Cardiovascular Medicine Book

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Preoperative Cardiovascular EvaluationAka: Perioperative Cardiovascular Risk

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  1. See Also
    1. Perioperative Beta Blocker
  2. Protocols for preoperative Cardiac Risk assessment
    1. ACC-AHA Preoperative Cardiac Risk Assessment
    2. ACP Preoperative Cardiac Risk Assessment
  3. Cardiovascular risks
    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 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
    2. Risk of cardiac event per anesthesia type
      1. Unclear whether regional is safer than general
      2. Christopherson (1996) J Clin Anesth 8:578
      3. Rodgers (2000) BMJ 321:1493
    3. Coronary revascularization prior to major surgery
      1. Patients with significant stable coronary disease
      2. Studied prior to major vascular surgery (e.g. AAA)
      3. Pre-op revascularization did not improve outcomes
      4. McFalls (2004) N Engl J Med 351:2795
  7. Prevention: Coronary events
    1. See Perioperative Beta Blocker
    2. Consider starting Statin Therapy 30 days before surgery
      1. Poldermans (2003) Circulation 107:1848
  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
    3. Eagle (1996) Circulation 93:1278
    4. Karnath (2002) Am Fam Physician 66:89
    5. Palda (1997) Ann Intern Med 127:313
    6. Schroeder (2002) Am Fam Physician 66(6):1096

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