PREOP CARDIAC EVALUATION

FOR NONCARDIAC SURGERY

Yatish B. Merchant, MD, FACC

Cardiology, New Jersey
USA
 Ultimate Goal

• Quality of care and serving the

patient’s best interests.
 Goals
• Understand how to estimate peri-operative
CV risk
• Know when to perform stress testing
preoperatively
• Learn how to reduce risk perioperatively in
those at higher risk
55 Years old man with history of hypertension & CAD but
asymptomatic runs for 30 minutes daily, needs inguinal
hernia repair. You are consulted to clear him for surgery.

• 1) Order Nuclear stress test to evaluate

CAD.
• 2) Order Regular stress test
• 3) Order Cardiac catheterization
• 4) Clear for surgery
 •Surgical Trauma
Triggers •Anesthesia/analgesia
•Intubation/extubation
•Pain •Anesthesia/analgesia
•Surgical Trauma •Surgical Trauma •Hypothermia
•Hypothermia
•Anesthesia/analgesia •Anesthesia/analgesia •Bleeding/anemia
•Bleeding/anemia
•Fasting

Inflammatory Hypercoagulable Stress Hypoxic

State State State State

↑TNF-α ↑ PAI-1 ↑ catecholamine and

↓oxygen delivery
↑IL-1 ↑ Factor VII cortisol levels
↑IL-6 ↑ Platelet reactivity
↑CRP ↓ antithrombin III
Coronary artery shear ↑ BP
stress ↑ HR
Plaque fissuring ↑ FFAs
↑ relative insulin
Plaque fissuring deficiency

↑ Oxygen demand

Acute Coronary Myocardial

Thrombus Ischemia

Perioperative Myocardial Infarction

 Overview
• Risk Assessment
• Preoperative Testing
• Postoperative Management to Reduce Risk
 Approaches to Risk Assessment

1. ASA/Dripps
2. Goldman Multifactorial Index
Quantitative
3. Detsky Modified Index
4. Revised Risk Index
5. ACC/AHA Task Force Strategic
Recommendations
 Dripps/ASA Classification
Class Systemic Disturbance Mortality*
1 Healthy patient with no disease outside of the surgical <0.03%
process
2 Mild-to-moderate systemic disease caused by the 0.2%
surgical condition or by other pathologic processes

3 Severe disease process which limits activity but is not 1.2%

incapacitating
4 Severe incapacitating disease process that is a constant 8%
threat to life
5 Moribund patient not expected to survive 24 hours with 34%
or without an operation
E Suffix to indicate an emergency surgery for any class Increased
 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 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.
 ACC/AHA Guidelines

J Am Coll Cardiol, 2007; 50:1707-1732

Stepwise Approach to the Pre-
operative Evaluation
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergency Yes Vigilant perioperative
noncardiac Operating room and postoperative
surgery management

No

Active Yes Evaluate and treat

Consider
cardiac per ACC/AHA
Operating Room
conditions Guidelines

No

Low Risk Yes Proceed with

Surgery planned surgery

No

Asymptomatic and Yes Proceed with

good functional
planned surgery
capacity

No Manage based on
clinical risk factors
Active Cardiac Conditions

High Risk:
•Acute or recent MI (7-30 d)
•Unstable coronary syndrome
•Decompensated CHF
•Significant Arrhythmias
•Severe Valvular Disease

Surgery
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergency Yes Vigilant perioperative
noncardiac Operating room and postoperative
surgery management

No

Active Yes Evaluate and treat

Consider
cardiac per ACC/AHA
Operating Room
conditions Guidelines

No

Low Risk Yes Proceed with

Surgery planned surgery

No

Asymptomatic and Yes Proceed with

good functional
planned surgery
capacity

No Manage based on
clinical risk factors
Low Risk Surgery Risk < 1%

 Endoscopic procedures
 Superficial procedure
 Cataract surgery
 Breast surgery
Low Risk Situations

Low Risk:

•Low risk surgery

•Good functional capacity
•No cardiac symptoms
•No “active cardiac conditions”
•No clinical risk factors

Reasonable to proceed with surgery

Functional Capacity :
Metabolic Equivalents (METs)
1. Correlates with maximum
oxygen uptake on treadmill
testing
2. Demonstrated predictor of
future cardiac events
2. Poor functional capacity may
hide low threshold cardiac
symptoms
 What is basal O2 consumption
(Vo2)?
1) 1.5 ml/kg/min
2) 2.5 ml/kg/min
3) 3.5 ml/kg/min
4) 4.5 ml/kg/min
 Duke Activity Status Index

1 MET Can you take care of yourself? 4 METs Climb a flight of stairs or walk up a
Eat, dress, or use the toilet? hill?
Walk indoors around the house? Walk on level ground at 4 mph or
6.4 km/h?
Walk a block or two on level
ground at 2-3 mph or 3.2-4.8 Run a short distance?
km/h? Do heavy work around the house
4 METs Do light work around the house like scrubbing floors or lifting or
like dusting or washing clothes? moving heavy objects?
Participate in moderate
recreational activities like golf,
bowling, dancing, doubles tennis,
or throwing a baseball or football?
10 METs Participate in strenuous sports like
MET = metabolic equivalent swimming, singles tennis, football,
baseball, or skiing?

