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Wave 2: Module 3: Aortic Week 1 – Case 2
- April 30, 2025
- Posted by: admin
- Category: Uncategorized
Week 1 – Case 2
68 years old male patient, ex smoker with background of HTN CKD. He never had any cardiac symptoms. He was found to have 6.8 cm AAA on US that he has had for RUQ pain. All of his blood tests came back as normal apart for eGFR of 29. Patient is not keen on surgery.
How would you approach his consultation?
What is the risk of rupture?
What is your recommendation of treatment?
How would you assess his risk for surgery?
Is there any pre op medication that can be used to reduce the risk of surgery?
Patient had CPET to assess his general fitness
Main finding on this was, He stopped after a total of 9.44 minutes of exercise on reaching a peak work rate of 116 Watts . There is no ECG changes showed on exercise. Anaerobic threshold 15.1 ml.kg-1.min-1 and FEV1/FVC is 81%
please comment on these finding and indicate the suitable clinical plan.
What is the definition of Anaerobic threshold? what is the cut off that indicate higher risk for open surgery?
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A1-first history
family history for aneurysm – htn -smoking -any cardiac condition
examination general for vital signs
abdomen for any tenderness ,ecchymosis
ll for any pop aneurysm and distal pulse
A2 around 6 percent
A3as the AAA is 6,4
it is indicated for interventio
as cardiac condition is good so open is preferred
EVAR by co2 as the parient is CKD
amd life style modification
A4-CTA to assess anatomy of AAA
cardiac assessment ecg-echo
renal function
pulmonary finction test
albumin assessment
CPET .
A5- aspirin and statin
A6 as ecg and anaerobic threthold is normal value and peak work load indicate low risk patient
A7-Anaerobic time is the time at which the metabolism will be shifted to anaerobic type and lactic acid will be accumulated as CVS cannot provide oxygen to tissues any more to get rid of produced lactic acid
cut-off >>> if anaerobic time (AT) is <11ml/kg/min , it means high risk for open surgery
How would you approach his consultation?
Firstly, history taking: present, past (HTN, cardiac, Smoking) and family history (any aneurysms)
What is the risk of rupture?
about 6% risk, if reaches 7 cm it will be higher as 18%.
What is your recommendation of treatment?
How would you assess his risk for surgery?
Cardiac risk, Pulmonary risk, renal and nutritional risk. Also, Cardiopulmonary exercise testing as mentioned by Chambers et al., 2019.
Is there any pre op medication that can be used to reduce the risk of surgery?
Statins and aspirin (or Clopidogrel) for cardiac risk management.
Please comment on these finding and indicate the suitable clinical plan.
Anaerobic Threshold (AT): 15.1 (Normal: 10–20 mL/kg/min).
Peak Work Rate: 116; low values (<100–150 Watts) suggest reduced fitness.
ECG and Heart Rate: Good
80% Pulmonary Function: FEV1/FVC ratio (normal >70%).
So, the patient is low to moderate risk
What is the definition of Anaerobic threshold? what is the cut off that indicate higher risk for open surgery?
is the exercise intensity at which lactate begins to accumulate in the blood due to the body’s inability to meet energy demands solely through aerobic metabolism. (Normal: 10–20 mL/kg/min).
———————-
References:
Chambers, D. J., & Wisely, N. A. (2019). Cardiopulmonary exercise testing-a beginner’s guide to the nine-panel plot. BJA education, 19(5), 158–164. https://doi.org/10.1016/j.bjae.2019.01.009
A1.. approach of consultation .
family history of AAAlife style > if he is active or notimaging> CT angiogram over aorta and both lower limbs with 1ml slices for accurate measurements and for planning for interventionlabs > urea creat albumintests for cardiac and pulmonary functionsdetermine the risk of rupture
A2.. rupture risk
an aneurysm size of 6-7 CM is 6%
A3..Recommendation of treatment
proper risk factors controlpreparation of the patient for elective repair (open surgical repair if anatomy isn’t suitable or EVAR if ptn prefered and to be done by co2 not contrast due to CKD)
A4..RF assessment
Cardiac condition by ECG, ECHOpulmonary condition by pulmonary function testRenal status by serum creatininenutritional status by Albumin level
A5..pre operative medications…..
antiplateletsstatinsanti hypertensive drugs to improve his cardiac status and to lower the riskDoxycycline is claimed to decrease the expansion rate by reducing Matrix metalloprotenase activity and thus decreasing extra cellular matrix degradation
A6..
There is on ECG change which indicates good cardiac functionsanaerobic time more than 11 ml/kg/min is good and since patient value is 15 it indicates his surgical risk is low FEV1/FVC >70% it indicates good pulmonary function and since the patient value is 81% he is in the normal side By interpreting the above results >>> the patient seems to have low surgical risk
A7..
Anaerobic time >>> is the time at which the metabolism will be shifted to anaerobic type and lactic acid will be accumulated as CVS cannot provide oxygen to tissues any more to get rid of produced lactic acidOSR cut-off >>> if anaerobic time (AT) is <11ml/kg/min , it means high risk for open surgery
Consultation approach:
AAA 6.8 cm = high rupture risk
Ask why he’s against surgery – fear? misunderstanding?
