Download medical complications related to surgery

Medical Complications Related to Surgery
The Harmonization of Assessment and Acceptance Criteria
For Living Kidney Donors Participating in the Canadian Transplant Registry Living Donor Paired Exchange
MEDICAL COMPLICATIONS RELATED TO SURGERY
Sub-Sections:
1. Cardiovascular Risk
2. Pulmonary Disease
3. Liver Disease and Bleeding Disorders
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This report was informed by discussions and consensus reached at the April 11-12, 2013 Workshop on
the Harmonization of Living Donor Assessment and Acceptance Criteria. Due to time restraints at the
Workshop the sub-sections were further reviewed by Workshop attendees and by the Living Donation
Advisory Committee on May 31, 2013.
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Goals:
1. Ensure safety of the surgical procedure for the donor.
2. Detect unrecognized disease and potential medical risk factors and hence reduce peri- and postoperative medical complications related to the surgery
Background:
Overt disease will exclude most individuals as potential donors as only healthy individuals will pass the
work-up process and be considered eligible as a living kidney donor. At this time consideration is
directed toward the assessment of donor peri-operative risk. Living donors do not require surgery and
have no clinical benefit from the donation and while surgery is part of an altruistic act it is never the less
associated with morbidity and mortality. As such, potential living donors should undergo a more
rigorous evaluation and stricter than usual criteria needs to be applied to define risk.
While the incidence of peri-operative complications is low, pulmonary embolus, bleeding and cardiac
events have been reported. The issue is to identify the most appropriate method of determining which
donors require additional testing to detect occult disease.
The overall surgical risk of donating a kidney is low in healthy individuals. The following gives a general
overview about medical risk factors and complications related to the surgical procedure. The perioperative mortality is approximately 1 in 3,000 (0.03%) after open living donor nephrectomy (Bia MJ,
Transplantation 1995; 60: 322-7; Najarian JS, Lancet 1992; 340: 807-10; Bay WH, Ann Intern Med 1987;
106: 719-27; Kasiske BL, J Am Soc Nephrol 1996; 7: 2288-313). A recent study in more than 80,000
donors showed a 90 day mortality of 3.1 in 10,000 donations (0.01%), despite increasing age and obesity
in the donor population (Segev DL, JAMA 2010; 303: 959-66). The most common causes of death after
living donation are pulmonary emboli and cardiac events (myocardial infarction and arrhythmias)
(Najarian JS, Lancet 1992; Bennett AH, Surg Gynecol Obstet 1974; 139: 894-8; Uehling DT, J Urol 1974;
111: 745-6).
The peri-operative morbidity for living donor nephrectomy have been summarised for a large number of
single centre studies (from UK guidelines; Kasiske BL, J Am Soc Nephrol 1996; 7: 2288-313). The mean
overall complication rate was 32% and the major peri-operative complication rate was 4.4%. The
estimated „major complication‟ rate in a survey by Bay and Hebert (Bay WH, Ann Intern Med 1987; 106:
719-27) was 1.8%, whereas the ASTP survey (Bia MJ, Transplantation 1995; 60: 322-7) reported that 22
out of 9,692 (0.23%) kidney donors experienced „potentially life-threatening or permanently
debilitating‟ complications. An overview of peri-operative complications is given by Kok NF et al (Kok NF,
BMJ 2006; 333: 221). Specific surgical complications after living donation include wound related
problems such as sepsis, hernia and chronic pain, conversion from laparoscopic to open surgery,
bleeding, requirement for blood products and cosmetic consequences.
Potential medical risk factors associated with peri-operative complications in patients requiring general
surgery are:
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






Exercise Capacity – key determinant of overall surgical risk. The ability to walk two blocks on
level ground or carry two bags of groceries up one flight of stairs without symptoms can give a
rough assessment. These activities expend approximately 4 metabolic energy equivalents
(METS) and translate into a low risk for major postoperative complications.
A functional capacity of > 4 METS predicts a very low peri-operative risk (Reilly DF, Arch Intern
Med 1999; 159: 2185–92; Older P, Chest 1999; 116: 355-62).
