70-year-old man for open AAA. 6cm supra-renal aneurysm. Asymptomatic
- Carotid Disease – under surveillance. No CVA/TIA
- Non-hodgkins lymphoma
- Recent angiogram in Private hospital – chronic occlusion of RCA with collaterals. Mild to moderate LAD disease.
- Works as a cleaner. DASI 7.6 MET’s
- Non-specific infero-lateral ST depression (1mm) on baseline ECG
- Peripheral vascular Disease – aorto-iliac stents. Not suitable for EVAR
- Complex surgery
- Current Smoker – 28 pack year history. Normal Spirometry
- Chronic Renal Impairment – Stage 2a
- Sub-maximal test – HRmax152 (80%pred). Limited by assessor due to ECG changes.
- Up-sloping infero-lateral ST depression during exercise
- 1mm ST depression during recovery
- No chest pain/dyspnoea
- Patient happy to continue exercising.
- Peak VO2 = 1.5ml/kg/min
- AT 10.3ml/kg/min
- Nadir VE/VCO2 36.4
- HRR = 11bpm
- Requested due to sub-maximal CPET and ECG changes
- Reversible ischaemic changes in mid basal-inferior wall
- Reduced ejection fraction (40%) post-stress
Urgent cardiology appointment via Rapid Access clinic
- Angiogram obtained from Private hospital (As Above)
- Sestamibi should be interpreted in the context of a chronically occluded RCA
- No angina despite good exercise tolerance
- Echocardiogram – normal LV systolic function and no regional wall motion abnormalities
- Nil further interventions required.
Increased risk of cardiovascular and renal complications
- RCRI 3 – 15% risk of MI, cardiac arrest, or death within 30 days of surgery
- Vascular Quality Initiative index:
- Existing renal impairment, supra-renal clamp, and predicted, complex surgery – increased risk of post-operative renal failure requiring long-term dialysis
- Discussed with surgeon and procedural anaesthetist – decision made to bring patient and family back to clinic for shared-decision making.
- Convey increased risks outlined above and allow for family discussion before proceeding.