Reassure him, explain EVAR is less invasive
If he still refuses, make sure he fully understands the risk
Involve family if needed
Rupture risk:
6 cm = 10–20% per year
Big risk if left untreated
Treatment recommendation:
Fit → EVAR (preferable if anatomy okay)
Open if not suitable for EVAR
Conservative only if unfit or fully refuses
Surgical risk assessment:
CPET
Echo
Bloods (esp. renal function)
MDT discussion
Pre-op meds:
•statin
Beta-blocker (if tachy or hypertensive)
ACEi/ARB – careful with eGFR 29
CPET findings:
AT = 15.1 good reserve
FEV1/FVC = 81% → lungs okay
No ECG changes → no cardiac concern
He’s fit for surgery (EVAR if possible)
Anaerobic threshold
Point where body shifts to anaerobic metabolism (starts making lactate)
High-risk cut-off:
AT <11 = higher risk for open surgery
A1:
History
Analysis the symptoms is there fullness or not
Sudden pain !!
Family history about AAA
Social history
Medical diseases and medication
Analysis of complaints
Examination
General cardiac resp
Local vascular and abdominal
Investigation
Labs
Imaging PAUS MRA regarding his CKD
…………..
A2:
6.8 AAA has 6% risk of rupture at 3 years
………….
A3:
EVAR regarding ptn preference and to be done by co2 not contrast due to CKD
………
A4:
Assessment of risk for surgery by
CPET
Cardiac ECG ECHO
respiratory PFT
Renal
………
A5:
Pre operative antipletles , statine, and anti hypertensive drugs to improve his cardiac status and to lower the risk
Doxycycline is claimed to decrease the expansion rate by reducing Matrix metalloprotenase activity and thus decreasing extra cellular matrix degradation
….
A6:
All the parameters concluded that the patient is fit for intervention and anesthesia with low risk regarding cardiac and pulmonary functions
…….
A7:
The anaerobic threshold is the point during exercise when your body must switch from aerobic to anaerobic metabolism, at which the O2 demand of the muscles exceeds the ability of the cardiopulmonary system to supply O2. process that produce lactic acid
The cut off for OSR Deficiencies in CPET-derived variables—specifically ventilatory anaerobic threshold (AT), peak O2 consumption (O2peak), and ventilatory efficiency for carbon dioxide
A1:
History
Family history
Op history
Social history
Medical diseases and medication
Analysis of complaints
Examination
General cardiac resp
Local vascular and abdominal
Investigation
Labs
Imaging PAUS MRA regarding his CKD
A2:
6.8 AAA has 6% risk of rupture at 3 years
A3:
EVAR regarding ptn preference and to be done by co2 not contrast due to CKD
A4:
Assessment of risk for surgery by
CPET
Cardiac ECG ECHO
respiratory PFT
Renal
A5:
Pre op medications
Anti platelets statins anti htn b blockers mainly antibiotics
A6:
All the parameters concluded that the patient is fit for intervention and anesthesia with low risk regarding cardiac and pulmonary functions
A7:
The AT is the point during exercise when your body must switch from aerobic to anaerobic metabolism, at which the O2 demand of the muscles exceeds the ability of the cardiopulmonary system to supply O2. process that produce lactic acid
The cut off for OSR Deficiencies in CPET-derived variables—specifically ventilatory anaerobic threshold (AT), peak O2 consumption (O2peak), and ventilatory efficiency for carbon dioxide
A1.. I will start by addressing some pints in the history .
If there is any family history of AAA
His life style and if he is active or not
I will ask for CT aortography for accurate measurements and for planning for intervention
I will do tests to exam cardiac and pulmonary functions
To balance between the risk of rupture and intervention
A2..t
he rupture risk of an aneurysm size of 6-7 CM is 6%
A3..
Recommendation of treatment is proper risk factors controle and preparation of the patient for elective repaire
A4..
I will assess his
Cardiac condition by ECG, ECHO
pulmonary condition by pulmonary function test
Renal status by serum creatinine
Alumin level to assess his nutritional status
A5..
Pre operative antipletles , statine, and anti hypertensive drugs to improve his cardiac status and to lower the risk
Doxycycline is claimed to decrease the expansion rate by reducing Matrix metalloprotenase activity and thus decreasing extra cellular matrix degradation
A6..
To comment on patient total time 9.15 and peak work rate of 116 the patient predicted values should be knows based on patient age weight and sex.
There is on ECG change which indicates good cardiac functions
Also as general speaking aneropic time more than 11 ml/kg/min is good and since patient value is 15 it indicates his surgical risk is low
WHEN FEV1/FVC >70% IT INDICATES good pulmonary function and since the patient value is 81% he is in the normal side
By interpreting the above results the patient seems to have good surgical risk
A7..
Anaerobic time is the time at which the metabolism will be shifted to anaerobic type and lactic acid will be produced and CVS cannot provide oxygen to tissues any more to get rid of produced lactic acid