Age – independent risk factor for post-operative pulmonary complications but predominantly
due to increasing numbers of co-morbidities associated with aging. A comparison of older and
younger donors regarding operative time, surgical blood loss and length of hospital stay did not
show significant differences (Smetana GW, Ann Intern Med 2006; 144: 581). A meta-analysis
indicated that surgical complications were not significantly higher for older or obese donors
(Young A, AJT 2008; 8: 1878).
Obesity – is not a risk factor for most major adverse postoperative outcomes, with the
exception of pulmonary embolism. Obesity increases the rates for wound infections (Dindo D,
Lancet 2003; 361: 2032; Herrera FA, Am Surg 2007; 73: 1009; Hofer RE, Mayo Clin Proc 2008; 83:
908; Smetana GW, NEJM 1999; 340: 937), for deep venous thrombosis and associated
pulmonary embolism (Smetana GW, Ann Intern Med 2006; 144: 581). Obese and non-obese
(usu. < 30 kg/m2) donors were compared on operative time, blood loss and hospital stay.
Differences were statistically significant but clinically insignificant. Surgical complications (e.g.
minor infections, hemorrhage, pneumonia or pneumothorax) were not significantly higher for
older or obese donors (Young A, AJT 2008; 8: 1878).
Obstructive Sleep Apnea – increases the risk for postoperative medical complications including
hypoxemia, respiratory failure, unplanned re-intubation, and ICU transfer (Kaw R, Chest 2012;
141: 436). As most patients are undiagnosed it is reasonable to screen patients for obstructive
sleep apnea before surgery.
Alcohol misuse – patients who misuse alcohol on a regular basis have an increased risk for
postoperative complications including surgical site infections, other infections and
cardiopulmonary complications (Harris AH, J Bone Joint Surg Am 2011; 93: 321).
Smoking – current smoking is associated with postoperative morbidity and mortality, smoking
cessation leads to decreased wound healing complications and pulmonary complications (Jones
R, Interact Cardiovasc Thorac Surg 2011; 12: 449; Mills E, Am J Med 2011; 124: 144; Myers K,
Arch Inter Med 2011; 171: 983).
Anaesthetic Complications – malignant hypertension is a rare, inherited complication. The preoperative assessment should include questioning about either personal or family history of
complications from anaesthesia.
PERI-OPERATIVE CARDIOVASCULAR RISK
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All living donor candidates should undergo minimal testing and assessment according to current
American Heart Association (www.heart.org ) and the Canadian Heart and Stroke Foundation
(www.heartandstroke.com) guidelines.
Gender:
 Men over the age of 55 and postmenopausal women are at greater risk of heart disease. Until
women reach menopause they have a lower risk of stroke than men.
Family History:
 The risk of heart disease is increased if close family members (parents, siblings or children),
developed heart disease before age 55 or, in the case of female relatives, before menopause.
 The risk of stroke is increased if close family members – parents, siblings or children – had a
stroke before age 65.
Ethnicity:
 First Nations people and those of African or South Asian descent are more likely to have high
blood pressure and diabetes, and therefore are at greater risk of heart disease and stroke than
the general population.
Communication with the living donor candidate and if necessary the candidate’s family doctor over the
timeframe following initial acceptance as a living donor candidate, is essential for ensuring the potential
donor continues to be considered as a suitable candidate. Cardiovascular risk is one area that may need
ongoing or further investigation pending the time lapse since registration.
A. Additional Testing of candidates based on medical Questionnaire,
physical Examination and Screening Test Results
1. Additional testing is indicated in the following potential donors as per current American
Heart Association/Canadian Heart and Stroke Foundation Guidelines:
i.
Men 50 and older*
ii.
Women 60 and older*
iii.
Where calculated 10-year cardiovascular disease risk of >10% based on Framingham risk
calculator or other similar calculator*
iv.
Potential donors with one or more cardiovascular risk factors (hypertension,
hypercholesterolemia and smoking)*
*according to cardiovascular risk calculator and documented
2. If there is a change in risk factors since initial assessment a cardiology consultation is
appropriate.
B. Acceptance Criteria
1. Based on total assessment findings and in accordance with current American Heart
Association/Canadian Heart & Stroke Foundation guidelines
C. Exclusions for Donation
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1. To be considered in conjunction with the medical questionnaire, the physical examination,
functional capacity, ECG & Chest X-ray and cardiology report.
