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Cardiac Risk Assessment. Moderator : Dr S. Aneja. Goals. Identify pts at risk history , physical examination, ECG Evaluate the severity of underlying cardiac disease

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cardiac risk assessment

Cardiac Risk Assessment

Moderator : Dr S. Aneja

  • Identify pts at risk

history , physical examination, ECG

  • Evaluate the severity of underlying cardiac disease
  • Stratify extent of risk & determine the need for pre op interventions to minimize risk of peri op cardiac complications
evaluation of cardiac risk
Evaluation of Cardiac Risk
  • Review of History
  • Physical Examination
  • Diagnostic tests
  • Knowledge of planned surgical procedure


  • Risk factors : Age, HTN, DM, Dyslipidemias,


  • Angina : Stable/ unstable, present medications.
  • Previous MI : How was it?
  • MI : NYHA grading, functional capacity
  • Dysrhythmias : Palpitations.
  • Associated CVS disease : Carotid, cerebral, aortic, PVD.

7) Presence of pacemaker/ ICD.


Valvular Heart disease :

  • Dyspnea, Orthopnea, PND.
  • Embolic events.
  • Hemoptysis.
  • Heart failure, palpitations.

Prior cardiac evaluation :

  • Non invasive tests.
  • Angiography/ Stenting.

Medications :

  • Details.
  • Effectiveness.

Physical examination :

  • General examination :

Cyanosis, pallor, dyspnea during conversation or with minimal activity, poor nutritional status, obesity, skeletal deformities, tremor & anxiety are just a few of the clues of underlying disease or CAD.

2) Vitals : Pulse, BP , Pulse pressure, Respiration.


3) Cardiac examination :

JVP, edema feet,

Displaced apical impulse (cardiomegaly),

S3 gallop ( increased LVEDP ),

S4 ( decreased compliance),

Apical systolic murmur ( Papillary muscle

dysfunction ),

Presence of murmurs,

Pulmonary edema.

functional capacity
Functional Capacity
  • Functional status has shown to be a reliable periop and long-term predictor of cardiac events
  • Functional status determined based on ability to do ADL’s
  • MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest wch is 3.5 ml/kg/min

Functional Capacity :

Excellent : > 10 METS

Good : 7 -10 METS

Moderate : 4 – 7 METS

Poor : < 4 METS


Moderate recreational golf, dancing, baseball

Strenuous sports swimming, basketball

DO light house work i.e. Washing dishes

Climb a flight of stairs

Run a short distances

Eat, dress

10 MET



goldman risk index
Goldman Risk Index

Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

goldman risk index1
Goldman Risk Index

Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

revised cardiac risk index rcri by lee
Revised Cardiac Risk Index (RCRI) by Lee
  • High Risk Surgical Procedure –

defined as thoracic, abdominal, or pelvic vascular(eg aorta, renal , mesenteric)

  • Ischemic heart ds – defined as

- h/o MI

- h/o or current angina

- use of s/l nitroglycerine

- positive exercise test

- Q waves on ECG

- h/o PTCA or CABG done


3. Heart failure - defined as

- LV failure by physical examination

- h/o PND

- h/o Pulmonary Edema

- S3 or b/lrales on physical exam

- pulmonary edema on CXR

4 . Cerebro vascular ds – defined as

- h/o transient ischemic attack

- h/o CVA


Insulin dependent DM

  • Chronic Renal Insufficiency – defined as

baseline creatinine > = 2.0 mg/dl

The rates of major cardiac complications were found to be 0.5 %,1.3% , 4 % & 9 % in pts with 0 , 1 , 2 or 3 or more of these risk factors, respectively.

acc aha 2007 guidelines

Overriding theme is that Intervention is RARELY necessary to simply lower the risk of sx, unless such intervention is indicated irrespective of the pre op context.

No test should be performed unless it is likely to influence pt treatment.

clinical assessment
Clinical Assessment

ACC/AHA 2007 have done away with segregation into major, intermediate & minor risk factors

Now : ACTIVE CARDIAC CONDITIONS that wn present indicate major clinical risk

Presence of 1 or more of these cond mandates intensive mx & may result in delay or cancellation of sx unless the sx is emergent


1. Unstable Coronary Syndromes

- Recent MI

- Unstable or severe angina

2. Decompensated congestive cardiac failure

3. Significant arrhythmias

4. Severe Valvulards


Intermediate risk category is replaced with CLINICAL RISK FACTORS from Lee’s Index

  • h/o ischemic heart ds
  • Compensated or prior cong heart failure
  • h/o cerebro vascular ds
  • DM
  • Renal insufficiency

Minor risk predictors like advanced age, abnormal ECG – LVH, LBBB, ST T abnormalities, uncontrolled systemic htn have been done away with.

Not proven to increase peri op risk independently


Noninvasive tests can be divided into :

  • Resting tests – Resting ECHO.
  • Exercise stress tests
  • pharmacologic tests
  • Dobutamine stress echo
  • Dipyridamole thallium scanning
  • Ambulatory ECG monitoring.
preoperative testing negative predictive value
Preoperative TestingNegative Predictive Value

Freedom from MI or Death

Eagle et al. JACC 1996;27:910.


Recommendations for Noninvasive Stress Testing According to the ACC/AHA Guidelines (2007)

Poldermans, D. et al. J Am CollCardiol 2008;51:1913-1924

pre op coronary revascularization with cabg or pci
Pre op coronary revascularization with CABG or PCI

The indication for CABG or PCI before non cardiac surgery remains the same as in non operative setting.

The philosophy of performing pre op coronary re vascularization merely “ to get the pt thro sx” is contrary to available evidence.

timing of surgery after pci
Timing of Surgery After PCI

Balloon angioplasty



< 14 days

> 14 days

< 30-45 days

> 30-45 days

< 365 days

> 365 days


Sx with



Sx with



Sx with


pci before anticipated surgery
PCI before anticipated surgery

Acute MIHigh Risk ACSHigh risk anatomy

Bleeding risk of anticipated surgery

Stent and continued

Dual-antiplatelet rx


Not low

14 to 29 Days

30 – 365 Days

> 365


Balloon angioplasty



preoperative therapy with b blockers
Preoperative Therapy with B-Blockers
  • Start pre-op, titrate to HR<60 bpm
  • Short acting beta-blockers provide more flexible dosing
  • Give orally, if possible, with IV supplementation when patient NPO

Postoperative Cardiac Events In High Risk Patients

  • 173 patients undergoing vascular surgery with positive DSE
  • Randomized to BB 1 week pre-op or placebo
  • Followed for 30 days

Placebo n=53

Bisoprolol n=59

Poldermans et al. NEJM 1999;341:1789.