preoperative cardaic evaluation for non cardiac surgery

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Case presentationby

Dr Tariq AlrashidiB1 unit

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40 yrs old philipino man admitted with 1 month H/O dray cough exertional dyspnia , progressive lower limbs and

abdominal wall edema , ?H/O of fever on and off .2 weeks before admission started to have palpitation ,one week before admission the swelling of lower limbs increase and the short of breath become s with minimal efforts later become at rest .On

the day of admission pt developed severe dyspnia and palpitation .

NO H/O chest pain ,no loose motion ,no drug history ,no significant illness or surgical procedure in

the past.

Later on (after pt sablized) he gave H/O???

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Any Q REGARDING HISTORY?

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O/E O/E pt conscious, oriented but

in respiratory distress

BP140/80, HR 200 (AF) , TEMP 39, O2 SAT ON OXYGEN MASK 100%

CONGESTED NECK VEINS , MILD SMOTH SOFT SwELLING ON ANTERIOR ASPECT OF THE NECK .

LOWER LIMBS ,SACRAL AND SCROTAL EDEMA PRESENT

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CHEST : DULNESS OVER THE RT LUNG ON PERCUTION ,DECREASE AIR ENTRY ON THE RT UPTO 2/3 OF THE LUNG, INSPIRSTORY AND EXPIRATORY CREPITATION ALL OVER THE LT LUNG.

HEART: VARIABLE S1 NORMAL S2 NO MURMUR OR ADD SOUND CAN BE HEARED DUE TO RAPID AF.

ABD: SOFT LAX ,SHIFTING DULLNESS POSTIVE

CNS: INTACT .

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WHAT IS THE DDx?

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DDx:1-LT HF CAUSING PULMONARY VENOUS HTN

2-DIFFUSE INTERSTIAL LUNG DISEASE (SARCOID ,PUL FIBROSIS,ARDS,COLLAGEN & VASCULAR DISEASE)

3-PE

4-PRIMARY PHT

5-CYSTIC FIBROSIS,COP , DIFFUSE BRONCHIECTASIS

6-SEVERE HYPERTHYROIDIS

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ADMISION DX WAS RT HF AND RAPID AF WITH CHEST INFECTION.

RXLASIX 40 IV DIGOXIN 1MG GIVEN IN RRCAPOTEN 6.25 MGCLEAXINE S/C

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INVESTIGATIONINVESTIGATION

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ABG:ph 7.30

pco2 5.6

po2 5.2

hco3 20

o2 sat 67

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CARDIAC ENZYMES : NORMAL

RF: 21

CRP: 7

AMYLASE: 51

LDH: 120INDIRECT HAEMAGGLUTINATION TEST FOR SCHISTOSOMIASIS NEGATIVE

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CT CHEST WITH ANGICT CHEST WITH ANGI.. NEGATIVE FOR PULMONARY EMBOLISM

U/S ABD NORMAL

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ECHO (21/5/2009): NORMAL LV

SYSTOLIC FUNCTION EF 60%

NO RWMA

MILD TO MODERAT MR AND LA DILATATION

RT SIDE DILATATION, MILD PA DILATATION , MILD TR , MOD TO SEVERE PHT (69)

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PLUERAL TAPPING DONE

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PLEURAL FLUID BIOCH

LDH:78 U/L

TP :42 G/L

ALB: 21 G/L

GLUCOSE: 8.1 MMOL/L

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BY REQESTIONING THE PT LATER HE GAVE H/O 66 months of wt loss ( 20kg in 6

month) ,increase appetite , nervousness and easy loosing his temper,insomenia and heat intolarence.

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TFT (0n 20/5/2009): TSH 0.01FT4 70.56

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THYROID SCAN: SHOWS DIFFUSELY ENLARGED GLAND WITH NO RETROSTERNAL EXTENSION SEEN . THE LT LOBE SHOWS HOMOGENEOUS UPTAKE OF TRACE WHLE LOWER POLE OF LT LOBE SHOWS PHOTOPENIC AREA IN

THE CENTER. THE PICTURE SUGGESTIVE OF GRAVE’S DISEASE WITH DOMINANT COLD NODULE IN THE CENTER . FNAC RECOMMENDED.

FNAC: FEATURE FAVOUR ABENIGN THYROID ASPIRATE

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ECHO (2/6/2009): NORMAL LV , NORMAL SYST FUNCTION , EF 60%

NO RWMA

NORMAL LA DIMENTION

NORMAL RT SIDE STRUCTRE

MILD MR , NORMAL AV , TRIVIAL TR

PAP 30 mmhg

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FINAL DXFINAL DXSEVERE THYROTOXICOSIS LEADS

TO AF AND PULMONARY HYPERTENSION AND RT HF WITH

RT SIDE MASSIVE PLUERAL EFFUSION AND RT SIDE LUNG

COLLAPSE

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PULMONARY HYPERTENSION IN MEN WITH THYROTOXICOSIS

CASE REPORT

(RESPIRATION JORNAL 2005;72:90-94)

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CASE 1CASE 141 YRS MAN PREVIOUSLY HEALTHY, PRESENTED WITH PALPITATION,DIAPHORESIS DYSPNIA ,BLURED VISION,WT LOS.

O/EO/E PROPTOSIS,LID LAG DIFFUSLY ENLARGED THYRIOD.CARDIO PULMONARY EXAM NORMAL.

