Transcript Preoperative Cardiac Assessment

Guidelines for Perioperative
Cardiovascular Evaluation for
Noncardiac Surgery
ACC/AHA Task Force
JACC 1996; 27:910-945
Circulation 1996; 93:1278-1317
3/99
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Objectives
• Understand ACC/AHA guidelines
• Evaluate and accurately manage cardiac
patients undergoing noncardiac surgery
• Identify preoperative techniques for
assessing cardiac risk in patients being
considered for noncardiac surgery
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Cardiac Risk Stratification (nonfatal MI and Death)
for Noncardiac Surgical Procedures
High (Reported cardiac risk often >5% )
Intermediate (risk generally <5% )
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Emergent major operations,
particularly in the elderly
Aortic and other major vascular
Peripheral vascular
Anticipated prolonged surgical
procedures associated with large fluid
shifts and / or blood loss
Carotid endarterectomy
Head and neck
Intraperitoneal and intrathoracic
Orthopedic
Prostate
Low * (cardiac risk generally <1% )
• Endoscopic procedures
• Superficial procedures
• Cataract
• Breast
* Further preoperative cardiac testing is generally unnecessary.
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ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
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Clinical Predictors of Increased Perioperative
Cardiovascular Risk (MI, CHF, Death)
Major
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Unstable coronary syndromes
– Recent MI ( >7 days but 30 days) with evidence of important ischemic risk
by clinical symptoms or noninvasive study
– Unstable or severe angina (Canadian Cardiovascular Society Class III or IV).
May include “stable” angina in patients who are unusually sedentary.
Decompensated congestive heart failure
Significant arrhythmia
– High-grade atrioventricular block
– Symptomatic ventricular arrhythmias in the presence of underlying heart
disease
– Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
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Clinical Predictors of Increased Perioperative
Cardiovascular Risk (MI, CHF, Death)
Intermediate
• Mild angina pectoris (Canadian Cardiovascular Society Class I or II)
• Prior myocardial infarction by history or pathological waves
• Compensated or prior congestive heart failure
• Diabetes mellitus
Minor
• Advanced age
• Abnormal electrocardiogram (LVH, LBBB, ST-T abnormalities)
• Rhythm other than sinus(eg. atrial fibrillation)
• Low functional capacity (eg. Unable to climb one flight of stairs with a bag
of groceries)
• History of stroke
• Uncontrolled systemic hypertension
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ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
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Grading of Angina of Effort
by the Canadian Cardiovascular Society
“Ordinary physical activity does not cause … angina,” such as walking and
climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or
recreation.
II. “Slight limitation of ordinary activity.” Walking or climbing stairs rapidly,
walking uphill, walking or stair climbing after meals, or in cold, or in wind, or
under emotional stress, or only during the few hours after awakening. Walking
more than 2 blocks on the level and climbing more than one flight of ordinary
stairs at a normal pace and in normal conditions.
III. “Marked limitation of ordinary physical activity.” Walking one to two blocks
on the level and climbing one flight of stairs in normal conditions and at normal
pace.
IV. “inability to carry on any physical activity without discomfort -- anginal
syndrome may be present at rest.”
I.
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Circulation 1976; 54:522-523
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Estimated Energy Requirements
for Various Activities
1 MET
4 METs
Can you take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the house?
Walk a block or two on level ground
at 2-3 mph or 3.2-4.8 km/h?
Do light work around the house like
dusting or washing clothes?
MET = metabolic equivalent
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4 METs
Climb a flight of stairs or walk up a
hill?
Walk on level ground at 4 mph or
6.4 km/h?
Run a short distance?
Do heavy work around the house
like scrubbing floors or lifting or
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
swimming, singles tennis, football,
baseball, or skiing?
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Stepwise Approach to Preoperative Cardiac Assessment
1. Need for
noncardiac
surgery
Urgent or
Elective
2. Coronary
No
revascularization
within 5 years ?
