Cardiovascular Pre-Operative Evaluation for Non-Cardiac Surgery Jessica Thom PGY-1

2007 ACC/AHA Pre-Op Guidelines for Cardiovascular Evaluation and Care for Non-Cardiac Surgery

Heart disease and procedures 1.3 million Canadians (4.3%) reported to have heart disease The prevalence of heart disease increases with age The largest number of non-cardiac surgical procedures performed in patients aged 65 and older.

Methodology & Evidence Literature searches in PubMed, MEDLINE and Cochrane Library Searches limited to studies published in English between Reviewed 400 relevant new articles focused on perioperative risk for cardiac complications following non-cardiac surgery

Role of the consultant Review available patient data Obtain a pertinent history Perform a thorough physical examination Suggest preoperative tests/procedures or higher levels of post-op care Pre-op tests are generally only indicated if the information obtained will change treatment Be weary of solely focusing on the question at hand. Aim instead to provide a comprehensive evaluation of the patient’s risk

History Cardiac history: unstable/stable angina, prior MI, decompensated HF, arrhythmias, severe valvular disease, presence of pacemaker/ICD If cardiac disease is present: any recent change in symptoms? Evidence of associated diseases: DM, CKD, stroke, PVD, chronic pulmonary disease Record all medications (including herbals) Social habits: smoking history Determine the functional capacity As determined based on METS

What’s a MET?

What cardiac conditions should I work up and treat?

Physical Exam Vital signs General appearance Cardiac exam Pulmonary exam Examination of area undergoing surgery

Clinical risk factors for cardiac complications in non-cardiac surgery High risk surgery Ischemic heart disease Heart failure Diabetes Renal insufficiency – Pre-op creatinine > 2.0mg/DL (175 mmol/L) Previous stroke

Relative risks of surgical procedures Low risk: Opthalmologic procedures, superficial procedures, endoscopy, breast surgeries Intermediate risk: Orthopedic surgeries, intra- abdominal surgeries, intra-thoracic surgeries, ENT surgeries, prostate surgery, carotid endarterectomies High risk: All other vascular surgeries

Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical conditions. †See Clas... Fleisher L A et al. Circulation 2007;116:e418-e500 Copyright © American Heart Association The all important algorithm

Additional Testing?

Role of a 12-lead EKG Indicated in: All patients undergoing vascular surgery Patients with at least 1 clinical risk factor undergoing intermediate risk surgery

Non-invasive stress testing Reasonable in patients with 3+ clinical risk factors and poor functional capacity (<4 METS) undergoing vascular surgery if it will change management (IIa) Consider in patients with 2+ clinical risk factors and poor functional capacity undergoing intermediate-risk surgery if it will change management (IIb)

Pre-op Coronary Revascularization with CABG or PCI Class I: In patients with acute STEMI In patients with high-risk unstable angina or NSTEMI In patients with stable angina who have: Significant left main disease 3-vessel disease (survival benefit greater in patients with EF <50%) 2-vessel disease + significant proximal LAD stenosis + either EF <50% or ischemia on non-invasive testing.

Class IIa: In patients whom PCI will mitigate cardiac symptoms and who need elective non-cardiac surgery in the next 12 months Balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is indicated.

Beta blockers? Limitations in the perioperative beta-blocker literature include the following: Few randomized trials have examined the role of perioperative beta-blocker therapy Most trials are inadequately powered. Studies to determine the optimal type of beta blockers are lacking. Few studies addressing the optimal time at which beta blockers should be started in the perioperative period.

Figure 2. Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion. Fleisher L A et al. Circulation 2007;116:e418-e500 Copyright © American Heart Association What to do about those stents?

Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery. Fleisher L A et al. Circulation 2007;116:e418-e500 Copyright © American Heart Association

For the full guidelines:

Pulmonary Pre-Operative Evaluation for Non-Pulmonary Surgery

Risk factors Age >50 Chronic lung disease Asthma Smoking OSA Pulmonary HTN Poor functional status Upper respiratory infection

Procedural risk factors Site of surgery Highest risk – thoracic, upper abdominal surgeries, AAA repair, ENT, neurosurgery Duration of surgery – greater than 3 to 4 hours Type of anesthesia?

Pulmonary Function Testing May be useful in the following cases: Identifying patients in whom risk of surgery does not justify the benefit Identifying patients at high risk that may benefit from aggressive pre-op optimization

Pulmonary Function Testing ACP recommendations: Do not obtain PFTs routinely to predict pulmonary post-op complications PFTs should NOT deny a patient surgery Obtain PFTs: In patients with COPD or asthma if clinical evaluation cannot determine is patient is at best baseline and would benefit from pre-op optimization In patients with dyspnea and exercise intolerance that remains unexplained after clinical evaluation

Chest X-Ray Add little to clinical evaluation of healthy patients Obtain CXR: In patients with known cardiopulmonary disease Unless CXR has been obtained in past 6 months In patients aged > 50 undergoing high risk procedures (thoracic/upper abdominal surgeries, AAA repair, ENT surgeries).

Arrouzullah Respiratory Failure Index Pre-operative predictorPoint value Type of surgery AAA27 Thoracic21 Neurosurgery, upper abdominal14 ENT11 Emergency surgery11 Albumin <3.0g/dL9 BUN >30 mg/dL8 Partially/fully dependent functional status7 History of COPD6 Age >

Arouzullah Respiratory Failure Index ClassPoint total%Resp Failure 1< >4026.6