Cardiac 00 / 31 , all cards and bookmarks
The governing rule 01 / 31 Order a preoperative test only when its result would change management; otherwise skip it.
Functional capacity: the number everything turns on 03 / 31 Before major surgery, every capacity measure has a fixed cut-off; ask and test, never estimate.
Capacity measure Capacity measure Verdict Under 4 METs Low functional capacity Duke Activity Status Index (DASI) ≤34 Low functional capacity Walks two blocks (3 METs) Fails: low functional capacity Climbs one flight of stairs (5 METs) Passes: adequate functional capacity Elevated risk, at least 4 METs without symptoms → , open its explanation Proceed; no echo, stress testing or cardiology referral
Biomarker in at-risk surgery Biomarker in at-risk surgery What to do B‑type natriuretic peptide (BNP) ≤92 Normal: stop the workup NT‑proBNP <300 ng/L Normal: stop the workup
Activity Report a problem with card 3: Functional capacity: the number everything turns on
Proceed, postpone, or refer 04 / 31 Unstable heart conditions delay elective surgery; emergencies and stable patients proceed, with setting adjusted to risk.
Finding What to do Right bundle branch block (RBBB) plus young sudden family death → , open its explanation Refer to cardiology for inherited arrhythmia, e.g. Brugada; do not proceed Good functional capacity or emergency → , open its explanation Proceed; no further work‑up Rest angina before non‑emergency surgery → , open its explanation Refer to cardiology; never proceed or stress test first Diabetic hypertensive pre‑op: chest pain, dyspnoea, ST elevation → , open its explanation Postpone surgery; urgent cardiology review, primary percutaneous coronary intervention (PCI) Elevated risk, under 4 METs, cannot exercise → , open its explanation Pharmacological stress test; echo if unexplained dyspnoea Hypotension, back pain, pulsatile mass → , open its explanation Ruptured abdominal aortic aneurysm (AAA): straight to theatre; permissive hypotension, no echo Basal crackles with severe aortic regurgitation → , open its explanation Postpone; treat and optimise heart failure first Day‑case TURP (transurethral resection of the prostate) in severe heart failure → , open its explanation Stable: proceed and admit as an inpatient Simultaneous bilateral knee replacement → , open its explanation Stage it for severe systemic disease, over 75, poor ventricle
Sources: AHA/ACC 2024 · §1.5 AHA/ACC 2024 · §7.7
Report a problem with card 4: Proceed, postpone, or refer
Which test 05 / 31 Order each cardiac test or line only for its specific indication, never routinely.
Tests before and after surgery Finding Test to order Valve lesion, unexplained dyspnoea, worsening heart failure → , open its explanation Echocardiogram; never routine, nor for stable cardiomyopathy Known cardiac disease, elevated‑risk surgery → , open its explanation ECG; never for low‑risk surgery Age alone, no other indication → , open its explanation No ECG for low‑risk surgery; European Society of Cardiology (ESC) counts age ≥65 otherwise Unassessable capacity, risk factors only, RCRI 0 → , open its explanation No stress test; BNP if a test is forced Cardiac marker needed → , open its explanation Troponin I or T, not troponin C Postoperative: cardiovascular disease, risk factors, high‑risk surgery → , open its explanation Troponin I or T surveillance against preoperative baseline; not BNP, lactate dehydrogenase (LDH), CK‑MB Postoperative symptomatic ischaemia → , open its explanation Bedside treatment and troponin now; catheterisation last Advanced chronic obstructive pulmonary disease (COPD) or suspected mass → , open its explanation Chest X‑ray, selectively; only for specific findings
Lines and catheters Sources: AHA/ACC 2024 · §4.3 AHA/ACC 2024 · §4.2.1
Report a problem with card 5: Which test
Scoring the risk 06 / 31 Score each tool by its exact criteria: RCRI predicts cardiac complications, CHA2DS2-VASc predicts stroke.
