Overview• Drafted out by American College of Cardiology (ACC) and American Heart

Association (AHA) initially in 1980 then revised again in 2002, 2007 and 2011.

• Comprising almost 20 topics relating to cardiac issues for patients undergoing non cardiac surgery.

• Eg : preoperative noninvasive evaluation of LV function; preoperative resting

12-lead ECG; noninvasive stress testing before non-cardiac surgery; reoperative coronary revascularization; betablocker therapy; statin therapy; preoperative ICU monitoring; use of volatile anesthetic agents; prophylactic

Nitroglycerin, maintenance of normothermia; glucose control; use of pulmonary artery catheters; intraoperative and postoperative ST-segment monitoring; surveillance for perioperative myocardial infarction; and the

tissue of when patients with cardiac stents can safely undergo elective surgery

Purpose

• Quick reference for decision making

• lower the risk of surgery

• evaluation of the patient’s current medical status

• make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire preoperative period

• provide a clinical risk profile can be of use in making treatment decisions that may influence short- and long-term cardiac outcomes

GOALS

– IDENTIFICATION OF PATIENTS WITH UNSTABLE CARDIOVASCULAR CONDITION

– IDENTIFICATION OF PATIENTS WITH KNOWN AND SYMPTOMATIC Coronary Heart Disease (CHD)

– IDENTIFICATION OF PATIENTS AT RISK OF CHD» PVD» HTN» DM» SMOKING» HYPERCHOLESTROLEMIA

CLASSIFICATION OF RECOMMENDATIONS

CLASS 1Benefit >>> Risk

SHOULD

CLASS II ABENEFIT >> RISK

REASONABLE

CLASS II BBENEFIT > RISK

MAYBE CONSIDERED

CLASS IIIRISK > BENEFIT

SHOULD NOT

LEVEL A Multiple (3-5) population risk

LEVEL BLimited (2-3) population risk

LEVEL CVery limited (1-2) population risk

PREOPERATIVE CARDIAC EVALUATION

• Evaluation

History taking

• to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent or past MI, decompensated HF, significant arrhythmias, and severe valvular disease

• history of a pacemaker or implantable cardioverter defibrillator

• Accurate recording of current medications used, including herbal and other nutritional supplements, and dosages

.

• Determine ASA status , surgery classification and functional capacity.

Status State

Class 1 No organic, physiologic, biochemical, or psychiatric disturbance.

Class 2 Mild to moderate systemic disturbance that may or may not be related to the reason for surgery Eg : Essential HTN, DM, Morbid Obesity, Anemia

Class 3 Severe systemic disturbance that may or may not be related to the reason for surgery, (does limit activity)Eg ; Uncontrolled HTN, DM with vascular complications, COPD with func. Limitation, angine pectoris, Hx of MI

Class 4 Severe systemic disturbance that is life-threatening with or without surgery Eg : CHF, advanced pulmonary, renal/hepatic dysfunction

Class 5 Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort)Eg : Uncontrolled hemorrhage from ruptured abdominal aneurysm, cerebal trauma, pulmonary embolism.

Emergency (E) Any patient in whom an emergency operation is required

Risk Stratification

5 FACTORS FOR RISK STRATIFICATION

– Recency Of Coronary Revascularization

– Recency Of Last Favourable Cardiac Evaluation

– Presence Of Comorbidities-clinical Predictors

– Functional Status

– Risk Of Proposed Surgery

1-CORONARY REVASCULARISATION

• Complete coronary surgical revascularization -5 yrs

• PCI-- > 6months-5 yrs

• No recurrent Symptoms or signs of ischemia

• Clinical status is stable

No further cardiac testing is necessary

2-Coronary evaluation

• Past 2 years

• Invasive/non invasive tech

– Favorable– No definite change or new symptom

No further cardiac testing is necessary

3-Clinical predictors

• Major– Unstable coronary syndromes

• recent MI with evidence for ischemia ( >7 days & < 30days)• unstable or severe angina

– Decompensated CHF– Significant arrhythmia

• high grade AV block• symptomatic ventricular arrhythmia • supraventricular arrhythmia with uncontrolled rate

– Severe valvular disease

• Intermediate– Mild angina pectoris (Canadian class I or II)– Prior MI by history or pathological Q waves– Compensated or prior CHF– Diabetes mellitus– Renal impairment (creatinine > 2mg per dL)– Anemia – Pulmonary Disease (obstructive/restrictive)

• Minor– Advanced age– abnormal ECG (LVH, LBBB, ST-T change)– Rhythm other than sinus– Low functional capacity– History of stroke– Uncontrolled systemic hypertension

Functional Capacity

• Functional capacity can be expressed as metabolic equivalents (METs); the resting or basal oxygen consumption (Vo2) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min, or 1 MET.

