Ryan Hampton January 2015

 Risks and benefits of surgery  Timing of surgery  Type of Surgery  Goal is to uncover undiagnosed problems or treat prior conditions previously sub-optimally treated.

 Myocardial Infarction  Heart Failure  Ventricular Fibrillation  Cardiac Arrest  Complete Heart Block  Cardiac Death

 Revised Cardiac Risk Index (RCRI)  American College of Surgeons’ National Surgical Quality Improvement Program (ACS- NSQIP) risk calculator  Gupta MI or cardiac arrest (MICA) calculator  These calculators generate risk as a percent

 Subjective  PMH: DM2, CKD, HTN, CVA, PAD  ROS: angina, dyspnea, syncope, palpitations  Cardiac Functional Status  Expressed in metabolic equivalents (METs)  1 MET = 3.5 mL O2 uptake/kg/min  Can use equivalent functions to determine METs  Eg: if patient can take care of self = 1 MET  Eg: can participate in strenuous sports = >10 METs

 Functional Status Threshold  Important Indicator: does patient’s cardiac function allow him/her to climb two flights of stairs or walk four blocks  Objective  Blood pressure  Auscultation of heart and lungs  Abdominal exam  Extremity exam for edema and vascular integrity  EKG for known CV disease  Limited utility in asymptomatic patient  Not part of RCRI or NSQIP criteria due to lack of prognostic specificity  However, routinely obtained pre-op for baseline comparison

 History of ischemic heart disease  History of heart failure  History of CVA  Insulin dependent DM  Pre-op serum Cr >2.0  American Society of Anesthesiologist’ class  Pre-operative functional status  Increasing age  Atrial Fibrillation*  Obesity* *Not used in prediction models

 POISE Trial (Perioperative Ischemic Evaluation)  8351 patients at high risk for or with atherosclerosis undergoing non-cardiac surgery  35 (0.4%) required coronary revascularization post- operatively  So, value of risk prediction models may be waning

 Information from assessment combined with risk associated with the surgery is used to estimate perioperative risk of adverse cardiac events.  Risk Determines:  If surgery can proceed without further CV testing  If stress testing, echo, 24-hour ambulatory monitoring, changing plan of surgery to decrease risk, or canceling surgery so coronary revascularization can be performed is necessary

 Used to determine risk factors associated with intraoperative/ postoperative MI or cardiac arrest (MICA)  Among 200,000 patients undergoing surgery in 2007, 0.65% developed perioperative MICA  5 Factors Contributing to MICA 1. Type of Surgery 2. Dependent Functional Status 3. Abnormal Creatinine 4. ASA Class 5. Increased Age

 Low Risk Patients  Estimated risk of death is less than 1 percent  No additional CV testing is required  Higher Risk Patients  Risk of death is 1% or higher  May require additional CV evaluation  Often, known CAD or valvular heart disease

 Stress testing  Not indicated in perioperative patient solely because of the surgery if there is no other indication  Patients with moderate to good function (>4 – 10 METs), reasonable to forego further testing  May be considered for patients undergoing elevated risk procedure in whom functional capacity is unknown if management will be affected (Level of Evidence: B)  Indicated with elevated risk and <4 METs or unknown functional capacity  Resting Echocardiography  Not indicated in the perioperative patient unless there is another indication (eg: murmur, valve function, LVEF, etc.)

 Routine preoperative coronary angiography NOT recommended – insufficient data to support coronary angiography in all patients