Cardiac risk stratification


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Brief look at Cardiac Risk Stratification in the pre-operative period

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Cardiac risk stratification

  1. 1. Cardiac Risk Stratification Presenter: Dr S. N. Bhagirath Moderator: Dr Sharanu Patil
  2. 2. Box 1 Factors to be Considered When Assessing Cardiac Risk Patient-Related Factors Age Chronic diseases (e.g., coronary artery disease, diabetes dellitus, hypertension) Functional status Medical therapy Implantable devices Previous surgeries Surgery-Related Factors Type of surgery (e.g., vascular, endoscopic, abdominal) Urgency of the operation (e.g., emergent, urgent, elective) Duration of the operation, possibility of blood loss and fluid shifts Test-Related Factors Sensitivity and specificity of a test Effect on management
  3. 3. Risk Factor Points Preoperative third heart sound or jugular venous distension indicating active heart failure 11 Myocardial infarction in the past 6 months 10 ≥5 premature ventricular complexes/min before surgery 7 Rhythm other than sinus 7 Age >70 years 5 Emergency surgery 4 Significant aortic stenosis 3 Intraperitoneal, intrathoracic, or aortic surgery 3 Markers of poor general medical condition (e.g., renal dysfunction, liver disease, lung disease, electrolyte imbalance) 3 Patients in the lowest risk quartile (0 to 5 points) had less than a 1% risk of postoperative major cardiac complications. In the two quartiles with 6 to 25 points, the major cardiac event risk was 9%, and 22% of the patients in the highest risk group (≥26 points) had a major perioperative cardiac event. Goldman Multifactorial Cardiac Risk Index
  4. 4. Eagle’s Cardiac Risk index One of the limitations of the Goldman criteria was the inability to predict the operative risk for patients undergoing vascular surgery because of the low number of patients with vascular operations included in the study population. This limitation was addressed by Eagle and colleagues •Q waves on the electrocardiogram (ECG) •History of angina pectoris •History of ventricular ectopy requiring treatment (most specific for predicting events) •Diabetes mellitus requiring therapy other than diet •Age older than 70 years •Thallium redistribution (most sensitive for predicting events) •Ischemic electrocardiographic changes during or after dipyridamole infusion •Combining both the clinical data and thallium imaging was more sensitive and specific than either alone in predicting postoperative complications.
  5. 5. Detsky’s Cardiac Risk Index A modified cardiac index that included •type of operation, •age, •frequency of premature ventricular contractions (PVCs), •and aortic stenosis •However, heart failure was defined in this study as pulmonary edema determined by chest radiograph or by history of severe respiratory distress and resolution of the symptoms by use of diuretics.
  6. 6. Revised (Lee’s) Cardiac Risk Index • High-risk surgery (intrathoracic, intra-abdominal. or suprainguinal vascular) • Ischemic heart disease (defined as a history of myocardial infarction [MI], pathologic Q waves on the ECG, use of nitrates, abnormal stress test, and chest pain secondary to ischemic causes) • Congestive heart failure • History of cerebrovascular disease • Insulin therapy • Preoperative serum Creatinine level higher than 2 mg/dL Each of the six risk factors was assigned one point. Patients with none, one, or two risk factor (s) were assigned to RCRI classes I, II, and III, and patients with more than two risk factors were considered Class IV. The risk associated with each class was 0.4%, 1%, 7%, and 11% for patients in Classes I, II, II, and IV, respectively.
  7. 7. American College of Cardiology Cardiac Risk Classification Box 2 Clinical Predictors of Increased Perioperative Cardiovascular Risk* Major Predictors Unstable coronary syndromes •Acute or recent MI† with evidence of important ischemic risk by clinical symptoms or noninvasive study •Unstable or severe‡ angina (Canadian Class III or IV) Decompensated heart failure Significant arrhythmias •High-grade atrioventricular block •Symptomatic ventricular arrhythmias in the presence of underlying heart disease •Supraventricular arrhythmias with uncontrolled ventricular rate Severe Valvular disease Intermediate Predictors Mild angina pectoris (Canadian Class I or II) Previous MI by history or pathologic Q waves Compensated or prior heart failure Diabetes mellitus (especially insulin-dependent type) Renal insufficiency Minor Predictors Advanced age Abnormal ECG (e.g., left ventricular hypertrophy, left bundle branch block, ST-T abnormalities) Rhythm other than sinus (e.g., atrial fibrillation) Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension ECG, electrocardiogram; MI, myocardial infarction.