Revised Cardiac Risk Index (RCRI) criteria (Lee 1999; Faust, Barash) Criterion, 1 point each Counts when High‑risk surgery → , open its explanation Intraperitoneal (laparoscopic too), intrathoracic or suprainguinal vascular Ischaemic heart disease → , open its explanation Previous infarct, positive exercise test, ischaemic chest pain or nitrate use Heart failure → , open its explanation Any history of heart failure Cerebrovascular disease → , open its explanation Any previous stroke or transient ischaemic attack (TIA) Diabetes → , open its explanation Only if treated with insulin; tablets score 0 Creatinine → , open its explanation Only above 2 mg/dL (176 µmol/L) Age or hypertension → , open its explanation Zero points; neither is an RCRI criterion
RCRI score and risk of major cardiac complications (Lee 1999) Worked RCRI sums CHA2DS2-VASc stroke score in atrial fibrillation (Stoelting) CHA2DS2-VASc score, stroke risk and anticoagulation (Miller; 2019 ACC/AHA) Score Meaning Patients scored (also by the older congestive heart failure, hypertension, age, diabetes, stroke (CHADS2) score) → , open its explanation Nonvalvular atrial fibrillation only; not rheumatic mitral stenosis or prosthetic valve 0 → , open its explanation Low: stroke 0.2% a year 1 → , open its explanation Intermediate: stroke 0.6% a year 2 or more → , open its explanation High: stroke over 2.2% a year Men 0, women 1 → , open its explanation Long‑term anticoagulation may be omitted Men 1, women 2 → , open its explanation Anticoagulation may be considered Men 2 or more, women 3 or more → , open its explanation Long‑term oral anticoagulation recommended
Report a problem with card 6: Scoring the risk
Which drug to stop, hold or continue 07 / 31 Continue cardioprotective drugs; hold those risking hypotension, hypoglycaemia or bleeding.
Cardiac and diabetes medicines Drug Before surgery Chronic beta blocker or statin → , open its explanation Continue perioperatively New beta blocker → , open its explanation Start at least 1 week before, slowly titrated Beta blocker contraindication → , open its explanation Decompensated failure, severe bronchospasm, high‑grade block, bradycardia Angiotensin‑converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), major fluid shifts → , open its explanation Hold 24 hours pre‑op; individualise, not routine stopping Induction hypotension on a continued ACE inhibitor or ARB → , open its explanation Expected; omitting it 24 hours before improves stability Metformin or sulfonylurea → , open its explanation Hold on the morning of surgery Sodium‑glucose cotransporter 2 (SGLT2) inhibitor → , open its explanation Stop 3–4 days before; euglycaemic ketoacidosis risk
Anticoagulant name endings (official drug-naming lists, outside the books) Name ending Class -parin (enoxaparin, dalteparin) → , open its explanation Heparin: acts through antithrombin -xaban (rivaroxaban, apixaban, edoxaban) → , open its explanation Direct factor Xa inhibitor -gatran (dabigatran) → , open its explanation Direct thrombin inhibitor -irudin (bivalirudin, lepirudin) → , open its explanation Direct thrombin inhibitor, hirudin type Warfarin → , open its explanation Vitamin K antagonist; no class ending
Stop times before high-bleeding-risk surgery Agent Stop before surgery Factor Xa inhibitor ≥3 days Dabigatran ≥4 days; 5–6 if creatinine clearance (CrCl)<50 Clopidogrel 5 days Ticagrelor 3 days Prasugrel 7 days Ticlopidine 10 days Rivaroxaban at 24 hours Low‑bleeding‑risk surgery only, not neuraxial
Sources: AHA/ACC 2024 · §6.3
Report a problem with card 7: Which drug to stop, hold or continue
How long to wait 08 / 31 Delay elective surgery according to stent age and indication; urgent surgery goes ahead without waiting.
