pre op evaluation of cardiac pts for non-cardiac surgery

1. Preoperative Evaluation of Cardiac
Patients Undergoing Non-cardiac
Surgery
Moderator: Prof. Dr Baburaja
Shrestha
22 Dec,2014

2. • 1-5 % of unselected pts have perioperative
cardiac morbiditya
• Pre-op Approach
clinical risk indices
pre-op cardiac testing

3. Cardiac disease
• Structural heart disease
• Coronary artery disease
• Valvular heart disease
• Cardiomyopathies
• Heart failure / Cor pulmonale

4. Perioperative cardiac morbidity
• 1-5% of unselected pts
• Myocardial infarction
• Heart failure
• Arrhythmias
• Sudden Cardiac death

5. Goals
• Define risks
• Determine if further testing beneficial
• Appropriate anesthetic plan
• Peri-op ?beta blockade, interventional
therapy,

6. History
• Symptoms, h/o cardiac disease
• Associated co-morbidities: peripheral vascular disease,
cerebrovascular disease, diabetes mellitus, renal impairment,
and chronic pulmonary disease
• History of surgery, anesthetic course
• Use of mechanical devices: ICD/pacemaker/stents/prosthetic
valves
• Exercise tolerance

7. • Indicators of disease severity: PND, orthopnea, dyspnea,
angina
• recent change in symptoms?
• Drug therapy & compliance : disease specific; over-the-
counter and illicit drugs, herbal and other nutritional
supplements; dosages/compliance/side-effects
• Alcohol, tobacco use
• Bleeding tendencies

8. Physical examination
• General appearance provides invaluable evidence of patient’s
overall status
• Assessment of vital signs (including measurement of blood pressure
in both arms)
• Carotid pulse contour and bruits, jugular venous pressure and
pulsations, auscultation of the lungs, precordial palpation and
auscultation, abdominal palpation, and examination of the
extremities for edema and vascular integrity.
• The presence of an implanted pacemaker or ICD

9. Risk Stratification
• Risk indices range from ASA-PS grading to
Goldman to revised cardiac risk index

10. Goldman’s cardiac risk index
Risk factors Points
Third heart sound, raised JVP 11
Recent myocardial infarction (within 6 months) 10
Rhythm other than sinus or >5 premature atrial
contractions
7
>5 premature ventricular contractions/min 7
Age >70 yrs 5
Emergency operations 4
Poor general health condition 3
Intrathoracic, intraperitoneal or aortic surgery 3
Severe aortic stenosis 3
Total score 53

11. Interpretation of scores of Goldman’s cardiac
risk index
Points Risk of cardiovascular
complications
0-5 1%
6-12 7%
13-25 14%
26-53 78%

12. Detsky cardiac risk index
Risk Points
Age older than 70 years 5
Myocardial infarction within six months 10
Myocardial infarction before six months 5
Canadian Cardiovascular Society Angina
Classification
Class III 10
Class IV 20
Unstable angina within six months 10
Alveolar pulmonary edema
Within one week 10
Ever 5
Suspected critical aortic stenosis 20
Arrhythmia
Rhythm other than sinus or sinus plus atrial premature beats 5
More than five premature ventricular beats 5
Emergency operation 10
Poor general medical status 5

13. Class Points Cardiac risk
I 0 to 15 Low
II 20 to 30 Moderate
III 31 + High
Interpretation of scores of Detsky cardiac index

14. Revised Cardiac Risk Index
SIX independent predictors,1999
Clinical variable Points
High-risk surgery 1
H/o Ischemic heart disease 1
H/o Congestive heart failure 1
H/o cerebrovascular disease 1
Insulin treatment for diabetes mellitus 1
Pre-operative serum creatinine level >2.0 mg/dl (180 mcgmol/L) 1
Risk class Points Risks of complications (%)
I. Very low 0 0.4 %
II. Low 1 0.9 %
III. Moderate 2 7.0 %
IV. High 3+ 11.0 %
Interpretation of risk score

