NSTEMI March ’20, PCI, converted to single antiplatelet therapy after 12/12
Admitted recently with unstable angina, possible lateral t wave changes but no trop rise. No angiographic findings suggesting revascularisation required. Some very distal LCA territory disease.
Recommenced on DAPT.
Ongoing daily GTN for angina at rest.
TTE shows mild apical hypokinesis and mildly reduced EF.
? Anti-Phospholipid syndrome
Patient diagnosed at one stage as positive
Further review by different haematologist and repeat results suggest patient does not have APL syndrome
Should surgery proceed?
GP encouraging patient to delay surgery, await further cardiologist review in 3/12
Cardiologist says patient may proceed with surgery now, happy for w/h of clopidogrel
Perioperative revascularisation reserved for lesions with a significant vascular territory (left main disease) or symptomatology. ? revasc not being offered despite daily symptoms, as not amenable to stenting.
Non-cardiac cause of chest pain due to essentially normal TTE in the setting of daily rest pain (e.g., recurrent PEs due to APL syndrome)
Non-anatomical cause for coronary ischaemic pain e.g., coronary artery thromboses from APL syndrome
ISCHEMIA trial showed that even with moderate to severe obstructive lesions, routine invasive therapy was not associated with a reduction in major adverse cardiac events compared to optimal medical therapy. (See attached article)
Patient leaning towards delaying surgery (which seems sensible from a purely elective surgery perspective) however, unlikely that anything will change before cardiology review to further guide the decision.
If surgery does proceed, patient may be a good candidate for postoperative troponin testing.
Confusing picture with alternate haematologist views
Is perioperative Tranexamic acid safe? Brief literature search suggests, and group consensus was, that TXA use is not associated with increased risk of VTE in this setting.
? impact on stent thrombosis risk
Patient currently postponing surgery
When/if surgery planned in future, formal discussion with current haematologist to ensure that the APL issue has been fully elucidated
Further discussion with treating cardiologist to guide postoperative monitoring/investigations given his IHD.
72yo male for gastroscopy and colonoscopy due to upper GIH and obstructive colonic symptoms
Presumed sarcoidosis (hasn’t attended F/U) with mediastinal adenopathy
? metastatic lung malignancy. Previous effusion (? parapneumonic) drainage showed no malignant cells. Effusion now recurred. Nodules in lungs stable on repeat CT.
Severe cardiac disease
TTE 2021 (in context of admission for anaemia) Severely dilated left ventricle with severe RWMAs. EF 26%. Moderately dilated right ventricle with moderate systolic dysfunction. Moderate AS and AR. Mild to moderate MR. Moderately dilated atria.
Last TTE May 2021 – mildly dilated LV with severe global systolic dysfunction, severely dilated LA (volume 53mls/m2), well-seated mechanical mitral valve, severe pulmonary HTN (PASP 68), moderate TR, mild AR, EF 19%
Current inpatient with CCF exacerbation
Recent reduction in exercise tolerance
Referred to ED from perioperative clinic with SpO2 80% after 20m walk. NYHA class 4 dyspnoea.
Should surgery proceed?
Life expectancy? Is he likely to die from his aneurysm or his cardiorespiratory comorbidities first (rupture rate for 6.7cm AAA is ~ 20% per year)
EVAR is a low physiologic stress procedure.
Need clear documentation of ceilings of care (i.e., not for open procedure in emergency or if complications from EVAR)
GA may facilitate faster procedure and less IV contrast use (protecting from renal injury) due to improved immobility.
Can be done under LA/sedation if patient can lie flat/still and cooperate with breath holds
Await outcome of current admission and liaise with surgical team (who are aware of admission)