Elective surgery after a coronary stent or infarct Stent and setting When to operate Any coronary stent, within 30 days of PCI → , open its explanation Never operate electively Stent placed for acute coronary syndrome (ACS) → , open its explanation Wait 12 months before elective surgery Drug‑eluting stent, chronic coronary disease → , open its explanation Wait 6 months, not 12 Myocardial infarction (MI) with catheterisation: assume a stent → , open its explanation Postpone 6 months; 60 days if no stent Drug‑eluting stent, clopidogrel stopped early, elective surgery → , open its explanation Cancel, restart clopidogrel, rebook 6 months from placement Time‑sensitive surgery after stent → , open its explanation Can proceed at 3 months Urgent surgery after stent → , open its explanation Proceed now on continued aspirin or dual antiplatelet therapy (DAPT)
Hip fracture timing Drug-eluting stent over a year Sources: AHA/ACC 2024 · §7.5
Report a problem with card 8: How long to wait
Procedures with their own rule 09 / 31 Each procedure here follows its own condition-specific rule, not the general default.
Situation What to do Mitral stenosis in labour → , open its explanation Vaginal delivery, early neuraxial analgesia, never withheld High‑risk cardiac lesion, gingival dental work → , open its explanation Prophylaxis; not for gastrointestinal or genitourinary procedures Dental work: which hearts get prophylaxis → , open its explanation Any prosthetic valve or repair material; unrepaired cyanotic congenital disease Child, unrepaired cyanotic heart disease, no allergy → , open its explanation IV cefazolin 50 mg/kg, max 1 g; skip clindamycin Postoperative epidural in cardiac disease Continue thoracic epidural at least 24 hours, optimally 2–4 days Lithotripsy: pregnancy, bleeding disorder, anticoagulation Absolute; pacemaker, implantable cardioverter‑defibrillator (ICD), aneurysm, obesity only relative Aortic stenosis or murmur found before elective surgery → , open its explanation Transthoracic Doppler echo: grades severity and ventricular function Severe aortic stenosis, pregnant, requesting epidural → , open its explanation Catheter epidural, extend slowly; relative contraindication only Coronary disease before non‑cardiac surgery → , open its explanation Revascularise only where indicated anyway: ST‑elevation myocardial infarction (STEMI), high‑risk non‑ST‑elevation myocardial infarction (NSTEMI), left main
Sources: AHA/ACC 2024 · §6.1.1 AHA/ACC 2024 · §4.3
Report a problem with card 9: Procedures with their own rule
The ECG 10 / 31 Each ECG pattern points to one specific diagnosis, lead or artery, not its look-alike.
QT and electrolytes Bundle branch blocks Diagnostic patterns Finding What it is Epsilon wave, V1–V3 → , open its explanation Arrhythmogenic right ventricular cardiomyopathy; minor Padua criterion Arrest with coved right precordial ST elevation → , open its explanation Brugada syndrome: pseudo‑RBBB, sodium‑channel disorder, normal heart Diffuse ST elevation, PR depression → , open its explanation Acute pericarditis, not territorial infarct Low QRS voltage ± alternans Pericardial effusion, COPD, constrictive pericarditis, restrictive cardiomyopathy
Ischaemia monitoring leads Electrodes and territories Report a problem with card 10: The ECG
Waveforms and pressures 11 / 31 Every waveform or pressure reading maps to one specific lesion, event or limit.
Arterial pulse CVP wave End-tidal to arterial CO2 gradient Pulmonary artery catheter and wedge pressure Pressure–volume loop Pulse contour cardiac output Report a problem with card 11: Waveforms and pressures
Echo 12 / 31 Choose the echo view, cardiac timing or monitor that directly shows the problem.
Best transoesophageal view or monitor for the task Task What shows it best Ischaemia monitoring on transoesophageal echocardiography (TOE) → , open its explanation Transgastric mid‑papillary short axis: all three coronary territories Suspected massive pulmonary embolism, right ventricular strain → , open its explanation Four‑chamber view: RV:LV ratio, D‑shaped septum, McConnell's sign Femoral VV‑ECMO cannulation → , open its explanation Mid‑oesophageal bicaval: wire tracked along the cavae into RA Suspected venous air embolism → , open its explanation Mid‑oesophageal bicaval view: right atrium, both venae cavae Detecting venous air embolism → , open its explanation TOE or precordial Doppler, not an oesophageal stethoscope
Structures on the TOE views Echo findings TOE contraindications Report a problem with card 12: Echo
Murmurs, grades and numbers 13 / 31 Name each finding by its exact numbers or signs, not the look-alike.
