 85% predicted. This patient reached 82% predicted, RER – 1.15. This patient – 1.12. RER (VCO2/VO2)
• Ventilatory reserve – MVV=FEV1x35, should have at least 20% reserve. Patient has encroached on his ventilatory reserve. HR also raised at this time which could suggest SV limitation. Note patient has not been taking bronchodilators.
• NAC – surgery planned for 8 weeks post NAC. Concern that patient will significantly decompensate with chemo
• Borderline – alcohol intake – unwilling to cut-down. Weight loss, non-compliant with medications
• Social issues – no car, may not be able to participate in prehab, from isolated area
• Prehab – multiple options. Dr Jen Mackney co-ordinates via CPET MDT and periop clinic. This patient would be better suited to a supervised program. 

Plan

• Restart antihypertensives and bronchodilators
• Formal stress imaging
• Prehab and re-test preoperatively before deciding if fit for surgery.