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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