Valve and ventricle thresholds Threshold What it means Mitral area 1–1.5 cm², gradient 5–10 mmHg → , open its explanation Moderate mitral stenosis; severe under 1.0 cm² Aortic <1 cm², >40 mmHg, >4 m/s → , open its explanation Severe aortic stenosis; either area or gradient suffices Ejection fraction (EF) <25%, pulmonary capillary wedge pressure (PCWP) >20 mmHg, cardiac index (CI) <2.5 L/min/m² → , open its explanation Poor dilated cardiomyopathy prognosis EF ≤40% → , open its explanation Reduced ejection fraction EF ≥50% → , open its explanation Preserved ejection fraction
Signs and what they mean Finding What it means Apical holosystolic murmur, inferior MI → , open its explanation Papillary muscle rupture, acute mitral regurgitation Parasternal thrill with shock Septal rupture Sail‑like displaced tricuspid valve → , open its explanation Ebstein anomaly Positional pain, fever, rub → , open its explanation Pericarditis, not pulmonary embolism (PE) or MI Crackles, S3, dilatation, low EF → , open its explanation Reduced‑fraction heart failure, not hypertrophic cardiomyopathy Raised CVP, hypotension, pulmonary hypertension in dilated cardiomyopathy → , open its explanation Poor prognosis; systemic hypertension is not a marker
What to do Report a problem with card 13: Murmurs, grades and numbers
The action potential 14 / 31 Each cardiac myocyte action potential phase is defined by its dominant ion current.
On bypass 15 / 31 Each bypass event has one specific move; the tempting alternative fails.
Event What to do Heparin reversal → , open its explanation Protamine, 1 mg/100 units heparin, test dose; not fresh frozen plasma (FFP) Right ventricle distends, pressure collapses → , open its explanation Reheparinise, resume bypass; not balloon pump Air in aortic line → , open its explanation Stop bypass immediately, not anti‑Trendelenburg or more flow Pressure crash as bypass begins → , open its explanation Haemodilution, falling resistance; not anaphylaxis or heparin‑induced thrombocytopenia IABP timing → , open its explanation Inflate in diastole, deflate before systole; LV volume falls Post‑CABG low index, high SVR, unraised wedge → , open its explanation Underfilled ventricle: give volume first, then reassess Profound hypotension post‑bypass, chronic ARB/ACE inhibitor → , open its explanation Vasoplegia: vasopressor infusion; if refractory, vasopressin or methylene blue Painless visual loss after bypass → , open its explanation Embolic branch retinal artery occlusion, not raised intraocular pressure Isoelectric EEG on bypass → , open its explanation Hypothermia; cortex silent at about 18–20 °C Circulatory arrest planned → , open its explanation Cool to 18 °C, not barbiturate or propofol Flat EEG, milder cooling → , open its explanation Drug intoxication, high volatiles, or brain death
Report a problem with card 15: On bypass
Cross clamping and the aorta 16 / 31 Treat each aortic clamping phase and aneurysm setting separately; timing decides which therapy belongs.
Rhythm in theatre 17 / 31 Let perfusion decide: unstable rhythms get shock or pacing, stable rhythms get drugs.
Tachycardias Rhythm What to do Unstable atrial fibrillation (AF), including Wolff‑Parkinson‑White (WPW) → , open its explanation Synchronised cardioversion, not a drug Stable new AF → , open its explanation Rate control Stable thyrotoxic AF → , open its explanation Rate control with a beta blocker such as propranolol Postoperative sinus tachycardia: sepsis or hypovolaemia → , open its explanation Treat cause: restore volume, treat infection; no rate‑slowing drugs, cardioversion Unstable wide‑complex tachycardia → , open its explanation Pulse check; synchronised cardioversion if pulse, defibrillate if pulseless Stable supraventricular tachycardia (SVT) unresponsive to 6 mg adenosine → , open its explanation 12 mg rapid push; start at 3 mg via central line Unstable SVT in a child → , open its explanation Synchronised cardioversion 0.5–1 J/kg; 2 J/kg if that fails Ventricular fibrillation during synchronised cardioversion → , open its explanation Unsynchronised defibrillation immediately
Cardiac arrest Bradycardia and heart block Report a problem with card 17: Rhythm in theatre
Sudden haemodynamic deterioration 18 / 31 Name the true cause of deterioration before treating; the reflex response often harms.
