CARDIAC RISK CARDIAC RISK ASSESSMENT FOR ASSESSMENT FOR

NONCARDIAC NONCARDIAC SURGERYSURGERY

JOHN HAMATY D.O.JOHN HAMATY D.O.

SOUTH JERSEY HEART GROUPSOUTH JERSEY HEART GROUP

SJHG.ORGSJHG.ORG

INTRODUCTION:INTRODUCTION:

CAD ACCOUNTS FOR THE MOST CAD ACCOUNTS FOR THE MOST DEATHS IN PTS UNDERGOING DEATHS IN PTS UNDERGOING NONCARDIAC SURGERY.NONCARDIAC SURGERY.

5% OF ELDERLY POPULATION IN US 5% OF ELDERLY POPULATION IN US UNDERGO NONCARDIAC UNDERGO NONCARDIAC SURGERY/YR.SURGERY/YR.

30% ARE AT RISK FOR CAD WITH IN-30% ARE AT RISK FOR CAD WITH IN-HOSPITAL COMPLICATIONS IN 1.5 MIL. HOSPITAL COMPLICATIONS IN 1.5 MIL. PTS.PTS.

PERIOPERATIVE RISK OF PERIOPERATIVE RISK OF EVENTSEVENTS

PATIENTS WITH NO PRIOR HISTORY PATIENTS WITH NO PRIOR HISTORY OF MYOCARDIAL INFARCTION HAVE A OF MYOCARDIAL INFARCTION HAVE A LOW RISK OF PERIOPERATIVE LOW RISK OF PERIOPERATIVE MI(0.1%-0.6%)MI(0.1%-0.6%)

PATIENTS WITH A HISTORY OF PRIOR PATIENTS WITH A HISTORY OF PRIOR MI ARE AT A SIGNIFICANTLY HIGHER MI ARE AT A SIGNIFICANTLY HIGHER RISK (2.8%-7%).RISK (2.8%-7%).

PERIOPERATIVE RISK OF EVENTSPERIOPERATIVE RISK OF EVENTS(HISTORY OF PRIOR MI)(HISTORY OF PRIOR MI)

MI WITHIN 3 MOS.-37% INCREASE IN MI WITHIN 3 MOS.-37% INCREASE IN EVENTSEVENTS

MI WITHIN 3-6MOS.-16% INCREASE IN MI WITHIN 3-6MOS.-16% INCREASE IN EVENTSEVENTS

MI GREATER THAN 6 MOS.-4% MI GREATER THAN 6 MOS.-4% INCREASE IN EVENTSINCREASE IN EVENTS

A STEPWISE APPROACH A STEPWISE APPROACH FOR PERIOPERATIVE RISK FOR PERIOPERATIVE RISK

ASSESSMENT OF A PATIENT ASSESSMENT OF A PATIENT UNDERGOING NONCARDIAC UNDERGOING NONCARDIAC

SURGERYSURGERY

URGENCY OF SURGERYURGENCY OF SURGERY

ALL PATIENTS UNDERGOING URGENT ALL PATIENTS UNDERGOING URGENT SURGERY SHOULD BE BETA-SURGERY SHOULD BE BETA-BLOCKED TO A HEART RATE OF 50 BLOCKED TO A HEART RATE OF 50 BEATS/MIN AND A BLOOD PRESSURE BEATS/MIN AND A BLOOD PRESSURE THAT IS CONTROLLED.THAT IS CONTROLLED.

PRIOR REVASCULARIZATIONPRIOR REVASCULARIZATION

PTS WHO HAVE UNDERGONE PTS WHO HAVE UNDERGONE COMPLETE REVASCULARIZATION IN COMPLETE REVASCULARIZATION IN THE FORM OF CORONARY ARTERY THE FORM OF CORONARY ARTERY BYPASS OR PTCA WITHIN 6 MONTHS BYPASS OR PTCA WITHIN 6 MONTHS TO 5 YEARS AND ARE FUNCTIONALLY TO 5 YEARS AND ARE FUNCTIONALLY ACTIVE AND HAVE NO CLINICAL ACTIVE AND HAVE NO CLINICAL EVIDENCE OF ISCHEMIA DO NOT EVIDENCE OF ISCHEMIA DO NOT NEED FURTHER CARDIAC TESTING.NEED FURTHER CARDIAC TESTING.

PRIOR EVALUATION FOR PRIOR EVALUATION FOR CAD CAD

PTS. THAT HAVE BEEN EVALUATED IN PTS. THAT HAVE BEEN EVALUATED IN THE PAST TWO YEARS WITH EITHER THE PAST TWO YEARS WITH EITHER INVASIVE OR NONINVASIVE INVASIVE OR NONINVASIVE TECHNIQUES WITH FAVORALE TECHNIQUES WITH FAVORALE FINDINGS GENERALLY DO NOT NEED FINDINGS GENERALLY DO NOT NEED FURTHER EVALUATION.FURTHER EVALUATION.