15. Clinical Predictors of Increased Perioperative
Cardiovascular Risk
• Major
- Unstable coronary syndromes
Acute or recent MI with evidence of important ischemic risk by clinical
symptoms or noninvasive study
Unstable or severe angina (Canadian class III and IV)
- Decompensated heart failure
- Significant arrhythmias
High-grade atrioventricular block
Symptomatic ventricular arrhythmias in the presence of
underlying heart disease
Supraventricular arrhythmias with uncontrolled ventricular rate
- Severe valvular disease

16. • Intermediate
- Mild angina pectoris (Canadian class I or II)
- Previous MI by history or pathological Q waves
- Compensated or prior heart failure
- Diabetes mellitus (particularly insulin dependent)
- Renal insufficiency
• Minor
- Advanced age
- Abnormal ECG (left ventricular hypertrophy, left bundle-branch block, ST-T
abnormalities)
- Rhythm other than sinus (eg, atrial fibrillation)
- Low functional capacity (eg, inability to climb one flight of stairs with a bag of
groceries)
- History of stroke
- Uncontrolled systemic hypertension
(ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

17. ACC/AHA cardiac evaluation
guidelines
• Step 1- determine urgency/emergency
if emergency- risk reduction, ↑peri-op
monitoring
• Step 2
any active cardiac condition?
Acute MI,Unstable angina, CHF, severe
valvular disease, significant arrhythmias
STILL ? Benefits > risks (lifesaving procedure)

18. • Postpone surgery in ACUTE, RECENT MI (with
symptoms,+ve stress test)
• Step 3- determination of surgical risk/severity
low risk surgery without active cardiac condition
can proceed
• STEP 4- Pts functional capacity
asymptomatic/excellent functional capacity>>
proceed to surgery
• Step 5 – poor functional status
– Further invasive test only “if it will change the
management

20. Disease specific

21. Hypertension
• Two or more readings > 140/90
• PAC an opportunity to identify pts with HTN &
initiate therapy
• Degree of end-organ damage, morbidity & mortality
correlate with disease duration and severity
• IHD most common end organ damage associated
• HTN with LVH have higher peri-op risk than non HTN
(Barash,7th edn)

22. • Evaluate to identify causes of HTN, end organ
damage, therapy and compliance
• Order ECG, BUN,Creatinine
electrolytes if on diuretics
• LVH and strain pattern>> futher evaluation
• Dyspnea/heart failure >> ECHO
• Little association between SBP <180 mm Hg or
DBP <110 mm Hg and peri-op outcomes
• In the absence of end-organ changes (eg renal
insufficiency/ LV strain) the benefits of optimizing
BP must be weighed against the risks of delaying
surgery

23. Coronary Artery Disease
• History, Physical exam & ECG
• RISK FACTORS as imp. as symptoms since CAD
can be insidious
• Classic risk factors (age,
gender,smoking,↑cholesterol) NOT
direct/independent risk to peri-op cardiac
event

24. • Enquiry abt type, duration,
precipitating/relieving factors of chest
discomfort
• Dyspnea with CAD risk factors >> further IHD
investigations

25. PERIOPERATIVE RISK OF EVENTS
• Patients With No Prior History Of MI Have A Low Risk Of Perioperative
MI (0.1%-0.6%)
• Patients With A History Of Prior MI Are At A Significantly Higher Risk
(2.8%-7%).
• MI Within 3 Mnths.-37% Increase In Events
• MI Within 3-6 mnths.-16% Increase In Events
• MI Greater Than 6 Mnths.-4% Increase In Events

26. • Taken together,data suggest that <60 days
(recent MI) should elapse after a MI before
noncardiac surgery in the absence of a
coronary intervention
• Recent MI also independent risk factor for
peri-op stroke (8 fold mortality)

27. Greatest risk
• Extensive 3-vessel disease
• Left main disease
• Ventricular dysfunction
• Residual ischemia remaining from previous MI
• Mortality rates exceed 50%