3. Recent
coronary
evaluation
No
Yes
Emergency
Operating
Room
Recurrent
symptoms
or signs ?
Yes
No
Favorable AND no
change in symptoms
Yes
Recent coronary
angiogram or
stress test ?
4. Clinical
predictors
Unfavorable
OR change in
symptoms
Postoperative risk
stratification and risk
factor management
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ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
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Stepwise Approach to Preoperative Cardiac Assessment
4. Clinical
predictors
5. Major
clinical
predictor
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6. Intermediate
clinical
predictor
Unstable coronary
syndromes
Decompensated
congestive heart failure
Significant arrhythmia
Severe valvular disease
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Mild angina pectoris
Prior myocardial
infarction
Compensated or prior
CHF
Diabetes mellitus
7. Minor or no
clinical
predictor
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Advanced age
Abnormal ECG
Rhythm other than sinus
Low functional capacity
History of stroke
Uncontrolled systemic
hypertension
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
9
Stepwise Approach to Preoperative Cardiac Assessment
5. Major
clinical
predictor
Major Clinical Predictor
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Consider delay
or cancel
noncardiac surgery
Medical
management and
risk factor
modification
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Consider
coronary
angiography
Subsequent care
dictated by
findings and
treatment results
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Unstable coronary
syndromes
Decompensated
congestive heart failure
Significant arrhythmia
Severe valvular disease
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
10
Stepwise Approach to Preoperative Cardiac Assessment
Functional
capacity
Surgical
risk
Poor
(<4 METs)
Noninvasive
testing
8. Noninvasive
testing
Invasive
testing
High risk
Low risk
6. Intermediate
clinical
predictor
High surgical
risk procedure
Moderate or
excellent
(>4 METs)
Intermediate
or low surgical
risk procedure
Low surgical
risk procedure
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Operating
room
Consider
coronary
angiography
Postoperative
risk stratification
and risk factor
reduction
Subsequent
care dictated
by findings and
treatment results
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
11
Stepwise Approach to Preoperative Cardiac Assessment
Functional
capacity
Surgical
risk
Noninvasive
testing
Poor
(<4 METs)
High surgical
risk procedure
8. Noninvasive
testing
Invasive
testing
High risk
Low risk
7. Minor or no
clinical
predictor
Intermediate
or low surgical
risk procedure
Moderate or
excellent
(>4 METs)
Low surgical
risk procedure
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Operating
room
Consider
coronary
angiography
Postoperative
risk stratification
and risk factor
reduction
Subsequent
care dictated
by findings and
treatment results
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
medslides.com
12
Indications for Coronary Angiography in Perioperative
Evaluation Before (or After) Noncardiac Surgery
Class I: (suspected or proven CAD)
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High-risk results during noninvasive testing
Angina pectoris unresponsive to adequate
medical therapy
Most patients with unstable angina
Nondiagnostic or equivocal noninvasive test in
a high-risk patient undergoing a high-risk
noncardiac surgical procedure
Class II:
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Intermediate-risk results during noninvasive
testing
Nondiagnostic or equivocal noninvasive test in
a lower-risk patient undergoing a high-risk
noncardiac surgical procedure
Urgent noncardiac surgery in a patient
convlescing from acute MI
Perioperative MI
Class III:
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Low-risk noncardiac surgery in a patient with
known CAD and low-risk results on invasive
testing
Screening for CAD without appropriate
noninvasive testing
Asymptomatic after coronary revascularization
with excellent exercise capacity (7 METs)
Mild stable angina in patients with good LV
function, low-risk noninvasive test result
Patient is not a candidate for coronary
revascularization because of concomitant
medical illness
Prior technically adequate normal coronary
angiogram within previous 5 years
Severe LV dysfunction (EF <20%) and patient
not considered candidate for revasularization
Patient unwilling to consider coronary
revascularization procedure
ACC/AHA Guidelines for Coronary Angiography
JACC 1987; 10:935-950; Circ 1987; 76:963A-977A
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