Duke’s Activity Status Index

• 1 MET– Can you take care of

self? – Eat, dress, use toilet?– Walk indoors in house?– Walk a block or two on

level at 2-3 mph?– Do light housework like

dusting or dishes?

• 4 METs

• 4 METsClimb a flight of stairs,

walk up hill?Walk on level at 4 mph?Run a short distance?Heavy houseworkGolf, bowling, dancing,

doubles tennisSwimming, singles tennis

football, basketball, skiing

• >10 METs

1 MET = 3.5 ml/kg/mt VO2

>10 METs-Excellent7-10 good4-7 moderate≤ 4 poor

Classification of surgeries according to Risk.

• High (reported cardiac risk > 5%)

• emergent major operations, esp. in elderly

• aortic and other major vascular procedures

• peripheral vascular procedures

• anticipated prolonged procedure with large fluid shift/blood loss

• Intermediate (reported cardiac risk < 5%)

– carotid endarterectomy

– head and neck

– intraperitoneal & intrathoracic

– orthopedic

– prostate

• Low (reported cardiac risk < 1%)

– endoscopic procedures

– superficial procedure

– cataract

– breast

9 step algorithm

9 step algorithm

9 step algorithm9 step algorithm

Cardiac Conditions that Need Evaluation and Treatment Before Surgery

Condition Examples

Unstable coronary syndromes

Unstable or severe angina (CCS class III, IV) , Recent MI

Decompensated HF

Significant Arrhythmias High Grade AV Block, Mobitz II AV Block, 3rd Degree AV block, Symptomatic Ventricular Arrhythmias, Supraventricular Arrhytmias with HR > 100 bpm at rest, Symptomatic Bradycardia, Newly Recognized VT

Severe Valvular Disease Severe aortic stenosis, Symptomatic Mitral Stenosis (dyspnea on exertion, exertional presyncope or HF)

• Class IIA

• It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms‡ proceed to planned surgery. 

• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for vascular surgery consider testing if it will change management. 

• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control.

• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.

• Class IIB

• Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery. ∥

• Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery. ∥

PREOP TESTING

• ECG

• DETECT LVH,BBB & CONDUCTION DEFECT

• PREVIOUS MI

• BASELINE FOR INTRA AND POST OP COMPARISON

• INCREASED PERIOP RISK• ST DEPRESSION MORE THAN .5 MM• LVH WITH STAIN PATTERN• LBBB

• EXERCISE STRESS TEST

• STRONGEST DETERMINANT OF RISK AND NEED FOR INVASIVE MONITORING

• LEAD SELECTION

• ECG CRITERIA– 1 M M OF J POINT DEPRESSION

– 2MM OF ST DEPRESSION AT 80 MS FROM J POINT

– ST ELEVATION

– NON ECG RESP• LOW ACHIEVED HR• SYSTOLIC HYPOTENSION• INABILITY TO EXERCISE FOR MORE THAN 3 MIN

PHARMACOLOGICAL STRESS TEST

• Two Categories– Dobutamine Stress Echo-incr. Mvo2

– New/Incr In Rwma– More Than 5/16 Lt Ventricular Segm Involvement

– Dipyridamole Thallium-mimics Coronary Art Dialatation Resp Associated With Exercise

– Infarcted Area-fixed Defect– Ischemic Area-reversible Defect

ECHOCARDIOGRAPHY

– LVEF– RWMA– Valvular Abn– Cong Cardiac Defects

CORONARY ANGIOGRAPHY

• Non Invasive Testing-high Risk Of Adverse Outcome

• Angina Unresponsive To adequate Medical Therapy

• Unstable Angina-intermediate And High Risk Sx

• High Clinical Predictor In High Risk Sx

PERIOP THERAPY

• BETA BLOCKERS– CVS EFFECTS

• ↓ HR-(diastolic Time)• ↓ Contractility• Plaque Stabilization- ↓ Shear Forces• Antiarrythmic Effect

– ELIGIBILITY CRITERIA• CLINICAL -ANY 2

– AGE>65– HTN– CHR SMOKER– SER CHOLESTROL>240 mg/dl– DM

• CARDIAC RISK INDEX CRITERIA– HIGH RISK SX PROCEDURE– IHD– CVA– DM– CRF

OTHER THERAPIES

• Alpha-2 Adrenergic Agonist

• Regional Anesthesia

– Epidural