Pro operative cardiac Pro operative cardiac clearence for non cardiac clearence for non cardiac

surgerysurgery

Dr Mohamed Ahmed MukhtarDr Mohamed Ahmed Mukhtar

MBBS,MRCP MBBS,MRCP King Fahd National Guard Hospital King Fahd National Guard Hospital

What is the rationale?What is the rationale?

About 500,000-900,000 per year suffer cardiac About 500,000-900,000 per year suffer cardiac death ,periop MI and nonfatal cardiac arrest death ,periop MI and nonfatal cardiac arrest during noncardiac surgery.during noncardiac surgery.

Risk of peri op.MI can be as high as 50 % in Risk of peri op.MI can be as high as 50 % in certain situations.certain situations.

Increasingly older patients undergo high risk Increasingly older patients undergo high risk noncardiac surgeries.noncardiac surgeries.

Periop hypercoagulable state,proinflamatory Periop hypercoagulable state,proinflamatory states and hypoxia conttribute to periop events.states and hypoxia conttribute to periop events.

What is the objective?What is the objective?

1- To assess current status .1- To assess current status . 2-To assess cardiac risks posed by the 2-To assess cardiac risks posed by the

specific operation.specific operation. 3-To recommend strategies to influence 3-To recommend strategies to influence

long term and short term outcomes.long term and short term outcomes.

General principles:General principles:

Not everybody needs a non invasive test.Not everybody needs a non invasive test. Non invasive test to be done only if the Non invasive test to be done only if the

result of the tests will influence the result of the tests will influence the outcome.outcome.

Preop cardiac intervention will only be Preop cardiac intervention will only be done if it is needed any way.done if it is needed any way.

Communication with the treating Communication with the treating department is an essential part of the department is an essential part of the process.process.

How to assess a patient going for a non How to assess a patient going for a non cardiac surgery from a cardiac stand cardiac surgery from a cardiac stand point?point?

History:History: Identify cardiac condition and Identify cardiac condition and

symptoms.Special attention to current symptoms.Special attention to current MI ,unstable angina ,decompensated MI ,unstable angina ,decompensated CHF,significant arrhythmia and severe CHF,significant arrhythmia and severe valvular heart disease .valvular heart disease .

Identify serious comorbid condition and Identify serious comorbid condition and cardiac risk factors.cardiac risk factors.

Assess functional capacity.Assess functional capacity.

Examination:Examination: Full exam with a focus on cardiovascular Full exam with a focus on cardiovascular

system with attention specially to severe system with attention specially to severe valvular disease and CHF signsvalvular disease and CHF signs

InvestigationsInvestigations

Predictors of riskPredictors of risk

MajorMajor IntermediateIntermediate MinorMinor

IntermediateIntermediate

MinorMinor

Age more than 70Age more than 70 Abnormal ECGAbnormal ECG Rhythm other than sinusRhythm other than sinus Uncontrolled HTNUncontrolled HTN

Specific surgical riskSpecific surgical risk

Stepwise assessmentStepwise assessment

Specific disease statesSpecific disease states

CADCAD

In patients with known CAD, as well as those with previouslyoccult coronary disease, the questions become 1) What is theamount of myocardium in jeopardy? 2) What is the ischemicthreshold, that is, the amount of stress required to produceischemia? 3) What is the patient’s ventricular function? and4) Is the patient on his or her optimal medical regimen?Clarification of these questions is an important goal of thepreoperative history and physical examination, and selectednoninvasive testing is used to determine the patient’s prognosticgradient of ischemic response during stress testing.

HTNHTN

Valve patientsValve patients

Severe ASSevere AS Severe MSSevere MS AF patientsAF patients Mechanical valves :Reduce INR to Mechanical valves :Reduce INR to

subtherapeutic range in superficial or dental subtherapeutic range in superficial or dental procedures ,in others with risk of thrombosis is procedures ,in others with risk of thrombosis is higher shift to heparin perioperatively(higher shift to heparin perioperatively(3 or more of the following risk factors put the patient at high risk: atrial fibrillation, previous embolus at any time,hypercoagulable condition, mechanical prosthesis, and LVejection fraction less than 30%).These also need BE prophylaxis