Assessment of Peri-Operative Risk (Not Pre-Op Clearance)

Assessment of Peri-operative Risk (not pre-op clearance)

Quick non-cardiac eval:

Long-standing rheumatoid arthritis – assess C-spine stability with flexion/extension films

Gathering Background Information

History

Past cardiac history

Recent changes in cardiac symptoms

Pacer/AICD

Current medications

Risk factors (HTN, HLD, DM, PVD, tobacco, illicit drug use)

Estimate of functional capacity

Physical Exam

Vitals

JVP

Cardiac/Chest exam

Bruits (carotid, abdominal, femoral)

Labs

HCT (hct <28% is associated with increased incidence of perioperative ischemia and postoperative complications in patients undergoing vascular and prostate surgery)

Risk stratifying the patient – Revised Cardiac Risk Index

Each risk factor is assigned one point.

1. High-risk surgical procedures

Intraperitoneal
Intrathoracic
Suprainguinal vascular

2. History of ischemic heart disease

History of myocardial infarction
History of positive exercise test
Current complain of chest pain considered secondary to myocardial ischemia
Use of nitrate therapy
ECG with pathological Q waves

3. History of congestive heart failure

History of congestive heart failure
Pulmonary edema
Paroxysmal nocturnal dyspnea
Bilateral rales or S3 gallop
Chest radiograph showing pulmonary vascular redistribution

4. History of cerebrovascular disease

History of transient ischemic attack or stroke

5. Preoperative treatment with insulin

6. Preoperative serum creatinine > 2.0 mg/dL

Risk of Major Cardiac Event
Points / Class/Risk
0 / Class I – 0.4%
1 / Class II – 0.9%
2 / Class III – 6.6%
3+ / Class IV – 11%

"Major cardiac event" includes myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block

Risk Stratify the Surgery

Evaluation of Specific Testing and Interventions

ECHO Indications

Dyspnea of unknown origin

Known HF with worsening dyspnea or other change in clinical status

ECG Indications

Vascular Surgery

Indicated if at least one clinical risk factor and undergoing vascular surgery

Reasonable for any vascular surgery

Intermediate Risk Surgery

Indicated for known CAD, PAD, CVD

Reasonable if one risk factor

Low-risk Surgery – Not indicated

Noninvasive Stress Testing

Treat per ACC guidelines if active cardiac condition and noncardiac surgery

3+ risk factors & poor functional capacity who require vascular surgery may be evaluated if it will change management

1-2 risk factors & poor functional capacity & intermediate-risk noncardiac surgery

1-2 risk factors and good functional capacity who are undergoing vascular surgery

Not useful for low-risk noncardiac surgery

Not useful for intermediate-risk surgery in patients with no risk factors

CABG/PCI

Useful in patients with stable angina and significant left main stenosis

Useful in stable angina and 3VD

Useful in stable angina & 2VD with stenosis of proximal LAD and EF < 50%, or demonstable ischemia on noninvasive testing

Recommended for unstable angina or NSTEMI

Recommended for STEMI

Beta-blocker therapy

Continue in all patients who were receiving them prior to surgery

Give to patients undergoing vascular surgery or who are at high cardiac risk

Probably recommended in patients with 1+ risk factor or CAD found in perioperative assessment who are undergoing vascular surgery

Uncertain for single risk factor and intermediate or vascular surgery

Uncertain in patients with no clinical risk factors who are not currently using them

Should not be given to those with contraindications

Care should be taken applying these recommendations to patients with decompensated heart failure, NICM, or severe valvular disease

Statin Therapy

Continue statins for those taking them

Reasonable for those undergoing vascular surgery

Consider for those with 1+ risk factor who are undergoing intermediate risk procedures

Alpha-2 Agonist

May be considered for perioperative control of hypertension in patients with CAD or 1+ risk factor