Resting or basal O2 consumption(Vo2) of a 70 kg, 40 yrs old man

is 3.5 mL per kg per min, or 1 MET.
 Clinical Risk Factors
• Known Ischemic Heart Disease
• Compensated or Prior Heart Failure
• Diabetes
• Renal Insufficiency
• Cerebrovascular disease
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergency Yes Vigilant perioperative
noncardiac Operating room and postoperative
surgery management

No

Active Yes Evaluate and treat

Consider
cardiac per ACC/AHA
Operating Room
conditions Guidelines

No

Low Risk Yes Proceed with

Surgery planned surgery

No

Asymptomatic and Yes Proceed with

good functional
planned surgery
capacity

No Manage based on
clinical risk factors
Clinical Risk Factors

•History of heart disease

•Compensated or prior CHF
•Cerebrovascular disease
•Diabetes Mellitus
•Renal Insufficiency

Proceed Cautiously
 Asymptomatic but
poor/unknown functional Manage based on
capacity clinical risk factors

3 or more clinical 1 or 2 clinical No clinical

risk factors* risk factors* risk factors*

Vascular Intermediate Vascular Intermediate

Surgery risk surgery Surgery risk surgery

Proceed with planned surgery with HR control Proceed with

Consider Testing
or consider non-invasive testing planned surgery

*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease
Intermediate Risk Surgery Risk < 5%

Carotid endarterectomy

Endovascular AAA repair

Head and neck

Intraperitoneal and intrathoracic

Orthopedic

Prostate
 High Risk Surgery Risk > 5%

Emergent major operations (3-5 times more risk)

Aortic and other major vascular
Peripheral vascular
Anticipated prolonged or associated with large fluid
shifts and/or blood loss
 Overview
• Risk Assessment
• Preoperative Testing
• Postoperative Management to Reduce Risk
 Most preoperative testing assesses for
presence of obstructive CAD and NOT
plaque vulnerability which truly predicts
the risk.
Unfortunately we have no way of
predicting this.
 ACC/AHA Recommendations
• Echocardiography:
– Dyspnea of unknown origin (Class IIa)
– Current or hx of HF and no echo in 12 months
(Class IIa)
• 12 Lead ECG
– Vascular surgery and 1 CRF (class I)
– CRFs and intermediate risk surgery (class I)
– All vascular surgery (class IIa)
 ACC/AHA Recommendations
• Treadmill stress testing
– High cardiac risk conditions
– 3 CRFs, poor functional capacity & vascular
surgery (class IIa)
• Nuclear stress testing
 Which test to choose?

Most ambulatory Treadmill Stress Test

patients

Abnormal resting
Exercise
ECG (dig, LVH) echo or sestamibi

LBBB DSE
Unable to exercise Adenosine sestamibi
dipyridamole sestamibi
 Preoperative Testing
Negative Predictive Value
Freedom from MI or Death
99.4
100 98.6
96.3
95

% 90

85

80
Stress ECG Dipyramadole Tl Dobutamine Echo

Eagle et al. JACC 1996;27:910.

 Preoperative Testing
Caveats
• Whenever feasible, an exercise stress test is best
choice
• Dipyridamole or adenosine perfusion scan and
DSE are reasonable choices if:
– unable to exercise
– BBB or other resting ECG abnormality
• Avoid dipyridamole and adenosine scan if
bronchspasm
• Avoid DSE if serious arrhythmias or severe
hypertension
 Overview
• Risk Assessment
• Preoperative Testing
• Perioperative Management to Reduce Risk
60 yrs old man with history of CAD, HTN, DM & Creatinine of
2.5 showed small I W ischemia on nuclear stress test at 10
METS & asymptomatic, needs to have prostatectomy for Ca.
How would you treat?
1) Cardiac cath & PCI as indicated.
2) Cancel surgery & request other Rx option.
3) BB with heart rate control perioperative.
4) Give nitrates & CCB & proceed with surgery.
 Perioperative Nitrates?
35
Control
30
TNG
Percent Ischemic

25
20
15
10
5
0
Preop Induction Incision Emerg. PostOp

Dodds, et al. Anesth. Analg. 1993;76:705-13

 Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
 Revascularization
• 5859 vets screened prior
to vascular surgery;4669
excluded
• 510 randomized to:
– Revascularization (258)
• 99 CABG
• 141 PCI
• 18 not revascularized
– 252 no revascularization
• 9 revascularized
• 143 medical rx

