CARDIAC RISK ASSESSMENT FOR NONCARDIAC SURGERY

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

2. 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.

3. 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%).

4. 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

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

6. 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.

7. 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.

8. 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

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

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

11. PREDICTORS OF INCREASED PERIOPERATIVE CV RISK INTERMEDIATE • MILD ANGINA • PRIOR MYOCARDIAL INFARCCTION • COMPENSATED OR PRIOR CHF • DIABETES MELLITUS

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

13. SURGERY SPECIFIC CARDIAC RISK HIGH(CARDIAC RISK>5%) • EMERGENT MAJOR OPERATION • AORTIC AND OTHER MAJOR VASCULAR • PERIPHERAL VASCULAR • ANTICIPATED PROLONGED PROCEDURE

14. SURGERY SPECIFIC CARDIAC RISK INTERMEDIAC(CARDIAC RISK<5%) • CAROTID ENDARTERECTOMY • HEAD AND NECK • INTRAPERITONEAL AND INTRATHORACIC • ORTHOPEDIC • PROSTATE

15. SURGERY SPECIFIC CARDIAC RISK LOW(CARDIAC RISK<1%) • ENDOSCOPIC PROCEDURES • SUPERFICIAL PROCEDURES • CATARACT • BREAST

16. FUNCTIONAL CAPACITY

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

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

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

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

21. Stepwise Approach to Preoperative Cardiac Assessment 1. Need fornoncardiacsurgery 2. Coronaryrevascularizationwithin 5 years ? 3. Recentcoronaryevaluation No No Urgent or Elective Yes 4. Clinical predictors Recurrentsymptomsor signs ? Emergency Yes Yes Recent coronaryangiogram or stress test ? No Operating Room Favorable AND no change in symptoms Unfavorable OR change in symptoms Postoperative risk stratification and risk factor management

22. Stepwise Approach to Preoperative Cardiac Assessment 4. Clinical predictors 5. Major clinical predictor 6. Intermediate clinical predictor 7. Minor or no 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

23. Stepwise Approach to Preoperative Cardiac Assessment 5. 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

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

25. Stepwise Approach to Preoperative Cardiac Assessment Functionalcapacity Surgicalrisk Noninvasivetesting Invasivetesting Poor (<4 METs) High surgical risk procedure 8. Noninvasive testing High risk Low risk 7. Minor or no clinical predictor Consider coronary angiography Intermediate or low surgical risk procedure Operating room Moderate or excellent (>4 METs) Postoperative risk stratification and risk factor reduction Subsequent care dictated by findings and treatment results Low surgical risk procedure

26. 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.