28. Heart failure
• Symptoms- SOB, fatigue,orthopnea,PND,
cough,periph. edema,recent wt gain
• Signs- S3/S4, tachycardia, rales,
↑JVP,ascites,hepatomegaly
• Identification and grading

29. NYHA Heart Failure Classification
Class Description
1
No limitation of physical activity - ordinary physical activity doesn't
cause tiredness, heart palpitations, or shortness of breath
2
Slight limitation of physical activity - comfortable at rest, but ordinary
physical activity results in tiredness, heart palpitations, or shortness
of breath
3
Marked or noticeable limitations of physical activity - comfortable at
rest, but less than ordinary physical activity causes tiredness, heart
palpitations, or shortness of breath
4
Severe limitation of physical activity - unable to carry out any
physical activity without discomfort. Symptoms also present at rest. If
any physical activity is undertaken, discomfort increases.

30. • Decompensated HF >> postpone surgery
• Correlation betwn HF and BNP levels
BNP > 100pg/ml >> heart failure
N-terminal pro-BNP < 300 pg/ml virtually
excludes acute HF!
• ECG,CXR,electrolytes,urea/creat & possible
BNP indicated
• ECHO for LVEF, Ventricular performance &
diastolic function

31. MURMURS &
VALVULAR ANOMALIES

32. Recommendations
• CLASS I
• 1. clinically suspected moderate or greater degrees of
valvular stenosis or regurgitation
• undergo preop echo if
1) no prior echocardiography within 1 year or
2) significant change in clinical status or physical
examination since last evaluation
• 2. for indications of valvular intervention
(replacement and repair) on the basis of symptoms
and severity of stenosis or regurgitation, valvular
intervention before elective noncardiac surgery is
effective in reducing perioperative risk (15). (LOE: C)

33. Importance of type of surgery

34. Cardiac riska stratification for non-cardiac surgery
• High (reported cardiac risk often greater than 5%)
- Emergent major operations, particularly in the elderly
- Aortic and other major vascular surgery
- Peripheral vascular surgery
- Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood
loss
• Intermediate (reported cardiac risk generally less than 5%)
- Carotid endarterectomy
- Head and neck surgery
- Intraperitoneal and intrathoracic surgery
- Orthopedic surgery
- Prostate surgery
• bLow (reported cardiac risk generally less than 1%)
- Endoscopic procedures
- Superficial procedure
- Cataract surgery
- Breast surgery

36. Functional capacity

37. METs
• functional capacity is classified as
Excellent (>10 METs),
Good (7 METs to 10 METs)
moderate (4 METs to 6 METs),
poor (<4 METs)
or unknown.
• Periop cardiac and long-term risks are
increased in pts unable to perform 4 METs of
work during daily activities

39. METs
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

40. Dukes Activity status index

41. The 12-Lead Electrocardiogram:
Recommendations
CLASS IIa
• ECG reasonable for patients with known coronary heart disease,
• significant arrhythmia, peripheral arterial disease, cerebrovascular
• disease, or other significant structural heart disease,
• except for those undergoing low-risk surgery (137–139).
• (Level of Evidence: B)
• CLASS IIb
• ECG may be considered for asymptomatic patients without known
coronary heart disease,except for those undergoing low-risk surgery
• (Level of Evidence: B)
• CLASS III: NO BENEFIT
• Routine 12-lead ECG is not useful for asymptomatic patients undergoing
low-risk surgical procedures
• (Level of Evidence: B)

42. Stepwise Approach to Preoperative Cardiac
Assessment
Poor
(<4 METs)
6. Intermediate
clinical
predictor
Moderate or
excellent
(>4 METs)
Intermediate
or low surgical
risk procedure
High surgical
risk procedure
Low surgical
risk procedure
8. Noninvasive
testing
Consider
coronary
angiography
Subsequent
care dictated
by findings and
treatment results
Operating
room
Postoperative
risk stratification
and risk factor
reduction
Low risk
High risk
Functional
capacity
Surgical
risk
Noninvasive
testing
Invasive
testing