References
A. Background Information Summarizing the Literature:
The major predictors of surgical complications related to cardiovascular disease are:
 High-risk surgery (vascular, cardiovascular)
 History of ischemic heart disease
 History of congestive heart failure
 History of cerebro-vascular disease
 Diabetes treated with insulin
 Significantly reduced GFR
None of these will apply to appropriately selected living kidney donors. Nephrectomy is not
considered a high risk operation; people with known cardiovascular disease, diabetes or
significantly impaired kidney function are excluded from donating according to international
guidelines and Canadian practice.
The ACC/AHA guidelines which apply to individuals undergoing non-cardiac surgery do NOT
recommend any further cardiac testing for those with no active heart disease who have
reasonable functional capacity (defined as 4 METS). These guidelines do NOT recommend
baseline ECG for individuals with no risk factor for cardiac disease.
However, as explicitly described in the UK guidelines, the transplant community has established
that living donors should undergo more rigorous evaluation given that donation is an altruistic
act associated with morbidity and potentially mortality.
B. Literature
The issue is: “What is the most appropriate method of determining which donors require
additional CV testing to detect occult coronary artery disease?”
The literature suggests two approaches.
a. One is to use conventional risk factors and available calculators to determine
whether an individual is at low (<10%), intermediate (10-20%) or high risk (>20%) for
a cardiovascular event in the next 10 years, and perform further testing on those
above a certain risk level, usually >10%. To put this in perspective, for non-smoking
men with systolic BP of 130 and total cholesterol/HDL cholesterol ratio of 4, the 10year risk of CVD increases with age and reaches a value of >10% around age 55; for
women with similar characteristics, a risk of >10% is not reached until age 65-70
(see attached graph).
b. The second is to assess the donor’s functional capacity by determining his ability to
perform various tasks which can be converted into METS. Impaired functional
capacity (<4 METS) has been associated with increased peri-operative risk. Good
exercise tolerance is an excellent predictor of good outcomes, even when coronary
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disease exists. The ACC/AHA Guidelines identify poor functional capacity (<4 METS)
as a potential indication for further cardiac testing, but only if there are other
cardiac risk factors or high risk surgery.
C. Summary of UNOS cardiovascular guidelines
a. Chest X-ray
b. ECG
c. ECHO and/or exercise stress test if the prospective donor is over 50 years old or has
a risk factor (hypertension, smoking, hyperlipidemia, family history, shortness of
breath from exercise) or physical findings that demonstrate increased risk for heart
disease including, but not limited to, borderline blood pressure, abnormal ECG,
abnormal CXR, murmur
d. Pulmonary function tests for smokers
D. Summary of UK cardiovascular guidelines
a. A low threshold should be set for screening potential donors for cardiovascular
disease, and for their exclusion from donation
b. Potential donors with an exercise capacity of < 4 METS or >10% estimated risk of
significant coronary atherosclerosis should undergo formal cardiological assessment
c. Potential donors with exercise capacity >10 METS are at very low cardiac risk
d. Screening of higher risk donors should be performed by CT calcium scoring and/or
functional assessments such as dynamic stress tests.
E. Canadian Practice:
All request ECG. No uniform practice with respect to stress testing or echocardiography (see the
table on Current Canadian Practice for Testing in references under Anaesthetic Reactions).
F. References:
These recommendations for testing for cardiovascular disease in potential living kidney donors
derive from the following sources:
a. UNOS guidelines (2007)
b. UK guidelines (2011)
c. Guidelines for peri-operative cardiovascular evaluation and care for non-cardiac
surgery: American College of Cardiology/American Heart Association (2007)
d. Current Canadian practice, derived from the survey of Canadian kidney transplant
programs (2012)
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10 Year CVD Risk
Systolic BP 130, TC/HDL 4.0, Non-smoker
University of Edinburgh Risk Calculator
25
20
15
Men
10
Women
5
0
30- 35- 40- 45- 50- 55- 60- 65- 7034 39 44 49 54 59 64 69 74
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PERI-OPERATIVE PULMONARY RISK
While some pulmonary conditions would not necessary negate kidney donation, they regardless pose
significant peri-operative risk to the donor candidate. These conditions include a history of asthma,
smoking, sleep apnea and chronic obstructive lung disease.
