Download CARDIAC RISK ASSESSMENT FOR NONCARDIAC SURGERY

CARDIAC RISK
ASSESSMENT FOR
NONCARDIAC
SURGERY
JOHN HAMATY D.O.
SOUTH JERSEY HEART GROUP
SJHG.ORG
INTRODUCTION:
CAD ACCOUNTS FOR THE MOST
DEATHS IN PTS UNDERGOING
NONCARDIAC SURGERY.
5% OF ELDERLY POPULATION IN US
UNDERGO NONCARDIAC
SURGERY/YR.
30% ARE AT RISK FOR CAD WITH INHOSPITAL COMPLICATIONS IN 1.5 MIL.
PTS.
PERIOPERATIVE RISK OF
EVENTS
PATIENTS WITH NO PRIOR HISTORY
OF MYOCARDIAL INFARCTION HAVE A
LOW RISK OF PERIOPERATIVE
MI(0.1%-0.6%)
PATIENTS WITH A HISTORY OF PRIOR
MI ARE AT A SIGNIFICANTLY HIGHER
RISK (2.8%-7%).
PERIOPERATIVE RISK OF EVENTS
(HISTORY OF PRIOR MI)
MI WITHIN 3 MOS.-37% INCREASE IN
EVENTS
MI WITHIN 3-6MOS.-16% INCREASE IN
EVENTS
MI GREATER THAN 6 MOS.-4%
INCREASE IN EVENTS
A STEPWISE APPROACH
FOR PERIOPERATIVE RISK
ASSESSMENT OF A PATIENT
UNDERGOING NONCARDIAC
SURGERY
URGENCY OF SURGERY
ALL PATIENTS UNDERGOING URGENT
SURGERY SHOULD BE BETA-BLOCKED
TO A HEART RATE OF 50 BEATS/MIN
AND A BLOOD PRESSURE THAT IS
CONTROLLED.
PRIOR REVASCULARIZATION
PTS WHO HAVE UNDERGONE
COMPLETE REVASCULARIZATION IN
THE FORM OF CORONARY ARTERY
BYPASS OR PTCA WITHIN 6 MONTHS
TO 5 YEARS AND ARE FUNCTIONALLY
ACTIVE AND HAVE NO CLINICAL
EVIDENCE OF ISCHEMIA DO NOT
NEED FURTHER CARDIAC TESTING.
PRIOR EVALUATION FOR
CAD
PTS. THAT HAVE BEEN EVALUATED IN
THE PAST TWO YEARS WITH EITHER
INVASIVE OR NONINVASIVE
TECHNIQUES WITH FAVORALE
FINDINGS GENERALLY DO NOT NEED
FURTHER EVALUATION.
MUST BE FREE OF CARDIAC
SYMPTOMS AND OR SIGNS OF
ISCHEMIA
PRESENCE OF CLINICAL
RISK FACTORS
HISTORY, PHYSICAL AND ECG ARE
GENERALLY SUFFICIENT TO ESTIMATE
CARDIAC RISK
ASSESSMENT OF CLINICAL RISK
FUNCTIONAL CAPACITY
PREDICTORS OF INCREASED
PERIOPERATIVE CV RISK
•
•
•
•
MAJOR
UNSTABLE ANGINA
RECENT MYOCARDIAL INFARCTION(>7
BUT <30 DAYS
DECOMPENSATED CHF
SYMPTOMATIC ARRHYTHMIAS(RAPID
VENTRICULAR RESPONSES.)
