Preoperative Cardiovascular Evaluation

1. See Also
   1. Perioperative Beta Blocker
   2. Preoperative Examination
   3. Antiplatelet Therapy for Vascular Disease
2. Protocols: Preoperative Cardiac Risk Assessment
   1. ACC-AHA Preoperative Cardiac Risk Assessment (preferred)
   2. ACP Preoperative Cardiac Risk Assessment
3. Risk Factors: Cardiovascular
   1. Patient risk factors
      1. See protocols for Cardiac Risk Assessment above
      2. See Eagle's Cardiac Risk Assessment
      3. See Cardiac Risk Factors
      4. Coronary Artery Disease
      5. Disease Mellitus
      6. Age over 70 years
      7. Prior Myocardial Infarction
   2. Surgical risk factors
      1. See Surgical Risk for Cardiac Event
4. 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
5. Diagnostics: Pertinent positive (abnormal) Electrocardiogram findings
   1. Myocardial Infarction
   2. Left Bundle Branch Block
   3. Bifascicular block
   4. Atrioventricular Block
   5. Prolonged QT interval
   6. Right Ventricular Hypertrophy
6. 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
   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
      3. Rodgers (2000) BMJ 321:1493-7
   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
      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
      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
7. Prevention: Medications recommended if Cardiac Risk Factors
   1. Beta Blockers
      1. See Perioperative Beta Blocker
      2. Perioperative Beta Blockers reduced cardiac events but were associated with more strokes and a higher mortality (POISE Trial)
         1. Devereaux (2008) Lancet 371(9627): 1839-47
      3. AHA guidelines (2009) modified indications for Perioperative Beta Blockers reflect this risk
         1. Continue Beta Blockers if already started (chronic use)
         2. Do not start a preoperative Beta Blocker without careful consideration
            1. Indicated for Higher cardiovascular risk with Revised Cardiac Index of 3 or more
            2. Avoid perioperatively starting Beta Blockers in lower risk patients (more adverse events)
            3. Lindenauer (2005) N Engl J Med 353(4): 349-61
         3. Initiate early (at least 2-4 weeks before surgery)
            1. Titrate to Heart Rate of 60-80 and avoid Hypotension (monitor preoperatively after starting)
   2. Statin medications
      1. Consider delaying surgery 1 month to start Statin before the procedure if significant cardiovascular risks
         1. Statins reduce risk of perioperative adverse cardiovascular event with Number Needed to Treat of 13
         2. Schouten (2009) N Engl J Med 361(10) 980-89
         3. Poldermans (2003) Circulation 107:1848-51
      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
            2. Schouten (2007) Am J Cardiol 100(2): 316-20
         2. Restart Statin within 1 day postoperatively
         3. Consider perioperative use of extended release Statin such as Lovastatin or Fluvastatin
   3. Antiplatelet agents
      1. See Antiplatelet Therapy for Vascular Disease
      2. Do not stop antiplatelet agents without carefully reviewing indications
      3. See Medications to Avoid Prior to Surgery
8. Resources
   1. Perioperative risk assessment tool
      1. http://statcoder.com
9. References
   1. (2002) ICSI Pocket Guidelines, p. 356-60
   2. Eagle (2002) Circulation 105:1257-67
   3. Eagle (1996) Circulation 93:1278-317
   4. Karnath (2002) Am Fam Physician 66:89-96
   5. Palda (1997) Ann Intern Med 127:313-328
   6. Schroeder (2002) Am Fam Physician 66(6):1096-1109