A. Additional Testing Based on the Findings Documented in the Medical
History and/or Physical Examination
1. Additional testing is indicated as applicable in the following situations:
i.
Age > 50 yrs (suggest 1.)
ii.
Smoking history (suggest 1.)
iii.
Chronic obstructive lung disease
iv.
Asthma
v.
Obstructive sleep apnea
vi.
Unexplained dyspnea and/or cough
2. Regarding the diseases iii - vi in conjunction with an anaesthesia and/or pulmonary consult
additional testing (see below tests i- v) should be undertaken to estimate disease severity and
associated medical risk :
i.
Pulmonary risk indices calculations (Arozullah AMl, Ann Surg 2000; 232: 242; Canet
J, Anesthesiology 2010; 113: 1338)
ii.
Pre-operative oxygen saturation
iii.
Pulmonary function testing
iv.
Exercise testing (see also cardiovascular stress testing)
v.
Arterial blood gases
B. Acceptance Criteria
1. Negative history and physical exam – no concerns
2. Age > 50 yrs. – no concerns (but information regarding risk of post-operative pulmonary
complications should be given based on risk indices calculations) (Smetana GW et al, Ann Intern
Med 2006; 144: 581; Arozullah AM, Ann Surg 2000; 232: 242; Canet J, Anesthesiology 2010; 113:
1338).
3. Smoking history – no concerns if overall assessment and determination shows minimal risk and
no sign of compromised pulmonary function (see also risk cardio-renal disease)
4. Asthma – depending on additional tests and Anaesthesia & pulmonologist consult
C. Exclusion for Donation
1. Exercise capacity < 4 METS (Fleisher LA, Circulation 2009; 120: e169; Hlatky, Am J Cardiol 1989;
64: 651)
2. Chronic lung disease with impairment of oxygenation or ventilation
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3.
Obstructive sleep apnea – mild sleep apnea might be accepted but only in conjunction with an
anaesthesia and/or pulmonary consult, obstructive sleep apnea associated with pulmonary
hypertension will be excluded.
References
A. Background Information Summarizing the Literature:
a. Postoperative pulmonary complications add significantly to morbidity and mortality
b. Major risk factors for postoperative pulmonary complications such as chronic lung
disease, poor general health status, pulmonary hypertension, heart failure, metabolic
factors are unlikely to occur in living donors after they have passed the work-up
process
c. Simple screening questionnaires and a thorough physical examination will rule out,
to a large extent, significant pulmonary diseases
d. contributing clinical findings are more predictive of the risk of postoperative
pulmonary complications than are spirometric results (Lawrence VA, Chest 1996;
110: 744)
B. Literature:
a. In the guidelines from the different national committees, pulmonary risk evaluation
is included in the cardiovascular risk assessment (see below the table summarizing
the UK, UNOS and Australian guidelines). The Current Canadian Practice for Testing is
shown below as a table.
b. Electronic textbook ‘UpToDate.com – website www.uptodate.com 2013’; gives an
excellent overview about risk and medical complications with general surgery. This
information is not covered sufficiently by the existing living donor literature and the
international guidelines. As such two topics for this workbook were chosen from
UpToDate:
 Smetana GW. Preoperative medical evaluation of the healthy patient. Last
updated Nov 2, 2012
 Smetana GW. Evaluation of preoperative pulmonary risk. Last updated Jan 24,
2013
c. Selected articles:
 Arozullah AM, Ann Surg 2000: 232: 242.
 Brooks-Brunn JA. Chest 1997; 111: 564.
 Canet J et al, Anesthesiology 2010; 113: 1338.
 Chung F et al, Anesthesiology 2008; 108: 812.
 Fleisher LA, et al, Circulation 2009; 120: e169.
 Hlatky et al, Am J Cardiol 1989; 64: 651.
 Kaw, et al, Chest 2012; 141: 436.
 Kroenke K et al, Chest 1993; 104: 1445.
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






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Lawrence VA, et al, Chest 1996; 110: 744.
Lawrence VA et al, Arch Intern Med 1989; 149: 280.