PREDICTORS OF INCREASED
PERIOPERATIVE CV RISK
INTERMEDIATE
•
•
•
•
MILD ANGINA
PRIOR MYOCARDIAL INFARCCTION
COMPENSATED OR PRIOR CHF
DIABETES MELLITUS
PREDICTORS OF INCREASED
PERIOPERATIVE CV RISK
MINOR
• ADVANCED AGE
• ABNORMAL ECG(LVH, LBBB)
• RHYTHM OTHER THAN
SINUS(CONTROLLED)
• LOW FUNCTIONAL CAPACITY
• HISTORY OF CVA
• UNCONTROLLED HYPERTENSION
SURGERY SPECIFIC
CARDIAC RISK
HIGH(CARDIAC RISK>5%)
• EMERGENT MAJOR OPERATION
• AORTIC AND OTHER MAJOR
VASCULAR
• PERIPHERAL VASCULAR
• ANTICIPATED PROLONGED
PROCEDURE
SURGERY SPECIFIC
CARDIAC RISK
INTERMEDIAC(CARDIAC RISK<5%)
• CAROTID ENDARTERECTOMY
• HEAD AND NECK
• INTRAPERITONEAL AND
INTRATHORACIC
• ORTHOPEDIC
• PROSTATE
SURGERY SPECIFIC
CARDIAC RISK
LOW(CARDIAC RISK<1%)
•
•
•
•
ENDOSCOPIC PROCEDURES
SUPERFICIAL PROCEDURES
CATARACT
BREAST
FUNCTIONAL CAPACITY
FUNCTIONAL CAPACITY
EXCELLENT(ACTIVITIES>7METS)
• CARRY 24 LBS UP 8 STEPS
• CARRY OBJECTS THAT WEIGH 80 LBS.
• RECREATION(SKI, BASKETBALL, WALK
5MPH)
FUNCTIONAL CAPACITY
MODERATE(ACTIVITIES >4 BUT <7
METS)
• HAVE SEXUAL INTERCOURSE
WITHOUT STOPPING
• WALK 4 MPH ON LEVEL GROUND
• OUTDOOR WORK(GARDEN, RAKE,
WEEK)
• RECREATION(DANCE, SWIM)
FUNCTIONAL CAPACITY
POOR (ACTIVITY <4 METS)
•
•
•
•
SHOWER/DRESS WITHOUT STOPPING
WALK 2.5 MPH ON LEVEL GROUND
OUTDOOR WORK(CLEAN WINDOWS)
RECREATION(PLAY GOLF, BOWL)
FUNCTIONAL CAPACITY IS
ONE OF THE MOST USEFUL
MEASURES OF PREOPERATIVE
RISK
Stepwise Approach to Preoperative Cardiac
Assessment
1. Need for
noncardiac
surgery
2. Coronary
No
Urgent or
revascularization
Elective
within 5 years ?
3. Recent
coronary
evaluation
No
Yes
Emergency
Operating
Room
Recurrent
symptoms
or signs ?
Yes
No
Favorable AND no
change in symptoms
Postoperative risk
stratification and risk
factor management
Yes
4. Clinical
predictors
Recent coronary
angiogram or
Unfavorable
stress test ?
OR change in
symptoms
Stepwise Approach to Preoperative Cardiac
Assessment
4. Clinical
predictors
5. Major
clinical
predictor
Unstable coronary
syndromes
Decompensated
congestive heart
failure
Significant
arrhythmia
Severe valvular
disease
6. Intermediate
clinical
predictor
Mild angina
pectoris
Prior myocardial
infarction
Compensated or
prior CHF
Diabetes mellitus
7. Minor or no
clinical
predictor
Advanced age
Abnormal ECG
Rhythm other than
sinus
Low functional
capacity
History of stroke
Uncontrolled
systemic
hypertension
Stepwise Approach to Preoperative Cardiac
Assessment
Major Clinical
Predictor
5. Major
clinical
predictor
Consider delay
or cancel
noncardiac surgery
Consider
coronary
angiography
Medical
management and
risk factor
modification
Subsequent care
dictated by
findings and
treatment results
Unstable coronary
syndromes
Decompensated
congestive heart
failure
Significant
arrhythmia
Severe valvular
disease
Stepwise Approach to Preoperative Cardiac
Assessment
Functional
capacity
Surgical
risk
Poor
(<4 METs)
Noninvasive
testing
Invasive
testing
8. Noninvasive
testing
High risk
Low risk
6. Intermediate
clinical
predictor
Moderate or
excellent
(>4 METs)
High surgical
risk procedure
Intermediate
or low surgical
risk procedure
Low surgical
risk procedure
Operating
room
Consider
coronary
angiography
Postoperative
risk stratification
and risk factor
reduction
Subsequent
care dictated
by findings and
treatment results
Stepwise Approach to Preoperative Cardiac
Assessment
Functional
capacity
Surgical
risk
Poor
(<4 METs)
High surgical
risk procedure
Noninvasive
testing
Invasive
testing
8. Noninvasive
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
Operating
room
Consider
coronary
angiography
Postoperative
risk stratification
and risk factor
reduction
Subsequent
care dictated
by findings and
treatment results
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.