AFP Journal Review March 1, 2007
Articles • Preparation of the Cardiac Patient for Noncardiac Surgery • Autoimmune Polyglandular Syndrome, Type II • Iron Deficiency Anemia • Asbestos-Related Lung Disease • Erythema Nodosum
Strength of Recommendation Grades • A – Consistent, good quality patient oriented evidence • B – Inconsistent or limited quality patient oriented evidence • C – Consensus, disease oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening
Preparation of the Cardiac Patient for Noncardiac Surgery • 20-40% of patients at high risk of cardiac-related morbidity develop MI perioperatively. • In 2002 ACC/AHA revised its evidence based guidelines. • Available for PDA - STAT Cardiac Clearance, www.statcoder.com/cardiac1.htm
2002 ACC/AHA Guidelines • Evaluation depends on: • Patient-specific risk factors • Surgery-specific risk factors • Exercise capacity. • Emergency surgery OR • Recent cardiac evaluation (< 6 months in a stable pt) or revascularization and no change in symptoms OR
Clinical Predictors • Major (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease) • Intermediate (mild angina, prior MI, compensated HF, DM, RF) • Minor (age > 75 yrs, abnormal EKG, non-sinus rhythm, low functional capacity, history of CVA, uncontrolled HTN)
Cardiac Risk Stratification for Noncardiac Surgery • High (risk > 5%) – Emergent operations in pts > 75 yrs, major vascular surgery, prolonged surgeries associated with large fluid shifts and/or blood loss. • Intermediate (risk 1-5%) – CEA, Head and neck, intraperitoneal and intrathoracic, orthopedic, prostate surgery. • *Low (risk < 1%) – Endoscopy, superficial, cataracts, breast surgery. * Generally do not require further pre-op cardiac testing
Minor or no clinical predictors Clinical predictors Moderate or excellent (> 4 METs) Functional capacity Poor (<4 METs) High surgical risk procedure Intermediate or low surgical risk procedure Surgical risk Noninvasive testing Low risk OR Post-op risk stratification and risk factor reduction High risk Consider angiography Subsequent care dictated by Findings and tx results
Intermediate clinical predictors Clinical predictors Moderate or excellent (> 4 METs) Functional capacity Poor (< 4 METs) Low risk procedure High risk procedure Intermediate Risk procedure Surgical risk Noninvasive testing Low risk OR High risk Post-op risk stratification and risk factor reduction Consider angiography Subsequent care dictated by findings tx results
Major clinical predictors Consider delay or Cancel surgery Consider angiography Subsequent care dictated by findings and treatment results Medical management and risk factor modification
Other Guides to Assess Cardiac Risk • Goldman criteria • Detsky’s clinical risk index • Lee’s revised cardiac risk index • All available for PDA with MedRules
SORT: Key Recommendations • Beta blockers should be given perioperatively to patients with known ischemic heart disease undergoing vascular surgery or who have previously taken beta blockers. – A • Beta blockers generally are NOT recommended for patients with low to moderate risk of peri-operative cardiovascular complications. – B
SORT: Key Recommendations • Statin use is associated with a reduction in perioperative risk in patients with preexisting CAD, although randomized trial data are lacking. – B • Alpha2-agonists such as clonidine (Catapres) are a possible alternative to beta blockers to reduce perioperative risk of cardiac complications in high-risk patients. – B
Autoimmune Polyglandular Syndrome, Type II • Combination of • Autoimmune Adrenal Insufficiency • Autoimmune Thyroid disease • Type I Autoimmune Diabetes Mellitus
Epidemiology • Incidence primary adrenal insufficiency is 5/100,000 in U.S. • 44 - 94% due to autoimmune disease. • Prevalence of APS II is 1.4-2.0/100,000. • Most common in pts 30 – 40 years of age. • More common in women. • Half of pts with APS II have family history of autoimmune disorders. • Genetic determinant is HLA DR3 (DQB*0201) and DR4 (DQB1*0302)
Other Associated Conditions • Vitiligo • Chronic atrophic gastritis w or w/o pernicious anemia • Hypergonadotropic hypogonadism • Chronic autoimmune hepatitis • Alopecia • Hypophysitis • Myasthenia gravis • Rheumatoid arthritis • Sjogren’s syndrome • Thrombocytic purpura
Diagnosis of Adrenal Insufficiency • Symptoms • Fatigue, weakness, anorexia, nausea, vomiting • Abdominal pain, salt craving, diarrhea, constipation, syncope • Signs • Weight loss, cutaneous and mucosal pigmentation, hypotension, hypoglycemia
Diagnosis • A.M. cortisol level < 3 mcg/dL strongly suggestive. • If > 8 mcg/dL excludes diagnosis. • Cosyntropin (Cortrosyn) test has sn 95% and sp 97% and is the standard test. – C • 250 mcg of cosyntropin (ACTH) IM or IV and serum cortisol level measured 30-60 min later. • Normal serum cortisol > 14 mcg/dL. • Test can be done anytime of day. • Primary adrenal insufficiency confirmed by increased plasma ACTH level.