McAlister FA et al, Am J Respir Crit Care Med 2003; 167: 741.
Nakagawa M et al, Chest 2001; 120: 705.
Qaseem A et al, Ann Intern Med 2006; 144: 575.
Smetana GW et al, Ann Intern Med 2006; 144: 581.
Smetana GW et al, NEJM 1999; 340: 937.
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LIVER DISEASE & BLEEDING DISORDERS
Hematological abnormalities and diseases can place both the donor and recipient at risk. A history
of prior jaundice; alcohol intake; liver disease; bleeding disorders including anaemia and bruising;
and clotting disorders (deep venous thrombosis or pulmonary embolism) should be obtained at the
time of the medical history and physical examination.
A. Additional Testing as Determined from the Medical History, Physical
Examination and Initial General Health Screening Tests
1. Hematology and hepatology consultations may be indicated for investigation of a history of
bleeding or thrombosis, or abnormalities in liver function tests uncovered during screening
investigations.
B. Acceptance Criteria
1. Acceptance in consideration of overall clinical assessment and peri-operative risk
C. Exclusion for Donation
1. To be determined following full clinical evaluation
References
A. Background Information Summarizing the Literature:
a) Rationale
The presence of an underlying bleeding or clotting disorder places a living donor at a higher risk
of significant bleeding complications or thrombotic complications.
As such, potential living donors should be evaluated for such disorders prior to surgery
b) Background
European Best Renal Practice Guidelines (EBPG) – no comment
UK Guidelines (2011) – Assess for history of thromboembolic disease. Measure PT/PTT, CBC;
thrombophilia screen where indicated.
UNOS – Assess for history of clotting disorders or DVT.
Canadian Practice- a scan shown below in the table – PT/PTT in almost all centres. Platelet count
in the minority (per survey, but in practice, universally available with CBC).
In 1983, Rapaport published a seminal review of pre-operative hemostatic evaluation, and his
recommendations remain relevant. He recommended that patients who undergo surgery should
be questioned about their response to various bleeding challenges, and recommended seven
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questions, which have been expanded below:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do you experience excess bleeding in your mouth or frequent nosebleeds?
Have you bled into a muscle or a joint?
Have you ever had blood in your stool?
Do you have profuse menstrual bleeding?
Do you develop large bruises even in the absence of obvious injury? Have you bled
excessively after small wounds?
Have you had teeth extracted? How long did you bleed? Was the bleeding immediate or
delayed?
What operations have you undergone, including minor procedures such as skin biopsies
or colonoscopy/bronchoscopy with biopsies? Was there any bleeding, either immediate
or delayed?
Do you have other medical problems? Is there a history of hepatic, renal, or hematologic
disease? Have you ever required a transfusion of whole blood, red blood cells, platelets,
plasma, or blood clotting factors?
What medications are you taking? Do you take anticoagulant medications? Have you
taken aspirin or other pain relievers within the last 10 days? Do you take over-thecounter remedies, supplements, or alternative medicine (e.g., herbal preparations)?
Do any relatives have bleeding tendencies or experience excessive bleeding following
surgery?
A positive history should prompt further evaluation, and referral to a hematologist, if indicated.
However, the history may be unreliable. This can be due to a poor history (i.e., the forgetful
physician), an unreliable patient (forgetful or unaware), an unchallenged patient (no prior
surgeries/extractions), or an acquired disorder. For these reasons, basic screening in the form of
a PT/PTT and platelet count is recommended for moderate or high risk surgery.
B. Literature:
Guidelines for the Medical Evaluation of Living Kidney Donors (Living Donor Committee). OPTN,
U.S Department of Health & Human Service. Visited on March 11, 2013.
http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_208.pdf
European Renal Best Practice (ERBP) Guideline on kidney donor and recipient evaluation and
peri-operative care, Draft 7. Visited on March 7, 2013. http://www.european-renal-best
practice.org/sites/default/files/u33/ATT00349.pdf
United Kingdom Guidelines for Living Donor Kidney Transplantation, third edition, May 2011.