Hypotension and shock: the right drug Event What to do Hypotension in mitral stenosis, aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM) → , open its explanation Phenylephrine, plus fluid in HOCM; never ephedrine, adrenaline, atropine Hypotensive cardiogenic shock, first vasopressor → , open its explanation Noradrenaline, not dopamine or adrenaline Poor perfusion once pressure is restored → , open its explanation Add an inotrope or a balloon pump Dobutamine in cardiogenic shock → , open its explanation Only without hypotension or hypoperfusion; else noradrenaline Local anaesthetic toxicity dysrhythmias: give → , open its explanation Lipid, adrenaline under 1 mcg/kg, amiodarone; bypass if refractory Local anaesthetic toxicity dysrhythmias: avoid → , open its explanation Vasopressin, calcium‑channel or beta blockers, more local anaesthetic Tamponade at induction: do → , open its explanation Fill first, keep rate high‑normal; drain under local if unstable Tamponade at induction: avoid → , open its explanation Positive pressure, vasodilators, myocardial depressants, bradycardia Hypertension after carotid endarterectomy → , open its explanation Carotid sinus denervation: the baroreceptor brake is lost Hypotension with fast pulse, hours after carotid endarterectomy → , open its explanation Bleeding until proven otherwise; a slow pulse means the reflex
Contrast reaction timing Contrast reaction Onset Pruritus, urticaria, angioedema, rhinitis, bronchospasm, laryngeal oedema Immediate
Report a problem with card 18: Sudden haemodynamic deterioration
Position and insufflation 19 / 31 Surgical positioning and insufflation bring predictable physiological changes; anticipate their direction and timing.
Complications of what you did 20 / 31 Trace each complication to its cause (device, gas, position or drug) and act on that.
Implanted devices 21 / 31 Cautery risk depends on current path and device type; set the mode deliberately, then interrogate.
Pacemakers and cautery: what to do Situation What to do Symptomatic bradycardia → , open its explanation Permanent pacemaker if symptoms are proven rate‑related; else weaker indication Monopolar cautery above umbilicus, pacemaker‑dependent → , open its explanation Reprogram to asynchronous pacing; magnet only if reprogramming unavailable Rapid sequence induction, pacing‑dependent ICD, no interrogation possible → , open its explanation Avoid suxamethonium: fasciculations inhibit pacing, trigger shocks; use non‑depolarising relaxant Cautery near a pacemaker → , open its explanation Bipolar cautery, short bursts, return pad away from generator Sick sinus syndrome, pacemaker, knee replacement, diathermy planned → , open its explanation Avoid diathermy if possible; else bipolar, short bursts Pacemaker after cautery → , open its explanation Interrogate the device
Device behaviour Inappropriate shock risk Sources: AHA/ACC 2024 · §6.6
Report a problem with card 21: Implanted devices
The cardiomyopathies and muscle disease 22 / 31 Behind each misleading surface picture lies the cardiomyopathy itself; name it and treat it accordingly.
Cardiomyopathy findings Finding What it is Apparently stable HOCM at baseline → , open its explanation Misleading; obstruction still hidden HOCM with tachycardia, hypovolaemia or falling afterload → , open its explanation Unmasked outflow obstruction Becker muscular dystrophy → , open its explanation Cardiac abnormality in 50–70%, not proportional to weakness Heart failure and dysrhythmias in phaeochromocytoma → , open its explanation Catecholamine‑induced cardiomyopathy Hypertension in phaeochromocytoma → , open its explanation Usually sustained; paroxysms only occasional but dangerous New breathlessness in dilated cardiomyopathy → , open its explanation Pulmonary oedema, not effusion, atelectasis or embolism Hypotension with tachycardia in dilated cardiomyopathy → , open its explanation Low output from decompensated heart failure
Cardiomyopathy management Sources: AHA/ACC 2024 · §6.3.1
Report a problem with card 22: The cardiomyopathies and muscle disease
The reflexes, as a set 23 / 31 Intraoperative bradycardia is never reassuring: it is either a vagal reflex or extreme blood loss.
