• Cardiac
• 3 METS: 100 yards
  4 METS: 2 flight of stairs
  6 METS: Short run
  7 METS: digging in the garden
  10 METS: Strenuous exercise
• 1 MET is about 3ml/kg/min
• CPEX: an AT of <11ml/kg/min is associated with poor cardiac outcome. 4 METS is about 14ml/kg/min
• Goldman Cardiac Index (1977)
• Third heart sound (11)
  Elevated JVP (11)
  MI in past 6 months (10)
  ECG not in S/R or premature contractions (7)
  ECG > 5 premature ventricular contractions (7)
  Age > 70 (5)
  Emergency procedure (4)
  Intra-thoracic, intra-abdominal/aortic surgery (3)
  Poor general status or bedridden (3)
• Score > 25 = 56% chance of death and 22% incidence of severe cardiovascular complications
• Lee's Revised Cardiac Risk Index (1999)
• (CCCCHD)
  Coronary artery disease (1)
  CCF (1)
  Creatinine > 177 (1)
  CVD (1)
  High-risk surgery (1)
  Diabetes on insulin (1)
• Risk of PE, MI, CHB, cardiac arrest
  0 = 0.4%
  1 = 0.9%
  2 = 6.6%
  3 = 11%
• High risk surgery
  Emergency procedures
  Aortic and major vascular procedures
  Long operations
  Operations with large fluid shifts
• Intermediate risk surgery
  Minor vascular procedures
  Orthopaedic surgery
  Head and neck surgery
  Prostate surgery
  Intra-peritoneal surgery
  Intra-thoracic procedures
• Low risk procedures
  Endoscopic procedures
  Superficial surgery
  Plastic and reconstructive surgery
  Breast surgery
  Eye surgery
• American Heart Association Guidelines
• Major Predictors
  1. MI or coronary intervention within 60 days
  2. Unstable or severe angina
  3. Decompensated CCF
  4. Significant arrhythmias
  5. Severe valvular disease
• Intermediate Predictors
  1. MI over 30 days
  2. Mild angina
  3. Compensated CCF
  4. Diabetes
  5. Renal insufficiency
• Minor Predictors
  1. Age >70
  2. Abnormal heart rhythm
  3. HT
  4. Cerebrovascular disease
  5. Hyperlipidaemia
  6. Smoker
• Heart Failure Severity:
  Normal - EF 60-80%
  Mild impairment - 40-50%
  Moderate impairment - 30-40%
  Severe impairment - < 30%
• NYHA Classification
  I = No symptoms or limitation in normal physical activity
  II = Mild symptoms (SOB/angina) during ordinary activity
  III = Marked limitation during less than ordinary activity (e.g. Walking short distances). Comfortable only at rest.
  IV = Severe limitations, symptoms while at rest.
• PPM nomenclature
  1. Paced (AVD)
  2. Sensed (AVDO)
  3. Response to sensing (IT)
  4. Programmability (O = none, C = communicating, P = programmable, M = multiprogrammability, R = rate modulation)
  5. Anti-tachycardia function (O = none, P = pacing, S = shocks, D = dual)
• Aortic regurgitation
• Acute
• Dissection
  SABE
• Chronic
• RhF
  Syphilis
  Connective tissue diseases
  Congenital (bicuspid valves)
  Inflammatory diseases (e.g SLE)
• Mitral valve is normally 4-6th sq
  Mild: 1.6-2.5 cm sq
  Moderate: 1.1-1.5 cm sq
  Severe < 1 cm sq
• Aortic stenosis
  1. Critical: <0.6 cm sq
  2. Severe: 0.6-0.8 cm sq
  3. Moderate: 0.8-1.2 cm sq
  4. Mild: 1.2-1.8 cm sq
  Normal valve area = 2.5-3.5 cm sq
• Symptom Triad
  1. Angina
  2. Syncope
  3. Dyspnoea
• Gradient 40-50 mmHg = moderate
  > 50 mmHg = severe
• Haemodynamic obstruction occurs at about 1cm sq or less valvular area
• Cardiomyopathies
  1. Dilated cardiomyopathy (DCM)
  2. Hypertrophic cardiomyopathy (HCM)
  3. Restrictive cardiomyopathy (RCM)
  4. Arrhythmogenic RV cardiomyopathy (ARVCM)
  5. Left ventricular non-compaction (LVNC)
• Hypertension
• Endocrine causes
• Cushing's
  Conn's
  Hypothyroidism
  Phaeochromocytoma
• Renal causes
• RAS
  GN
  PCKD