www.bts.org.uk & www.renal.org
Rapaport S. Pre-operative hemostatic evaluation: which tests, if any? Blood, 1983; 61: 229-231
Coutre S. Preoperative assessment of hemostasis. In: UpToDate, Leung LLK (Ed), UpToDate,
Waltham, MA, 2013
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D. International Assessment and Acceptance Criteria Living Kidney Donation (selected in relation to all
topics in this work group)
Assessment
Cardiovascular
Surgery: Donor
Risk and PeriOperative Care
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UK
US
AUS
ERBP
2011
2008
2007-2010
2013
- low threshold for
screening for CV
disease and exclusion
from donation (B1)
- potential donors with
an exercise capacity of
<4 METS or >10%
estimated risk of
significant coronary
atherosclerosis should
undergo formal
cardiological
assessment (B1)
- potential donors with
exercise capacity >10
METS are at very low
cardiac risk (B1)
- screening of higher
risk donors should be
performed by CT
calcium scoring and/or
functional assessments
such as dynamic stress
tests (B2)
- all LDs should receive
adequate thromboprophylaxis. Intraoperative mechanical
compression and postoperative compression
stockings, along with
LMW heparin, are
recommended (A2)
- pre-operative
hydration with an
overnight infusion
and/or fluid bolus
- ECG
- ECHO and/or
exercise stress test if
> 50 yrs or risk
factors (HTN,
smoking, lipids, FH,
dyspnea on exercise)
or physical findings
indicating increased
risk for heart disease
incl. borderline blood
pressure, abnormal
ECG, abnormal CXR,
murmur
- pulmonary function
tests for smokers
Based on level III &
IV evidence
- in open surgery,
the risks appear
related to perioperative
complications incl.
pulmonary emboli,
pneumonia and
ischemic events
- with laparoscopic
surgery,
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Assessment
UK
US
AUS
ERBP
2011
2008
2007-2010
2013
during surgery may be
beneficial for
laparoscopic donor
nephrectomy (B2)
complications are
largely due to
catastrophic intraoperative events
related to securing
of the vascular
pedicle. Measures to
reduce these specific
problems should be
undertaken and
tailored to the
technique used by
individual transplant
units
- Laparoscopic donor
surgery is the preferred
technique for LD Nx,
offering a quicker
recovery, shorter
hospital stay and less
pain. Mini-incision
surgery is preferable to
standard open surgery
(B1)
- death and major
complications occur
infrequently
following donor Nx.
This limits the
feasibility of
randomized
controlled trials
comparing donor
surgical techniques.
The best available
evidence over time
with comprehensive
registry data.
Contraindications
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- history of
thrombosis or
embolism
- obesity: BMI >35
- coronary artery
disease
- symptomatic
valvular disease
- chronic lung disease
with impairment of
oxygenation or
- coagulation screen
(PT and APTT)
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Assessment
UK
US
AUS
ERBP
2011
2008
2007-2010
2013
ventilation
- peripheral vascular
disease
Relative CI:
- moderate Cardiac
Valvular disease with
otherwise normal
ECHO findings
- mild sleep apnea
without pulmonary
hypertension
Current Canadian Practice of Living Donor Testing for Surgical Risk
TEST
CENTRES
SPH VGH FMC UAH STP
SMH
TGH
CHUM-ND
HMR
EKG
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
MIBI
N
N
N
Y*
N
N
Y
N
Y
N
N
Y
N
Y
CXR
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
16
0
PTT
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
N
14
2
INR
Y
Y
N
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
N
13
3
Platelets
Y
Y
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
5
11
BMI
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
16
0
AST
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
15
1
ALK Phos
Y
Y
Y
Y
N
Y
N
Y
Y
N
N
N
N
Y
Y
N
9
7
GGT
Y
Y
Y
N
Y
Y
N
Y
N
N
Y
Y
Y
N
Y
N
10
6
Bilirubin
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
15
1
LDH
N
N
Y
N
N
Y
N
N
N
N
N
N
Y
Y
N
N
4
12
ECHO
SECHO
>40
OTHER
TM
LHSC SJH
ECHO
Legend
Y
Testing Done
N
Testing Not Done
TOH MUHC
TOTAL/16
Testing Testing
Not Done
CHUQ QEII Done
16
Y
Y
0
6
Y
N
10
Sress ECG
Cardiac US ECHO
Additional Comments*
UAH - MIBI - >60 y.
Additional Tests
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