Reflex bradycardia from surgical handling Event What to do Bradycardia, hypotension on eye‑muscle traction → , open its explanation Oculocardiac reflex: surgeon stops traction first High PaCO2, hypoxaemia or light anaesthesia, eye surgery → , open its explanation Stronger oculocardiac reflex: ventilate, oxygenate, deepen anaesthesia Bradycardia, hypotension on carotid manipulation → , open its explanation Carotid baroreceptor reflex: surgeon stops first Bradycardia, hypotension during microvascular decompression → , open its explanation Vagal reflex: surgeon stops first
Other bradycardia reflexes Finding What it is Bradycardia in massive haemorrhage → , open its explanation Extreme blood loss, not reassurance Bradycardia, hypotension, coronary dilatation from the left ventricle → , open its explanation Bezold–Jarisch reflex: ischaemic or underfilled ventricle; never tachycardia Chest pain, ST changes, bradycardia despite hypotension → , open its explanation Bezold–Jarisch reflex from the ischaemic left ventricle Pelvic bleed, bradycardia, carotid/aortic receptors firing → , open its explanation Chemoreceptor reflex (acidosis, hypoxia): more breathing, slower heart, less contractility
Report a problem with card 23: The reflexes, as a set
Physiology worth holding 24 / 31 Predict the cardiovascular response first; it dictates what to expect and what to give.
Coronary perfusion The denervated transplanted heart Cirrhosis Cardiac output and its nerves Other responses Event What to expect Electroconvulsive therapy (ECT) → , open its explanation Bradycardia/hypotension, then tachycardia/hypertension; cardiovascular effects dominate Valsalva manoeuvre → , open its explanation Central venous pressure up; venous return, output, pressure down Atrial natriuretic peptide Vasodilates, natriuresis, raises glomerular filtration rate (GFR); inhibits renin and aldosterone After hip or knee arthroplasty → , open its explanation Cardiac events first, then PE, pneumonia, infection After hip fracture → , open its explanation Delirium commonest; chest infection and heart failure also
Report a problem with card 24: Physiology worth holding
Drugs 25 / 31 Name each drug's class and effect; in long QT, avoid QT-prolonging antiemetics and repeated classes.
Antiarrhythmic classes (Vaughan Williams; Lei et al. 2018, outside the books) Class Blocks · drugs Class I Sodium channels · Ia quinidine, Ib lidocaine, Ic flecainide Class II Beta receptors · esmolol, metoprolol, propranolol Class III Potassium channels, longer QT · amiodarone, sotalol Class IV Nodal calcium channels · verapamil, diltiazem Amiodarone Class III; also class I, II and IV actions Basis of the classes The channel or receptor each drug blocks
Congenital long QT syndrome Nausea with a long QT Beta-2 agonists Finding Drug Most potent beta‑2 agonist, falling SVR with tachycardia Isoprenaline, not adrenaline, dobutamine or noradrenaline
Coronary vessel effects Report a problem with card 25: Drugs
Anatomy that decides a line 26 / 31 Put the arterial line in a limb whose artery still gives true systemic readings.
Congenital heart disease in children 28 / 31 Know each lesion's shunt: protect preload and systemic resistance in tetralogy, spontaneous breathing in Fontan.
Induction in congenital heart disease Tetralogy of Fallot spells Shunts and inhalational induction speed Recognising the lesion in infants Fontan circulation Report a problem with card 28: Congenital heart disease in children
Heart disease in pregnancy 29 / 31 In pregnancy, fixed-output lesions carry highest maternal mortality; regurgitant lesions are well tolerated.
Heart failure 30 / 31 End-stage heart failure that cannot proceed to transplant gets a destination left ventricular assist device (LVAD), not medical therapy alone.
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Sheet 01 · Cardiac 31 / 31
That is Cardiac, all 31 cards.
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Back to the sheets The 31 rules One rule per card, in the sheet's order. Tap one to open its card.