CARDIAC RISK ASSESSMENT FOR NONCARDIAC SURGERY JOHN HAMATY D.O. SOUTH JERSEY HEART GROUP SJHG.ORG

INTRODUCTION: CAD ACCOUNTS FOR THE MOST DEATHS IN PTS UNDERGOING NONCARDIAC SURGERY. 5% OF ELDERLY POPULATION IN US UNDERGO NONCARDIAC SURGERY/YR. 30% ARE AT RISK FOR CAD WITH IN- HOSPITAL COMPLICATIONS IN 1.5 MIL. PTS.

PERIOPERATIVE RISK OF EVENTS PATIENTS WITH NO PRIOR HISTORY OF MYOCARDIAL INFARCTION 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%).

PERIOPERATIVE RISK OF EVENTS (HISTORY OF PRIOR MI) MI WITHIN 3 MOS.-37% INCREASE IN EVENTS MI WITHIN 3-6MOS.-16% INCREASE IN EVENTS MI GREATER THAN 6 MOS.-4% INCREASE IN EVENTS

A STEPWISE APPROACH FOR PERIOPERATIVE RISK ASSESSMENT OF A PATIENT UNDERGOING NONCARDIAC SURGERY

URGENCY OF SURGERY ALL PATIENTS UNDERGOING URGENT SURGERY SHOULD BE BETA- BLOCKED TO A HEART RATE OF 50 BEATS/MIN AND A BLOOD PRESSURE THAT IS CONTROLLED.

PRIOR REVASCULARIZATION PTS WHO HAVE UNDERGONE COMPLETE REVASCULARIZATION IN THE FORM OF CORONARY ARTERY BYPASS OR PTCA WITHIN 6 MONTHS TO 5 YEARS AND ARE FUNCTIONALLY ACTIVE AND HAVE NO CLINICAL EVIDENCE OF ISCHEMIA DO NOT NEED FURTHER CARDIAC TESTING.

PRIOR EVALUATION FOR CAD PTS. THAT HAVE BEEN EVALUATED IN THE PAST TWO YEARS WITH EITHER INVASIVE OR NONINVASIVE TECHNIQUES WITH FAVORALE FINDINGS GENERALLY DO NOT NEED FURTHER EVALUATION. MUST BE FREE OF CARDIAC SYMPTOMS AND OR SIGNS OF ISCHEMIA

PRESENCE OF CLINICAL RISK FACTORS HISTORY, PHYSICAL AND ECG ARE GENERALLY SUFFICIENT TO ESTIMATE CARDIAC RISK ASSESSMENT OF CLINICAL RISK FUNCTIONAL CAPACITY

PREDICTORS OF INCREASED PERIOPERATIVE CV RISK MAJOR MAJOR UNSTABLE ANGINAUNSTABLE ANGINA RECENT MYOCARDIAL INFARCTION(>7 BUT 7 BUT <30 DAYS DECOMPENSATED CHFDECOMPENSATED CHF SYMPTOMATIC ARRHYTHMIAS(RAPID VENTRICULAR RESPONSES.)SYMPTOMATIC ARRHYTHMIAS(RAPID VENTRICULAR RESPONSES.)

PREDICTORS OF INCREASED PERIOPERATIVE CV RISK INTERMEDIATE INTERMEDIATE MILD ANGINAMILD ANGINA PRIOR MYOCARDIAL INFARCCTIONPRIOR MYOCARDIAL INFARCCTION COMPENSATED OR PRIOR CHFCOMPENSATED OR PRIOR CHF DIABETES MELLITUSDIABETES MELLITUS

PREDICTORS OF INCREASED PERIOPERATIVE CV RISK MINOR MINOR ADVANCED AGEADVANCED AGE ABNORMAL ECG(LVH, LBBB)ABNORMAL ECG(LVH, LBBB) RHYTHM OTHER THAN SINUS(CONTROLLED)RHYTHM OTHER THAN SINUS(CONTROLLED) LOW FUNCTIONAL CAPACITYLOW FUNCTIONAL CAPACITY HISTORY OF CVAHISTORY OF CVA UNCONTROLLED HYPERTENSIONUNCONTROLLED HYPERTENSION

SURGERY SPECIFIC CARDIAC RISK HIGH(CARDIAC RISK>5%) EMERGENT MAJOR OPERATIONEMERGENT MAJOR OPERATION AORTIC AND OTHER MAJOR VASCULARAORTIC AND OTHER MAJOR VASCULAR PERIPHERAL VASCULARPERIPHERAL VASCULAR ANTICIPATED PROLONGED PROCEDUREANTICIPATED PROLONGED PROCEDURE