IINVESTIGATIONNVESTIGATIONCXR PROMINENT VASCULAR MARKINGTSH<0.05 MN/ML, FT49.18ng/dlTHYROID SCAN CONSIST WITH GRAVE’S DISEASEPFT ..MILD RESTRICTIVE PATTERN

ECHOECHO…DILATED LA, RA AND RV, BUT NORMAL LV,SPAP 57 mmhg.

CTCT PULMONARY ANGIO NEGATIVE FOR PE , COLLAGEN SCREENING NEGATIVE , AND OTHER 2NDRY CAUSES FOR PHT NEGATIVE apt given propylthiouracil,propranolol later treated with radioactive iodine

9MONTHS LATER ECHO DONE SYST PAP36 MMHG9MONTHS LATER ECHO DONE SYST PAP36 MMHG WITH RESOLUTION OF RA AND RV DILATATION AND WITH RESOLUTION OF RA AND RV DILATATION AND NORMAL LV.NORMAL LV.

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CASE 2CASE 268 YRS MALE WITH PEPTIC ULCER ,OA KNEE PRESENT WITH TREMOR, BLURRED VISION, EXERTIONAL DYSPNIA , WIEGHT LOS OVER 3 MONTHS.

O/EO/ELID LAG,TREMOR,THYROMEGALY, NORMAL CARDIOPULMONARY EXAM.INVESTIGATIONINVESTIGATIONTSH 0.05 mu/ml, FT4 3.66 ng/dl .THYRIOD SCAN …GRAVE’S DISEASE, ANTI MICROS AB POSTIVE CXR..NORMALPFT..MILD OBSTRUCTIVE PATTERNECHO… PAP 52 mmhg , DILATED RA,RV AND NORMAL LV.V/Q SCAN NEGATIVEPT NEGATIVE FOR OTHER 2NDRY CUASES OF PHT.

PATIENT GIVEN RAI AND BECOMES ASYMPTOMATIC PATIENT GIVEN RAI AND BECOMES ASYMPTOMATIC ECHO DONE 2 YRS LATER …SYST PAP 32 mmhgWITH ECHO DONE 2 YRS LATER …SYST PAP 32 mmhgWITH NORMALIZED CARDIAC CHAMBERSNORMALIZED CARDIAC CHAMBERS

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Case 3Case 359yrs male h/o htn presented heat intoierance, tremor, diahria,weakness ,palpitation,wt loss over 4 month.

O/EO/ESMOOTH VELVETY SKIN , LID LAG , EXOPH , THYROMEGALY , RT VENTRICULAR HEAVE , AF.INVESTIGATIONINVESTIGATIONTSH 0.11 UM/ML , FT4 51.08 , ANTI MICRISM +VE , ANTI THYROGLOBULIN NEGATIVE.CXR NORMAL , PFT MILD OBST , NO EVEDANCE OF THROMBOEMBOLIC DISEASE.ECHOECHO : SEVERE TR , SPAP 51 MMHG, RA AND RV DILATATION WITH NORMAL LV .

OTHER 2NDRY CUASES OF PHT NEGATIVE.

RXRXPT GIVEN PROPNALOL , DIGOXIN AND WARFARIN TO CONTROL HR, ANTI HYPERTHYROIDISM (PTU) LATER RAI THERAPY.

REPATED ECHO 2 YRS LATER REVEALED SPAP 34 MMHG RESOLUTION OF OTHER CARDIAC ABNORMALITY.

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STUDY PUPLESHED IN JORNAL OF CLINICAL ENDOCRINOLOGY AND

METABOLISM 2006THEY PREFORMED SERIAL ECHO CARDIOGRAPHY EXAMINATIONS ON

75 COSECUTIVE PATIENTS WITH HYPERTHYROIDISM(43+-2 YRS, 47 WOMEN) TO ESTIMATE PULMONARY ARTERY SYSTOLIC PRESSURE

(PASP) , CARDIAC OUTPUT(CO) , TOTAL VASCULAR RESISTANCE (TVR) , LEFT VENTRICULAR FILLING PRESSURE .EXAMINATION PREFORMED AT BASE LINE AND 6 MONTHS AFTER INITIATION OF ANTITHYROID

RX .RESULT WERE COMPARED WITH 35 AGE –SEX- MATCHED HEALTY CONTROLS .

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CONCLUSION IN PATIENTS WITH HYPERTHYRIODISM ANDNORMAL LV SYSTOLIC FUNCTION ,UPTO 47% HAD PHT DUE TO EITHER PAH WITH INCREASE CO (70%) OR PVH WITH ELEVATED LV FILLING PRESSURE (30%).

MOST IMPORTANTLY HYPERTHYRIODISM –RELATED PHTPHT WAS LARGELY ASYMPTOMATIC AND REVERSIBLEREVERSIBLE AFTER RESTORATION TO EUTHYROID STATE.

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FINALYFINALYTHESE CASES SUPPORT FOR HYPERTHYROIDISMHYPERTHYROIDISM AS 2NDRY CAUSE OF PHTPHT .IT IS IMPORTANT TO RECOGNIZE THIS ASSOCIATION SINCE IT IS REVERSIBLEREVERSIBLE And THEREFORE TREATABLEREATABLE CUASE OF PHT .

IT IS RECOMMENDEDRECOMMENDED THAT ALL PATIENTS WITH

DIAGNOSIS OF IDIOPATHIC HFHF BE EXAMINED FOR

TFTTFT IN ORDER TO IDENTIFY HYPERTHYROID SUBJECTS WITH REVERSIBLE MYOCARDIAL DYSFUNCTION.

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THANK UTHANK U