II. Protocols: Preoperative Cardiac Risk Assessment

  1. Preferred protocol
    1. ACC-AHA Preoperative Cardiac Risk Assessment
  2. Older protocol (listed for historical reasons only)
    1. ACP Preoperative Cardiac Risk Assessment

III. Risk Factors: Cardiovascular

IV. Exam: Relevant Cardiovascular Findings

  1. Signs of Left Ventricular Dysfunction
    1. Displaced point of maximal impulse
    2. Left ventricular lift
    3. Diminished S1 Heart Sound
    4. Diminished S2 Heart Sound
    5. Mitral Regurgitation murmur
    6. Alteration in pulse volume
  2. Signs of Pulmonary Hypertension
    1. Parasternal lift
    2. Accentuated P> heart sound
    3. Right ventricular S3 Heart Sound
    4. Right ventricular S4 Heart Sound
    5. Tricuspid regurgitation murmur
    6. Prominent A-wave in neck
    7. Jugular Venous Distention
  3. Signs of severe valvular heart disease

V. Diagnostics: Electrocardiogram (EKG)

  1. Indications (ICSI 2012 guidelines)
    1. Age over 65 years (some hospitals require ekg at age 55 years)
    2. Coronary Artery Disease or Chest Pain
    3. Congestive Heart Failure
    4. Peripheral Vascular Disease
    5. Diabetes Mellitus
    6. Hypertension
    7. Morbid Obesity
    8. Inability to Exercise (e.g. 4 METS)
    9. Additional indications per Cornell study below (not on ICSI list)
      1. Hyperlipidemia
      2. Severe Valvular Heart Disease
    10. Exceptions: EKG not needed in these cases
      1. Minimal risk procedures (e.g. Cataract surgery)
  2. Timing (if indicated)
    1. Within 1 year minimum or
    2. Within 30 days if known Coronary Artery Disease
    3. Following last cardiovascular symptom episode (if within the last year)
  3. Pertinent positive (abnormal) Electrocardiogram findings
    1. Myocardial Infarction
      1. Major Q Waves
      2. Major ST segment depression or ST Elevation
      3. Major T Wave changes
    2. Left Bundle Branch Block
    3. Bifascicular block
    4. Atrioventricular Block (Mobitz II or higher)
    5. Prolonged QT interval
    6. Right Ventricular Hypertrophy
    7. Atrial Fibrillation
  4. References
    1. Correll (2009) Anesthesiology 110:1217-22 [PubMed]

VI. Diagnostics: Echocardiogram Indications

  1. Evaluation of left ventricular function
    1. Dyspnea with unknown cause
    2. Congestive Heart Failure (current or prior)
      1. Progressive Dyspnea or other clinical status changes and
      2. No Echocardiogram in the last year
  2. Murmur evaluation
    1. Not indicated for benign, 2/6 mid-Systolic Murmurs without other signs or symptoms
    2. Asymptomatic patients with undiagnosed cardiac murmur
      1. Diastolic Murmur, Continuous murmur or Late Systolic Murmur
      2. Murmur associated with ejection click
      3. Murmur radiation to the neck or back
      4. Grade 3 Mid-peaking Systolic Murmur (or louder)
    3. Symptomatic patient with cardiac murmur
      1. Abnormal cardiac signs
      2. Abnormal EKG or Chest XRay

VII. Evaluation: Special circumstances

  1. Risk for CAD patients undergoing general anesthesia
    1. MI within 3 months: Reinfarction rate 27-37%
    2. MI within 6 months: Reinfarction rate 11-16%
    3. MI more than 6 months ago: Reinfarction rate 5%
    4. Steen (1978) JAMA 239:2566-70 [PubMed]
  2. Risk of cardiac event per anesthesia type
    1. Unclear whether regional is safer than general
    2. Christopherson (1996) J Clin Anesth 8:578-84 [PubMed]
    3. Rodgers (2000) BMJ 321:1493-7 [PubMed]
  3. Coronary revascularization prior to major surgery is unlikely to provide benefit over maximal medical therapy
    1. Exception: High risk patients who would benefit from CABG
      1. Consider CABG prior to Intermediate Risk Surgery or High Risk Surgery
    2. CARP Trial
      1. No benefit of revascularization prior to major vascular surgery
      2. McFalls (2004) N Engl J Med 351:2795-804 [PubMed]
    3. DECREASE-V Trial
      1. No benefit of revascularization even in very high risk patients prior to major vascular surgery
      2. Poldermans (2007) J Am Coll Cardiol 49(17): 1763-9 [PubMed]
    4. COURAGE Trial
      1. No benefit of revascularization even in stable Angina prior to major vascular surgery
      2. Boden (2007) N Engl J Med 356(15):1503-16 [PubMed]

VIII. Protocol: Cardiovascular Risk Assessment

  1. See Preoperative Cardiovascular Evaluation
  2. See ACC-AHA Preoperative Cardiac Risk Assessment
  3. No cardiac testing needed if
    1. No acute cardiovascular disease and able to perform 4 METS of Exercise without symptoms
    2. Coronary revascularization in last 6 months to 5 years and asymptomatic, stable (discuss with cardiologist)
    3. Normal coronary evaluation in the last 2 years without intervening symptoms
  4. Additional evaluation needed if criteria above not met
    1. See ACC-AHA Preoperative Cardiac Risk Assessment
    2. High risk patient identification tools
      1. Eagle's Cardiac Risk Assessment
      2. Revised Cardiac Risk Index
      3. Detsky's Modified Cardiac Risk Index

IX. Prevention: Medications recommended if Cardiac Risk Factors

  1. Beta Blockers
    1. See Perioperative Beta Blocker
  2. Statin medications
    1. Consider delaying surgery 1 month to start Statin before the procedure if significant cardiovascular risks
      1. Indicated before vascular surgery and before non-cardiac surgery with higher cardiac event risk (see above)
      2. Statins reduce risk of perioperative adverse cardiovascular event with Number Needed to Treat of 13
      3. Schouten (2009) N Engl J Med 361(10) 980-89 [PubMed]
      4. Poldermans (2003) Circulation 107:1848-51 [PubMed]
    2. Do not stop Statin drugs in the perioperative period
      1. Significant increased risk of cardiovascular events on abruptly stopping Statins
        1. Le Manach (2007) Anesth Analg 104(6): 1326-33 [PubMed]
        2. Schouten (2007) Am J Cardiol 100(2): 316-20 [PubMed]
      2. Restart Statin within 1 day postoperatively
      3. Consider perioperative use of extended release Statin such as Lovastatin or Fluvastatin
    3. References
      1. Winchester (2010) J Am Coll Cardiol 56:1099-109 [PubMed]
  3. Antiplatelet agents
    1. See Perioperative Antiplatelet Therapy
    2. See Antiplatelet Therapy for Vascular Disease
    3. See Medications to Avoid Prior to Surgery
    4. Do not stop antiplatelet agents without carefully reviewing indications
  4. Other medication precautions
    1. Do not start Clonidine perioperatively (however may be continued if on longterm Clonidine)
      1. Risk of significant Hypotension and nonfatal Cardiac Arrest
      2. Devereaux (2014) N Engl J Med 370(16): 1504-13 [PubMed]
    2. ACE Inhibitors and ARBs may be continued perioperatively
      1. Safe to continue unless adverse effects (Hypotension, renal dysfunction, electrolyte abnormalities)

X. Resources

  1. Perioperative risk assessment tool
    1. http://statcoder.com

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