  8. 8. Factors Affecting Cardiac Risk • Coronary Artery Disease • Diabetes • Advanced Age • Hypertension • Valvular Disease • Arrhythmias and Heart Conduction Defects • Permanent Pacemakers and Implantable Cardioverter-Defibrillators • Congestive Heart Failure • Pulmonary Arterial Disease • Congenital Heart Disease • Obesity • Type of Surgery
  9. 9. Box 6 Modified Johns Hopkins Surgical Criteria Grade I Minimal to Mild Risk Independent of Anesthesia •Breast biopsy Excludes •Open exposure of internal body organs Minimal to Moderately Invasive Procedure Includes •Removal of minor skin or subcutaneous lesions Excludes •Repair of vascular or neurologic structures Potential Blood Loss Less than 500 mL Includes •Myringotomy tubes •Hysteroscopy •Cystoscopy, vasectomy •Circumcision •Fiberoptic bronchoscopy •Diagnostic laparoscopy dilatation and curettage •Fallopian tube ligation, arthroscopy •Inguinal hernia repair •Laparoscopic lysis of adhesion •Tonsillectomy, rhinoplasty Excludes •Placement of prosthetic devices •Postoperative monitored care setting •Open exposure of abdomen, thorax, neck, cranium •Resection of major body organs
  10. 10. Grade II Moderately to Significantly Invasive Procedures Includes •Thyroidectomy Excludes •Open thoracic or intracranial procedure Potential Blood Loss of 500-1500 mL Includes •Hysterectomy Excludes •Major vascular repair (e.g., aortofemoral bypass) Moderate Risk to Patient Independent of Anesthesia Includes •Myomectomy •Cystectomy •Cholecystectomy, laminectomy •Hip, knee replacement, nephrectomy •Major laparoscopic procedures •Resection, reconstructive surgery of the digestive tract Excludes •Planned postoperative monitored care setting (ICU, PACU)
  11. 11. Grade III Highly Invasive Procedure •Major orthopedic-spinal reconstruction Potential Blood Loss More than 1500 mL •Major reconstruction of the gastrointestinal tract Major to Critical Risk to Patient Independent of Anesthesia •Major genitourinary surgery (e.g., radical retropubic prostatectomy) Usual Postoperative ICU Stay with Invasive Monitoring •Major vascular repair without postoperative ICU stay •Cardiothoracic procedure Intracranial procedure •Major procedure on the oropharynx •Major vascular, skeletal, neurologic repair
  12. 12. Box 7 Cardiac Risk* Stratification for Noncardiac Surgical Procedures High Risk (reported cardiac risk often >5%) Emergent major operations, particularly in older patients Aortic and other major vascular surgeries Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts, blood loss, or both Intermediate Risk (reported cardiac risk generally <5%) Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery Low Risk (reported cardiac risk generally <1%)† Endoscopic procedures Superficial procedure Cataract surgery Breast surgery
  13. 13. Minimization Of Risk Using Medical Therapy • Beta Blockers • Lipid-Lowering Agents • a2-Adrenergic Agonists • Preoperative Laboratory Tests for Risk Assessment Test Cutoff Value OR/HR of Myocardial ischemia OR/HR of Death/nonfatal MI OR/HR of all cardiac complications BNP >189 pg/ml NA NA 28.78 NT proBNP >270 ng/L 1.49* 1.59* NA NT proBNP >319 ng/L NA 4† 10.9‡ HbA1c >7% 2.8 3.6 5.6 IGT 5.6-7 mmol/L§ 2.2 2 1.9 DM >7 mmol/L§ 2.6 2.7 3.1
  14. 14. Metabolic Equivalents of Functional Capacity MET Functional Levels of Exercise 1 Eating, working at a computer, dressing 2 Walking down stairs or in your house, cooking 3 Walking 1-2 blocks 4 Raking leaves, gardening 5 Climbing 1 flight of stairs, dancing, bicycling 6 Playing golf, carrying clubs 7 Playing singles tennis 8 Rapidly climbing stairs, jogging slowly 9 Jumping rope slowly, moderate cycling 10 Swimming quickly, running or jogging briskly 11 Skiing cross country, playing full-court basketball 12 Running rapidly for moderate to long distances MET, metabolic equivalent of the task. 1 MET = consumption of 3.5 mL O2/min/kg of body weight.
  15. 15. References • Miller’s Anaesthesia • Johns Hopkins Medical Hospital Website • Goldman and Eagle’s Risk Indices • Stoelting’s Co-existing diseases • Morgan’s Clinical Anaesthesiology • Clinical Anaesthesiology by Paul G. Barash • WebMD • Springer Online