cardiovascular pre-operative evaluation for non-cardiac surgery jessica thom pgy-1
TRANSCRIPT
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Cardiovascular Pre-Operative Evaluation for Non-Cardiac Surgery
Jessica ThomPGY-1
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2007 ACC/AHA Pre-Op Guidelines for Cardiovascular Evaluation and Care
for Non-Cardiac Surgery
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Heart disease and procedures1.3 million Canadians (4.3%) reported to have
heart disease
The prevalence of heart disease increases with age
The largest number of non-cardiac surgical procedures performed in patients aged 65 and older.
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Methodology & EvidenceLiterature searches in PubMed, MEDLINE and Cochrane
Library
Searches limited to studies published in English between 2002-07
Reviewed 400 relevant new articles focused on perioperative risk for cardiac complications following non-cardiac surgery
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Role of the consultantReview available patient data
Obtain a pertinent history
Perform a thorough physical examination
Suggest preoperative tests/procedures or higher levels of post-op care Pre-op tests are generally only indicated if the information obtained will
change treatment
Be weary of solely focusing on the question at hand. Aim instead to provide a comprehensive evaluation of the patient’s risk
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HistoryCardiac history: unstable/stable angina, prior MI,
decompensated HF, arrhythmias, severe valvular disease, presence of pacemaker/ICD If cardiac disease is present: any recent change in symptoms?
Evidence of associated diseases: DM, CKD, stroke, PVD, chronic pulmonary disease
Record all medications (including herbals)
Social habits: smoking history
Determine the functional capacity As determined based on METS
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What’s a MET?
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What cardiac conditions should I work up and treat?
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Physical ExamVital signs
General appearance
Cardiac exam
Pulmonary exam
Examination of area undergoing surgery
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Clinical risk factors for cardiac complications in non-cardiac surgery
High risk surgery
Ischemic heart disease
Heart failure
Diabetes
Renal insufficiency – Pre-op creatinine > 2.0mg/DL (175 mmol/L)
Previous stroke
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Relative risks of surgical procedures
Low risk: Opthalmologic procedures, superficial procedures, endoscopy, breast surgeries
Intermediate risk: Orthopedic surgeries, intra-abdominal surgeries, intra-thoracic surgeries, ENT surgeries, prostate surgery, carotid endarterectomies
High risk: All other vascular surgeries
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Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical
conditions. †See Clas...
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
The all important algorithm
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Additional Testing?
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Role of a 12-lead EKG Indicated in:
All patients undergoing vascular surgeryPatients with at least 1 clinical risk factor undergoing
intermediate risk surgery
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Non-invasive stress testingReasonable in patients with 3+ clinical risk factors and poor
functional capacity (<4 METS) undergoing vascular surgery if it will change management (IIa)
Consider in patients with 2+ clinical risk factors and poor functional capacity undergoing intermediate-risk surgery if it will change management (IIb)
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Pre-op Coronary Revascularization with CABG or PCI
Class I:
In patients with acute STEMI
In patients with high-risk unstable angina or NSTEMI
In patients with stable angina who have:
Significant left main disease
3-vessel disease (survival benefit greater in patients with EF <50%)
2-vessel disease + significant proximal LAD stenosis + either EF <50% or ischemia on non-invasive testing.
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Class IIa:
In patients whom PCI will mitigate cardiac symptoms and who need elective non-cardiac surgery in the next 12 months
Balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is indicated.
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Beta blockers?Limitations in the perioperative beta-blocker literature include
the following:
Few randomized trials have examined the role of perioperative beta-blocker therapy
Most trials are inadequately powered.
Studies to determine the optimal type of beta blockers are lacking.
Few studies addressing the optimal time at which beta blockers should be started in the perioperative period.
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Figure 2. Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion.
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
What to do about those stents?
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Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery.
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
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For the full guidelines:http://circ.ahajournals.org/content/116/17/e418.full
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Pulmonary Pre-Operative Evaluation for Non-Pulmonary Surgery
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Risk factorsAge >50
Chronic lung disease
Asthma
Smoking
OSA
Pulmonary HTN
Poor functional status
Upper respiratory infection
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Procedural risk factorsSite of surgery
Highest risk – thoracic, upper abdominal surgeries, AAA repair, ENT, neurosurgery
Duration of surgery – greater than 3 to 4 hours
Type of anesthesia?
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Pulmonary Function Testing
May be useful in the following cases: Identifying patients in whom risk of surgery does
not justify the benefit Identifying patients at high risk that may benefit
from aggressive pre-op optimization
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Pulmonary Function Testing
ACP recommendations:Do not obtain PFTs routinely to predict pulmonary
post-op complicationsPFTs should NOT deny a patient surgeryObtain PFTs:
In patients with COPD or asthma if clinical evaluation cannot determine is patient is at best baseline and would benefit from pre-op optimization
In patients with dyspnea and exercise intolerance that remains unexplained after clinical evaluation
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Chest X-RayAdd little to clinical evaluation of healthy patients
Obtain CXR: In patients with known cardiopulmonary disease
Unless CXR has been obtained in past 6 months In patients aged > 50 undergoing high risk
procedures (thoracic/upper abdominal surgeries, AAA repair, ENT surgeries).
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Arrouzullah Respiratory Failure Index
Pre-operative predictor Point value
Type of surgery
AAA 27
Thoracic 21
Neurosurgery, upper abdominal 14
ENT 11
Emergency surgery 11
Albumin <3.0g/dL 9
BUN >30 mg/dL 8
Partially/fully dependent functional status 7
History of COPD 6
Age
>70 6
60-69 4
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Arouzullah Respiratory Failure Index
Class Point total %Resp Failure
1 <10 0.5
2 11-29 1.8
3 20-27 4.2
4 28-40 10.1
5 >40 26.6