MUST BE FREE OF CARDIAC MUST BE FREE OF CARDIAC SYMPTOMS AND OR SIGNS OF SYMPTOMS AND OR SIGNS OF ISCHEMIAISCHEMIA

PRESENCE OF CLINICAL PRESENCE OF CLINICAL RISK FACTORSRISK FACTORS

HISTORY, PHYSICAL AND ECG ARE HISTORY, PHYSICAL AND ECG ARE GENERALLY SUFFICIENT TO GENERALLY SUFFICIENT TO ESTIMATE CARDIAC RISKESTIMATE CARDIAC RISK

ASSESSMENT OF CLINICAL RISKASSESSMENT OF CLINICAL RISK

FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

PREDICTORS OF INCREASED PREDICTORS OF INCREASED PERIOPERATIVE CV RISKPERIOPERATIVE CV RISK

MAJORMAJOR• UNSTABLE ANGINAUNSTABLE ANGINA• RECENT MYOCARDIAL INFARCTION(>7 RECENT MYOCARDIAL INFARCTION(>7

BUT <30 DAYSBUT <30 DAYS• DECOMPENSATED CHFDECOMPENSATED CHF• SYMPTOMATIC ARRHYTHMIAS(RAPID SYMPTOMATIC ARRHYTHMIAS(RAPID

VENTRICULAR RESPONSES.)VENTRICULAR RESPONSES.)

PREDICTORS OF INCREASED PREDICTORS OF INCREASED PERIOPERATIVE CV RISKPERIOPERATIVE CV RISK

INTERMEDIATEINTERMEDIATE

• MILD ANGINAMILD ANGINA

• PRIOR MYOCARDIAL INFARCCTIONPRIOR MYOCARDIAL INFARCCTION

• COMPENSATED OR PRIOR CHFCOMPENSATED OR PRIOR CHF

• DIABETES MELLITUSDIABETES MELLITUS

PREDICTORS OF INCREASED PREDICTORS OF INCREASED PERIOPERATIVE CV RISKPERIOPERATIVE CV RISK

MINORMINOR• ADVANCED AGEADVANCED AGE• ABNORMAL ECG(LVH, LBBB)ABNORMAL ECG(LVH, LBBB)• RHYTHM OTHER THAN RHYTHM OTHER THAN

SINUS(CONTROLLED)SINUS(CONTROLLED)• LOW FUNCTIONAL CAPACITYLOW FUNCTIONAL CAPACITY• HISTORY OF CVAHISTORY OF CVA• UNCONTROLLED HYPERTENSIONUNCONTROLLED HYPERTENSION

SURGERY SPECIFIC SURGERY SPECIFIC CARDIAC RISKCARDIAC RISK

HIGH(CARDIAC RISK>5%)HIGH(CARDIAC RISK>5%)

• EMERGENT MAJOR OPERATIONEMERGENT MAJOR OPERATION

• AORTIC AND OTHER MAJOR AORTIC AND OTHER MAJOR VASCULARVASCULAR

• PERIPHERAL VASCULARPERIPHERAL VASCULAR

• ANTICIPATED PROLONGED ANTICIPATED PROLONGED PROCEDUREPROCEDURE

SURGERY SPECIFIC SURGERY SPECIFIC CARDIAC RISKCARDIAC RISK

INTERMEDIAC(CARDIAC RISK<5%)INTERMEDIAC(CARDIAC RISK<5%)

• CAROTID ENDARTERECTOMYCAROTID ENDARTERECTOMY

• HEAD AND NECKHEAD AND NECK

• INTRAPERITONEAL AND INTRAPERITONEAL AND INTRATHORACICINTRATHORACIC

• ORTHOPEDICORTHOPEDIC

• PROSTATEPROSTATE

SURGERY SPECIFIC SURGERY SPECIFIC CARDIAC RISKCARDIAC RISK

LOW(CARDIAC RISK<1%)LOW(CARDIAC RISK<1%)

• ENDOSCOPIC PROCEDURESENDOSCOPIC PROCEDURES

• SUPERFICIAL PROCEDURESSUPERFICIAL PROCEDURES

• CATARACTCATARACT

• BREASTBREAST

FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

EXCELLENT(ACTIVITIES>7METS)EXCELLENT(ACTIVITIES>7METS)

• CARRY 24 LBS UP 8 STEPSCARRY 24 LBS UP 8 STEPS

• CARRY OBJECTS THAT WEIGH 80 LBS.CARRY OBJECTS THAT WEIGH 80 LBS.