SURGERY SPECIFIC CARDIAC RISK INTERMEDIAC(CARDIAC RISK<5%) CAROTID ENDARTERECTOMYCAROTID ENDARTERECTOMY HEAD AND NECKHEAD AND NECK INTRAPERITONEAL AND INTRATHORACICINTRAPERITONEAL AND INTRATHORACIC ORTHOPEDICORTHOPEDIC PROSTATEPROSTATE

SURGERY SPECIFIC CARDIAC RISK LOW(CARDIAC RISK<1%) ENDOSCOPIC PROCEDURESENDOSCOPIC PROCEDURES SUPERFICIAL PROCEDURESSUPERFICIAL PROCEDURES CATARACTCATARACT BREASTBREAST

FUNCTIONAL CAPACITY

EXCELLENT(ACTIVITIES>7METS) CARRY 24 LBS UP 8 STEPSCARRY 24 LBS UP 8 STEPS CARRY OBJECTS THAT WEIGH 80 LBS.CARRY OBJECTS THAT WEIGH 80 LBS. RECREATION(SKI, BASKETBALL, WALK 5MPH)RECREATION(SKI, BASKETBALL, WALK 5MPH)

FUNCTIONAL CAPACITY MODERATE(ACTIVITIES >4 BUT 4 BUT <7 METS) HAVE SEXUAL INTERCOURSE WITHOUT STOPPINGHAVE SEXUAL INTERCOURSE WITHOUT STOPPING WALK 4 MPH ON LEVEL GROUNDWALK 4 MPH ON LEVEL GROUND OUTDOOR WORK(GARDEN, RAKE, WEEK)OUTDOOR WORK(GARDEN, RAKE, WEEK) RECREATION(DANCE, SWIM)RECREATION(DANCE, SWIM)

FUNCTIONAL CAPACITY POOR (ACTIVITY <4 METS) SHOWER/DRESS WITHOUT STOPPINGSHOWER/DRESS WITHOUT STOPPING WALK 2.5 MPH ON LEVEL GROUNDWALK 2.5 MPH ON LEVEL GROUND OUTDOOR WORK(CLEAN WINDOWS)OUTDOOR WORK(CLEAN WINDOWS) RECREATION(PLAY GOLF, BOWL)RECREATION(PLAY GOLF, BOWL)

FUNCTIONAL CAPACITY IS ONE OF THE MOST USEFUL MEASURES OF PREOPERATIVE RISK

Stepwise Approach to Preoperative Cardiac Assessment 1. Need for noncardiac surgery 2. Coronary revascularization within 5 years ? Recurrent symptoms or signs ? 3. Recent coronary evaluation Recent coronary angiogram or stress test ? Postoperative risk stratification and risk factor management Operating Room 4. Clinical predictors Urgent or Elective Emergency Yes No Unfavorable OR change in symptoms Favorable AND no change in symptoms

Stepwise Approach to Preoperative Cardiac Assessment 4. Clinical predictors 6. Intermediate clinical predictor 7. Minor or no clinical predictor 5. Major clinical predictor Unstable coronary syndromes Decompensated congestive heart failure Significant arrhythmia Severe valvular disease Mild angina pectoris Prior myocardial infarction Compensated or prior CHF Diabetes mellitus Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension

Stepwise Approach to Preoperative Cardiac Assessment 5. Major clinical predictor Major Clinical Predictor Major Clinical Predictor Unstable coronary syndromes Decompensated congestive heart failure Significant arrhythmia Severe valvular disease Consider delay or cancel noncardiac surgery Consider coronary angiography Medical management and risk factor modification Subsequent care dictated by findings and treatment results

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

Stepwise Approach to Preoperative Cardiac Assessment Poor (<4 METs) 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 7. Minor or no clinical predictor

IN THE ABSENCE OF CONTRAINDICATIONS, BETA BLOCKADE THERAPY SHOULD BE GIVEN TO ALL PATIENTS AT HIGH RISK FOR CORONARY EVENTS(DIABETICS) TREATMENT SHOULD BE GIVEN SEVERAL DAYS OR WEEKS PRIOR TO OR AT DOSES TO ACHIEVE HR 50 AND BP OF 100mm hg.