McFalls, et al. NEJM 2004;351:2795-2804

Intervention is rarely necessary to simply lower
the risk of surgery.
Revascularization (surgery or PCI) should be
considered only if standard indications are
present.
PCI before anticipated surgery
Acute MI
High Risk ACS
High risk anatomy

Bleeding risk of Stent and continued

anticipated surgery Low Dual-antiplatelet rx

Not low

14 to 29 30 – 365 > 365

Days Days Days

Balloon Bare-metal Drug-eluting

angioplasty stent stent
 Timing of Surgery After PCI

Balloon Bare-metal Drug-eluting

angioplasty stent stent

< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days

Surgery Surgery Surgery

Delay Delay Delay
with ASA with ASA with ASA
 Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
 Postoperative Mortality Reduction
Beta-Blockers

25
21 Mortality • 200 pts undergoing
20 non-cardiac surgery
6 Months • Random assignment
15 14
1 Year to:
2 Years 10 – IV followed by oral
10 8 atenolol or
5 – Placebo
3
0
• Double-blind follow-
0 up over 2 years
Placebo Atenolol

Mangano, et al. NEMJ 1996;335:1713.

Postoperative Cardiac Events In High
Risk Patients
Beta-Blockade

25 •173 patients
Cardiac Death
undergoing vascular
20 Non-fatal MI
17 17 surgery with positive
15 DSE
%
10 •Randomized to BB
1 week pre-op or
5 3.4 placebo
0 0
Placebo Bisoprolol
•Followed for 30
days
Placebo n=53 Bisoprolol n=59
Poldermans et al. NEJM 1999;341:1789.
 Perioperative Beta Blockers
AHA/ACC Recommendations: 2006 Update
•Beta blockers required in recent past to control symptoms of angina or
patients with symptomatic arrhythmias or hypertension
•Patients at high cardiac risk owing to the finding of ischemia on
preoperative testing who are undergoing vascular surgery
•Patients undergoing vascular surgery and with identified CAD
•Vascular surgery and multiple cardiac risk factors
•Moderate or high risk surgery and multiple cardiac risk factors

Key Point: if known or suspected CAD and

undergoing moderate or high risk surgery, use a
beta blocker!
 Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
 Perioperative Statins?
• 100 patients pre-op before
vascular surgery
• Random assignment:
– Atorvastatin 20 mg
– Placebo
• Started 30 days preoperatively
• Follow-up 6 month
• Endpoint:
– Cardiac death
– Non-fatal MI
– USA
– Stroke

J Vasc. Surgery 2004;39:967

 Perioperative Statins

Hindler, et al. Anesthesiology 2006;105:1260-72

 Perioperative Statins
• 44% reduction in mortality after all types of
surgery.
• 59 % after vascular surgery alone

Hindler, et al. Anesthesiology 2006;105:1260-72

 Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
 Perioperative Alpha-2 Agonists
• Clonidine prophylaxis in patients with or at
risk of CAD undergoing noncardiac surgery
reduced perioperative ischemia significantly.
(P=0.01) & mortality up to 2 yrs was also
reduced (P=0.035)

» Wallace et al (PDBT)
 Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
Preoperative Hgb and Mortality
Study of Untreated Anemia
14
Relative Risk Mortality

12 No CAD
10 CAD
8
6
4
2
0
6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 >12

Preop Hemoglobin

Carson, et al. Lancet. 1996;348:1055-60

 Perioperative Hypothermia
Normothermia Hypothermia

7.9
8 • 300 pts undergoing
7 6.3 general surgery
Cardiac Morbidity

6
• Randomized,
(percent)

5
4 double blinded
3 2.4
assignment to
2 1.4 routine care or
1 supplemental
0 warming
Morbidity VT

Frank SM JAMA 1997;227(14)

 •Surgical Trauma
Triggers •Anesthesia/analgesia
•Intubation/extubation
•Pain •Anesthesia/analgesia
•Surgical Trauma •Surgical Trauma •Hypothermia
•Hypothermia
•Anesthesia/analgesia •Anesthesia/analgesia •Bleeding/anemia
•Bleeding/anemia
•Fasting

Inflammatory Hypercoagulable Stress Hypoxic

State State State State

↑TNF-α ↑ PAI-1 ↑ catecholamine and

↓oxygen delivery
↑IL-1 ↑ Factor VII cortisol levels
↑IL-6 ↑ Platelet reactivity
↑CRP ↓ antithrombin III
Coronary artery shear ↑ BP
stress ↑ HR
Plaque fissuring ↑ FFAs
↑ relative insulin
Plaque fissuring deficiency

↑ Oxygen demand

Acute Coronary Myocardial

Thrombus Ischemia

Perioperative Myocardial Infarction

 Key Point:
Avoid Sympathetic Stimulation in those at Risk!

• Beta blocker if able

• Limit hypothermia
• Aggressive post-operative pain control
• Avoid significant anemia
THANK YOU