• RECREATION(SKI, BASKETBALL, WALK RECREATION(SKI, BASKETBALL, WALK 5MPH)5MPH)

FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

MODERATE(ACTIVITIES >4 BUT <7 METS)MODERATE(ACTIVITIES >4 BUT <7 METS)

• HAVE SEXUAL INTERCOURSE WITHOUT HAVE SEXUAL INTERCOURSE WITHOUT STOPPINGSTOPPING

• WALK 4 MPH ON LEVEL GROUNDWALK 4 MPH ON LEVEL GROUND• OUTDOOR WORK(GARDEN, RAKE, WEEK)OUTDOOR WORK(GARDEN, RAKE, WEEK)• RECREATION(DANCE, SWIM)RECREATION(DANCE, SWIM)

FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

POOR (ACTIVITY <4 METS)POOR (ACTIVITY <4 METS)

• SHOWER/DRESS WITHOUT STOPPINGSHOWER/DRESS WITHOUT STOPPING

• WALK 2.5 MPH ON LEVEL GROUNDWALK 2.5 MPH ON LEVEL GROUND

• OUTDOOR WORK(CLEAN WINDOWS)OUTDOOR WORK(CLEAN WINDOWS)

• RECREATION(PLAY GOLF, BOWL)RECREATION(PLAY GOLF, BOWL)

FUNCTIONAL CAPACITY IS ONE OF THE MOST USEFUL MEASURES OF PREOPERATIVE RISK

Stepwise Approach to Preoperative Cardiac Stepwise Approach to Preoperative Cardiac AssessmentAssessment

1. Need fornoncardiac

surgery

2. Coronaryrevascularizationwithin 5 years ?

Recurrentsymptomsor signs ?

3. Recentcoronary

evaluation

Recent coronaryangiogram orstress test ?

Postoperative riskstratification and riskfactor management

OperatingRoom

4. Clinicalpredictors

Urgent orElective

Emergency

Yes

Yes Yes

No

No No

Unfavorable OR change insymptoms

Favorable AND nochange in symptoms

Stepwise Approach to Preoperative Cardiac Stepwise Approach to Preoperative Cardiac AssessmentAssessment

4. Clinicalpredictors

6. Intermediateclinical

predictor

7. Minor or noclinical

predictor

5. Majorclinical

predictor

Unstable coronary Unstable coronary syndromessyndromes

Decompensated Decompensated congestive heart failurecongestive heart failure

Significant arrhythmiaSignificant arrhythmia

Severe valvular diseaseSevere valvular disease

Mild angina Mild angina pectoris pectoris

Prior myocardial Prior myocardial infarctioninfarction

Compensated or Compensated or prior CHFprior CHF

Diabetes mellitusDiabetes mellitus

Advanced ageAdvanced age

Abnormal ECGAbnormal ECG

Rhythm other than sinusRhythm other than sinus

Low functional capacity Low functional capacity

History of strokeHistory of stroke

Uncontrolled systemic Uncontrolled systemic hypertensionhypertension

Stepwise Approach to Preoperative Cardiac Stepwise Approach to Preoperative Cardiac AssessmentAssessment

5. Majorclinical

predictor

Major Clinical Major Clinical Predictor Predictor

Unstable coronary Unstable coronary syndromessyndromes

Decompensated Decompensated congestive heart congestive heart failurefailure

Significant arrhythmiaSignificant arrhythmia

Severe valvular Severe valvular diseasedisease

Consider delayor cancel

noncardiac surgery

Considercoronary

angiography

Medicalmanagement and

risk factormodification

Subsequent caredictated by

findings andtreatment results

Stepwise Approach to Preoperative Cardiac Stepwise Approach to Preoperative Cardiac AssessmentAssessment

Poor(<4 METs)

6. Intermediateclinical

predictor

Moderate orexcellent(>4 METs)

Intermediateor low surgicalrisk procedure

High surgicalrisk procedure

Low surgicalrisk procedure

8. Noninvasivetesting

Considercoronary

angiography

Subsequentcare dictated

by findings andtreatment results

Operating room

Postoperativerisk stratification

and risk factorreduction

Low risk

High risk

Functionalcapacity

Surgicalrisk

Noninvasivetesting

Invasivetesting

Stepwise Approach to Preoperative Cardiac Stepwise Approach to Preoperative Cardiac AssessmentAssessment

Poor(<4 METs)

Moderate orexcellent(>4 METs)

Intermediateor low surgicalrisk procedure

High surgicalrisk procedure

Low surgicalrisk procedure

8. Noninvasivetesting

Considercoronary

angiography

Subsequentcare dictated

by findings andtreatment results

Operating room

Postoperativerisk stratification

and risk factorreduction

Low risk

High risk

Functionalcapacity

Surgicalrisk

Noninvasivetesting

Invasivetesting

7. Minor or noclinical

predictor

IN THE ABSENCE OF CONTRAINDICATIONS, BETA BLOCKADE THERAPY SHOULD BE GIVEN TO ALL PATIENTS AT HIGH RISK FOR CORONARY EVENTS(DIABETICS)

TREATMENT SHOULD BE GIVEN SEVERAL DAYS OR WEEKS PRIOR TO OR AT DOSES TO ACHIEVE HR 50 AND BP OF 100mm hg.