Preoperative assessment

of cardiac patient with

non-cardiac surgery

Presented by: Dr Bhargav Baldaniya

Moderator :Dr Mamta damor mam

GOALS
1) To identify patients at risk through
• history, physical examination & ECG.

• 2) To evaluate the severity of underlying cardiac

disease through cardiac tests.

• 3) Stratify the extent of risk & determine the need

for preoperative interventions to minimize risk of
peri operative complications.
Why is there perioperative
risk?

• Major hemodynamic stress,

• Changes in cholinergic activity,
• Changes in catecholamine activity,
• Body temperature fluctuations,
• Pulmonary function is altered,
• Fluid shifts,
• Pain.
• The initial history, physical examination, and
electrocardiogram assessment should focus on
identification of potentially serious cardiac
disorders.

• In addition to identifying the presence of pre-

existing manifested heart disease, it is essential to
define disease severity, stability, and prior
treatment.
Risks of anesthesia:

• Decreased systemic vascular resistance,

• Decreased stroke volume,
• Induction of general anesthesia lowers systemic
arterial pressures by 20-30%, tracheal intubation
increases the blood pressure by 20-30 mm Hg, and
many anesthetic agents lower cardiac output by
15%.
• Other factors that help determine cardiac risk include
functional capacity, age, co morbid conditions (e.g.,
diabetes mellitus, peripheral vascular disease, renal
dysfunction, and chronic pulmonary disease).

• The type of surgery (vascular procedures and prolonged,

complicated thoracic, abdominal, and head and neck
procedures) are considered higher risk.

• The presence of anemia may also place a patient at higher

perioperative risk.
• Numerous risk indices have been developed over
the years on the basis of multivariate analyses.

• In addition to the presence of CAD and HF, a history

of cerebrovascular disease, preoperative elevated
creatinine greater than 2 mg per deciliter, insulin
treatment for diabetes mellitus, and high-risk
surgery have all been associated with increased
perioperative cardiac morbidity.
Evaluation of cardiac risk:

• The cornerstone of preoperative cardiac evaluation

includes :-

• - review of history,
• - physical examination,
• - diagnostic tests,
• - knowledge of the planned surgical procedure.
HISTORY
1. Presence , severity and reversibility of coronary
artery disease

2.Valvular heart disease

3.Prior cardiac evaluation

4.Medications
Importance of an ECG:

• The ECG is frequently obtained as part of a

preoperative evaluation in all patients over a
specific age or undergoing a specific set of
procedures.
• Metabolic & electrolyte disturbances, medications,
intracranial disease, pulmonary disease can alter
ECG.
• Conduction disturbances (RBBB) or first-degree AV
block, may lead to concern but usually do not
justify further workup.
• Preoperative resting electrocardiogram is readily
available, inexpensive, easy to perform and able to
interpret and detect previous myocardial infarction,
acute ischemia, or arrhythmias.
• The presence of abnormalities such as Q waves and
non sinus rhythms has been shown to correlate
with adverse postoperative cardiac events.
OVERVIEW OF CARDIAC
RISK INDICES :
• ASA - used for assessment of the patient's overall physical
status and to predict morbidity & mortality.

• NYHA/CCS-used for risk stratification of medical patients

with angina, but they have been adapted for use in surgical
patients.

• Cardiac Risk Index (CRI) by Goldman et al identified 9

independent variables that correlated with adverse
perioperative events.
• Modified Cardiac Risk Index,is modified by Detsky et al identified risk
factors for cardiac morbidity but were very cumbersome to apply.

• Revised Cardiac Risk Index (RCRI) by Lee identified 6 independent

predictors of adverse cardiac outcome in patients undergoing
noncardiac surgery.

• ACC/AHA guidelines :
• The ACC/AHA guidelines provide a framework for screening and
identifying patients who are at high risk for perioperative cardiac
events (PCE).
Clinical Predictors of Increased Perioperative
Cardiovascular Risk (Myocardial Infarction, Heart
Failure, Death)

• Major:

• Unstable coronary syndromes.

• Acute or recent MI with evidence of important ischemic risk by
clinical symptoms or noninvasive study.
• Unstable or severe angina. Decompensated heart failure. Significant
arrhythmias. High-grade AV block.
• Symptomatic ventricular arrhythmias in the presence of underlying
heart disease.
• Supraventricular arrhythmias with uncontrolled ventricular rate.
• Severe valvular disease
•
• Intermediate Predictors

• Intermediate clinical predictors –

• Mild angina,
• Prior MI by history or pathologic Q waves,
• compensated or prior CHF,
• diabetes mellitus,
• renal insufficiency.
• Minor:
• Advanced age,
• Abnormal ECG (LVH,LBBB, ST-T abnormalities),
• Rhythm other than sinus (e.g. AF),
• Low functional capacity (e.g., inability to climb one
flight of stairs),
• History of stroke,
• Uncontrolled systemic hypertension.
FUNCTIONAL CAPACITY
Stepwise approach on peri-
operative evaluation
Indications for preoperative
cardiac testing:

• 1. Patients with intermediate clinical predictors.

• 2. Prognostic assessment of patients undergoing
initial evaluation for suspected or proven CAD.
• 3. Evaluation of patients with change in clinical
status.
• 4. Evaluation of adequacy of medical treatment
• 5. Prognostic assessment after an acute coronary
syndrome.
• Noninvasive tests can be divided into :

• Resting tests - Resting ECHO.

• Exercise tests and pharmacologic tests.

• 1. Exercise stress test.
• 2.Dobutamine stress echocardiography
• 3. Dipyridimole thallium scintigraphy
• 4. Ambulatory ECG monitoring.
• Risk reduction strategies:

• 1. Perioperative management :-

• a. Anesthetic techniques.
• i. General versus regional anesthesia,
• ii. Temperature regulation,
• iii. Invasive monitoring - PAC, TEE.

• b. Surgical approach.
• i. Laparoscopic, endovascular procedures.
• 2. Medical management :-

• a. Beta blockers.
• b. Other anti-ischemic medications.
• c. Statins.

• 3. Preoperative coronary revascularization /

valvuloplasty.
• Recommandations for Preoperative coronary
angiogram / coronary intervention:

• 1. patients with stable angina who have significant

LMCA stenosis.

• 2.patients with stable angina who have 3-vessel

disease. (Survival benefit is greater when LVEF is
less than 0.50.)
• 3. patients with stable angina who have 2-vessel
disease with significant proximal LAD stenosis and
either EF less than 0.50 or demonstrable ischemia
on noninvasive testing.
• 4. for patients with high-risk unstable angina or
non- ST segment elevation MI.
• 5. Coronary revascularization before noncardiac
surgery is recommended in patients with acute ST-
elevation MI. (All have level of evidence A).
THANK YOU