Cardiovascular Pre-Operative Evaluation for Non-Cardiac Surgery

Jessica ThomPGY-1

2007 ACC/AHA Pre-Op Guidelines for Cardiovascular Evaluation and Care

for Non-Cardiac Surgery

Heart disease and procedures1.3 million Canadians (4.3%) reported to have

heart disease

The prevalence of heart disease increases with age

The largest number of non-cardiac surgical procedures performed in patients aged 65 and older.

Methodology & EvidenceLiterature searches in PubMed, MEDLINE and Cochrane

Library

Searches limited to studies published in English between 2002-07

Reviewed 400 relevant new articles focused on perioperative risk for cardiac complications following non-cardiac surgery

Role of the consultantReview available patient data

Obtain a pertinent history

Perform a thorough physical examination

Suggest preoperative tests/procedures or higher levels of post-op care Pre-op tests are generally only indicated if the information obtained will

change treatment

Be weary of solely focusing on the question at hand. Aim instead to provide a comprehensive evaluation of the patient’s risk

HistoryCardiac history: unstable/stable angina, prior MI,

decompensated HF, arrhythmias, severe valvular disease, presence of pacemaker/ICD If cardiac disease is present: any recent change in symptoms?

Evidence of associated diseases: DM, CKD, stroke, PVD, chronic pulmonary disease

Record all medications (including herbals)

Social habits: smoking history

Determine the functional capacity As determined based on METS

What’s a MET?

What cardiac conditions should I work up and treat?

Physical ExamVital signs

General appearance

Cardiac exam

Pulmonary exam

Examination of area undergoing surgery

Clinical risk factors for cardiac complications in non-cardiac surgery

High risk surgery

Ischemic heart disease

Heart failure

Diabetes

Renal insufficiency – Pre-op creatinine > 2.0mg/DL (175 mmol/L)

Previous stroke

Relative risks of surgical procedures

Low risk: Opthalmologic procedures, superficial procedures, endoscopy, breast surgeries

Intermediate risk: Orthopedic surgeries, intra-abdominal surgeries, intra-thoracic surgeries, ENT surgeries, prostate surgery, carotid endarterectomies

High risk: All other vascular surgeries

Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical

conditions. †See Clas...

Fleisher L A et al. Circulation 2007;116:e418-e500

Copyright © American Heart Association

The all important algorithm

Additional Testing?

Role of a 12-lead EKG Indicated in:

All patients undergoing vascular surgeryPatients with at least 1 clinical risk factor undergoing

intermediate risk surgery

Non-invasive stress testingReasonable in patients with 3+ clinical risk factors and poor

functional capacity (<4 METS) undergoing vascular surgery if it will change management (IIa)

Consider in patients with 2+ clinical risk factors and poor functional capacity undergoing intermediate-risk surgery if it will change management (IIb)

Pre-op Coronary Revascularization with CABG or PCI

Class I:

In patients with acute STEMI

In patients with high-risk unstable angina or NSTEMI

In patients with stable angina who have:

Significant left main disease

3-vessel disease (survival benefit greater in patients with EF <50%)

2-vessel disease + significant proximal LAD stenosis + either EF <50% or ischemia on non-invasive testing.

Class IIa:

In patients whom PCI will mitigate cardiac symptoms and who need elective non-cardiac surgery in the next 12 months

Balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is indicated.

Beta blockers?Limitations in the perioperative beta-blocker literature include

the following:

Few randomized trials have examined the role of perioperative beta-blocker therapy

Most trials are inadequately powered.

Studies to determine the optimal type of beta blockers are lacking.

Few studies addressing the optimal time at which beta blockers should be started in the perioperative period.

Figure 2. Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion.

Fleisher L A et al. Circulation 2007;116:e418-e500

Copyright © American Heart Association

What to do about those stents?

Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery.

Fleisher L A et al. Circulation 2007;116:e418-e500

Copyright © American Heart Association

For the full guidelines:http://circ.ahajournals.org/content/116/17/e418.full

Pulmonary Pre-Operative Evaluation for Non-Pulmonary Surgery

Risk factorsAge >50

Chronic lung disease

Asthma

Smoking

OSA

Pulmonary HTN

Poor functional status

Upper respiratory infection

Procedural risk factorsSite of surgery

Highest risk – thoracic, upper abdominal surgeries, AAA repair, ENT, neurosurgery

Duration of surgery – greater than 3 to 4 hours

Type of anesthesia?

Pulmonary Function Testing

May be useful in the following cases: Identifying patients in whom risk of surgery does

not justify the benefit Identifying patients at high risk that may benefit

from aggressive pre-op optimization

Pulmonary Function Testing

ACP recommendations:Do not obtain PFTs routinely to predict pulmonary

post-op complicationsPFTs should NOT deny a patient surgeryObtain PFTs:

In patients with COPD or asthma if clinical evaluation cannot determine is patient is at best baseline and would benefit from pre-op optimization

In patients with dyspnea and exercise intolerance that remains unexplained after clinical evaluation

Chest X-RayAdd little to clinical evaluation of healthy patients

Obtain CXR: In patients with known cardiopulmonary disease

Unless CXR has been obtained in past 6 months In patients aged > 50 undergoing high risk

procedures (thoracic/upper abdominal surgeries, AAA repair, ENT surgeries).

Arrouzullah Respiratory Failure Index

Pre-operative predictor Point value

Type of surgery

AAA 27

Thoracic 21

Neurosurgery, upper abdominal 14

ENT 11

Emergency surgery 11

Albumin <3.0g/dL 9

BUN >30 mg/dL 8

Partially/fully dependent functional status 7

History of COPD 6

Age

>70 6

60-69 4

Arouzullah Respiratory Failure Index

Class Point total %Resp Failure

1 <10 0.5

2 11-29 1.8

3 20-27 4.2

4 28-40 10.1

5 >40 26.6