Diagnosis • Other Laboratory Abnormalities • Low sodium, bicarb, chloride • Low serum aldosterone levels • Increased potassium • Mild to mod increased calcium level • Normocytic anemia (uncommon) • Thyroid and Diabetes diagnosed in usual manner. • Autoimmune basis must be demonstrated.
Autoantibodies • Adrenal Insufficiency • adrenal Cortex Ab found early • 21-Hydroxylase Ab highly SN and SP • Hashimoto’s thyroiditis • thyroid peroxidase Ab • thyroglobulin Ab • Type I Diabetes • islet cell Ab occur in 80% • glutamic acid decarboxylase 65 Ab (GAD) highest diagnostic sensitivity
Treatment • Each condition of APS II should be treated the same way as if they occurred separately. – C • Initiating treatment for autoimmune hypothyroidism in a patient with APS II and untreated adrenal insufficiency can precipitate a life-threatening adrenal crisis.
Treatment • Addisonian Crisis • Reverse hypotension and electrolyte problems with iv fluids (D5NS). • IV Steroids (hydrocortisone 100 mg or dexamethasone 2-4 mg) tapered over 3 days to maintenance dose of 15 – 20 mg po daily. • Fludrocortisone (Florinef) 0.1 mg given for primary adrenal insufficiency.
Iron Deficiency Anemia • Most common nutritional deficiency worldwide. • Men and non-menstruating women lose 1 mg of iron per day. • Menstruating women can lose an extra 10 mg to 42 mg of iron per cycle. • Pregnancy takes 700 mg of iron • 2 packs of whole blood contains 250 mg of iron.
Iron Deficiency Anemia • Absorption occurs in jejunum • Two forms of dietary iron • Heme (found in meat) not affected by dietary factors • Nonheme (plant and dairy) requires acid digestion, enhanced by ascorbate, meat and inhibited by calcium, fiber, tea, coffee, wine
Iron Deficiency Anemia • Caused when demand not met by absorption from diet. • Inadequate dietary intake • Hampered absorption • Physiologic losses in woman of reproductive age • Blood loss, occult or known
Risk Factors in U.S. • Black • Blood donors > 2 Units/yr women and 3 Units/yr men • Low SES AND postpartum • Mexican ethnicity • Child and adolescent obesity • Vegetarian diet
Screening and Primary Prevention • USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. • High-risk infants six to 12 months of age should be given routine iron supplementation. – B • Dietary Reference Intakes (DRI) for iron is 8 mg/day for healthy non-menstruating adults; 18 mg for menstruating women; 16 mg for vegans, and 20 mg for blood donors.
High Risk Infants • Poverty • Black, Native American, or Alaskan Native • Immigrants from a developing country • Preterm or low birth weight • Primary dietary intake is unfortified cow's milk.
Definition of Anemia Hemoglobin level
Differential Diagnosis of Microcytic Anemia (MCV < 80 fL) • Iron deficiency • Thalassemia • Sideroblastic anemia • Chronic disease • Lead poisoning
Diagnostic Tests for IDA • Serum Ferritin <25 ng/ml • Falls before other indices • Most sensitive for IDA • Falsely elevated in Hepatitis • TIBC rises • Serum Iron • Falls after Serum Ferritin • Falls after TIBC • Transferrin Saturation decreases • Falls after Serum Ferritin • Serum transferrin receptor increased (normal levels in anemia of chronic disease)
SORT: KEY Recommendations • Pts older than 65 with IDA should be screened for occult GI malignancy. – B • In men and postmenopausal women younger than 65, screening for occult GI malignancy should be done in absence of another cause for IDA. – B
Treatment of IDA • Consider transfusion for all pts who are symptomatic and for asymptomatic cardiac pts with Hgb < 10 g/dL. • Oral therapy is usually first line. • An increase in Hgb level of 1 g/dL should occur every 2-3 weeks. • Iron stores take up to 4 months to return to normal after Hgb has corrected.
Treatment of IDA • FeSO4 300 mg provides 60 mg of elemental iron. • FeGluconate 325 mg provides 36 mg of elemental iron. • Bone marrow response to iron limited to 20 mg per day of elemental iron. • IV iron available • iron dextran (risk of anaphylaxis) • ferric gluconate (safer) • iron sucrose
Asbestos-Related Lung Disease • Asbestos – a naturally occurring crystalline mineral used in many industries due to its flexibility, durability and resistance to heat and chemical corrosion. • Inhalation of asbestos fibers first linked to lung disease in 1890 and first deaths reported in 1907. • Legislation in U.S. enacted to limit exposure 1971.
