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The following echo was ordered for a murmur in pre-operative evaluation for TKA

 

Notable for diastolic dysfunction and mild concentric LV hypertrophy 

Any further cardiac w/u recommendations pre-op? 

Edited by SCPA

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bad idea to ask specific medical questions on this forum....

 

But

 

EKG

Echo done

Consider perioperative betablockers and stress test based on activity level of the patient - if they are a runner doing 10k's with this EKG unsure of the value of a stress, if they are a 100pk year smoker, every relative has died of AMI < 50 yrs old, and cholesterol is cruddy, well then you know what to do (right, you do know what to do right???)

 

Some of this will also depend on what you have to access to specialty care 

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The echo is fairly innocuous. Most people by the time they hit 70 have diastolic dysfunction. The risk there is for diastolic heart failure (HFpEF) with too much fluids during surgery. 

I agree with ventana. We sometimes clear people for urgent surgery (or minor surgery) on an echo alone, but a stress test is recommended as the person with a bum hip is probably not that active (such that their normal life is not a stress test for them). I'd recommend a Lexiscan nuclear test (or a dobutamine stress echo) be considered.

Edited by UGoLong

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On 3/12/2019 at 8:36 PM, UGoLong said:

The echo is fairly innocuous. Most people by the time they hit 70 have diastolic dysfunction. The risk there is for diastolic heart failure (HFpEF) with too much fluids during surgery. 

I agree with ventana. We sometimes clear people for urgent surgery (or minor surgery) on an echo alone, but a stress test is recommended as the person with a bum hip is probably not that active (such that their normal life is not a stress test for them). I'd recommend a Lexiscan nuclear test (or a dobutamine stress echo) be considered.

Here we go again.   

 

Why always go to a nuc stress.  First get to know the patient.  Are they capable of an ETT.  If so do that.  Stepping to a nuc stress on everyone is fraud in my mind.  In needed.  Not supported by data, exposure to radiation and in general just cards folks overthinking (and over ordering testing). 

 

Now if the patient can’t do an ETT I will be first to order nuc    I have literally had a cards doc order crazy stresses on a guy doing mtb races and 2+ hours of competitive A level racquet ball   Patient finally fired the cards doc, got another one   Did fine with surgery and still doing fine years later   Turns out the overzealous doc owned a catch lab and was known to do thus with all patients    Sorry my band wagon   I will be quiet now     

 

See my my other thread about 6 months ago on this exact topic.  

 

 

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Gotta add one thing. 

 

For those that do preop evals.  Please read review and learn UpToDate sections on how to do them.  Commonly people do way to much.  Simply talking, figuring out surgery  reviewing data. Is all that is needed.  

There is no evidence that ore operative cath and stent placement on asymptomatic active folks does anything but make money and sentence the patients to a lifetime of accessing care.  First the stent.  Then plavix then the Er.  Then the follow up.  Then the recath. Blah blah blah.  

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6 hours ago, ventana said:

Here we go again.   

 

Why always go to a nuc stress.  First get to know the patient.  Are they capable of an ETT.  If so do that.  Stepping to a nuc stress on everyone is fraud in my mind.  In needed.  Not supported by data, exposure to radiation and in general just cards folks overthinking (and over ordering testing). 

 

Now if the patient can’t do an ETT I will be first to order nuc    I have literally had a cards doc order crazy stresses on a guy doing mtb races and 2+ hours of competitive A level racquet ball   Patient finally fired the cards doc, got another one   Did fine with surgery and still doing fine years later   Turns out the overzealous doc owned a catch lab and was known to do thus with all patients    Sorry my band wagon   I will be quiet now     

 

See my my other thread about 6 months ago on this exact topic.  

***

I know you have a bug about nucs, having interacted with you on the thread you mention. My point here on this particular thread wasn't to rush to order one but to recognize that people who need total hips (the case presented here) or total knees are generally NOT currently active marathoners or competitive racquetball players. And it often hurts like crap for them to even try to exercise. Add in some risk factors and the patient ends up needing an evaluation.

If the patient can't exercise (as in many THR cases), the fallback evaluation would be a chemical stress test -- like with dobutamine -- which certainly should be considered. From a practical standpoint, these can take a lot of clinician time (I've done many of them) in that the patients often need a kicker of atropine and then sometimes yet another injection of metoprolol after the test is over. Compared with that, the 4 minute Lexiscan nuclear stress test is often less stressful for the patient and it takes way less clinician time (I've done a fair number of these, too).

Going with a nuc for a relatively sedentary patient (due to hip pain) is not an instant indication of fraud or contraindicated by data. And it bothers me greatly to see my specialty painted with that particular brush as I know it would pain you to have yours similarly labelled.

Now I'll hop off of my soap box, too.

 

 

Edited by UGoLong

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I know you have a bug about nucs, having interacted with you on the thread you mention. My point here on this particular thread wasn't to rush to order one but to recognize that people who need total hips (the case presented here) or total knees are generally NOT currently active marathoners or competitive racquetball players. And it often hurts like crap for them to even try to exercise. Add in some risk factors and the patient ends up needing an evaluation.

If the patient can't exercise (as in many THR cases), the fallback evaluation would be a chemical stress test -- like with dobutamine -- which certainly should be considered. From a practical standpoint, these can take a lot of clinician time (I've done many of them) in that the patients often need a kicker of atropine and then sometimes yet another injection of metoprolol after the test is over. Compared with that, the 4 minute Lexiscan nuclear stress test is often less stressful for the patient and it takes way less clinician time (I've done a fair number of these, too).

Going with a nuc for a relatively sedentary patient (due to hip pain) is not an instant indication of fraud or contraindicated by data. And it bothers me greatly to see my specialty painted with that particular brush as I know it would pain you to have yours similarly labelled.

Now I'll hop off of my soap box, too.

 

 

The patient I was referencing was for a total hip!  just because a joint needs replacing does not mean the person can not move. In this case he was highly mobile and giving himself a great stress test 2-4 times per week with maximal effort on the court and bike.  My point is apply the guidelines, don't just default to the nuc because you can and it provides pretty pictures.  I have also seen more then one person (many) get cath'ed of a ? nuc - to have a normal cath oh those "attenuation errors or possibly ischemi$" lines kill me......

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