Asbestos-Related Lung Disease • Asbestosis – Prevalence 200,000 and 2,000 deaths/yr • Lung Cancer – 2000-3000 deaths/yr • Mesothelioma – 2,000 deaths/yr • Pleural plaques – Among exposed 3-58%; general population 0.5-8%
Asbestos-Related Lung Disease • Risk of asbestos exposure should be assessed with occupational history. Screening should be considered in patients with a high risk of exposure. – C • CXR and PFTs should be performed every 3-5 yrs in pts with asbestos-related disease. – C
Potential Sources of Occupational and Environmental Asbestos Exposure • Asbestos-containing products • Asbestos-containing flight materials: aircraft mechanics, aerospace and missile production, aircraft manufacturing • Asbestos-lined electrical products: electrical workers, electrical linemen, telephone linemen, and power plant workers • Asbestos shipping materials: shipyard workers (e.g., insulators, laggers, painters, pipe fitters, maintenance workers, welders), Coast Guard personnel, merchant mariners, longshoremen, U.S. Navy personnel, asbestos manufacturing plant workers, insulators, machinists, persons working at packing and gasket manufacturing plants, pipe fitters, and power plant workers
Potential Sources of Occupational and Environmental Asbestos Exposure • Brake linings and clutch pads: auto mechanics, those involved in brake and clutch manufacturing, and assembly workers • Building materials: building engineers, cement plant production workers, building material manufacturers, construction workers (including insulators, boilermakers, steelworkers, ironworkers, plumbers, steamfitters, plasterers, drywallers, cement and masonry workers, roofers, tile/linoleum installers, carpenters, and welders) • Other asbestos-containing products: railroad workers, steamfitters, refinery workers, sheet metal workers, refractory products plant workers, rubber workers, and warehouse workers
Potential Sources of Occupational and Environmental Asbestos Exposure • Asbestos removal • Removal of insulation, asbestos removal, and waste handling • Building demolition and ship breaking • Environmental exposure • Asbestos in public buildings (e.g., hospitals, libraries, schools); occurs when the asbestos is disturbed during building or maintenance work • Family members of persons exposed occupationally • Asbestos production • Asbestos mining; textile mill workers who weave asbestos into cloth • Asbestos transport • Packing and handling of asbestos
Asbestosis • Fibrotic lung disease, or pneumoconiosis, resulting from inhalation of asbestos fibers. Currently no treatment alters course of disease. • Latent period of 20 to 30 yrs. • PFTs reveal decreased DLCO and exertional oxygen desaturation restrictive pattern with TLC and VC. • CXR and CT show interstitial markings lower lobes, pleural plaques. • Clinically similar to idiopathic pulmonary fibrosis, but slower progression.
Benign Pleural Disease • Most common pathologic pulmonary response to asbestos exposure. • Deposition of collagen in the pleura, which calcify. • Usual asymptomatic and no evidence that they transform into malignant lesions. • Benign pleural effusions, unilateral, exudative most common 10-20 yrs after exposure. Diagnosis of exclusion.
Figure 1. Computed tomographic scan of the chest demonstrating severe asbestosis. There is marked parenchymal remodeling and tissue destruction ("honeycombing" [arrow]), leading to restrictive lung disease (forced vital capacity: 56 percent of predicted) and decreased oxygen exchange. Figure 2. Chest radiograph of a patient with previous asbestos exposure who has developed pleural plaques (arrows)). These plaques are characteristically located symmetrically along the lateral chest wall but also may occur on the domes of the diaphragm.
Lung Cancer • Asbestos exposure significantly increases risk of small cell and non-small cell carcinoma. • Smoking increases this risk several-fold. • Evaluation of new non-calcified pulmonary nodule is the same with or without a history of exposure.
Diffuse Malignant Mesothelioma • Aggressive tumor derived from mesothelial cells, most commonly of the pleura. • Uniformly fatal, median survival of 6 to 18 months from diagnosis. Surgery, radiation, chemo do not improve survival. • CXR and CT unilateral pleural effusion with irregular pleural thickening. • Advanced cases associated with superior vena cava syndrome, Horner’s syndrome, dysphagia, invasion of neighboring structures.
Mesothelioma Irregular diffuse pleural thickening / mass on left Blunting of costophrenic angle Loss of left diaphragmatic silhouette Left hemithorax larger
Erythema Nodosum: A Sign of Systemic Disease • Most common panniculitis – painful disorder of subcutaneous fat • Prevalence 1-5/100,000; Women > Men (6:1) • Peak incidence 20-30 yrs • Usually cause is unknown, but can be sign of underlying systemic disease. • Type IV delayed hypersensitivity response to a variety of antigens.
Erythema Nodosum • Basic Features • Painful, symmetric, red nodules • Anterior legs most common location • Involutes in weeks with bruise-like appearance • Does not ulcerate; tends to heal completely • Prodrome 1-3 weeks before onset of lesions; wt loss, malaise, fever, cough, arthralgia