Koshy

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  • The purpose of preoperative evaluation is to perform an evaluation of the patient’s current medical status, make recommendations concerning the risk of cardiac problems over the entire perioperative period, and provide a clinical risk profile that the patient, his or her primary physician, anesthesiologist, and surgeon can use in making treatment decisions. No test should be performed unless it is likely to influence patient treatment .
  • The consultant should review available patient data, obtain a history, and perform a physical examination pertinent to the patient's problem and the proposed surgery. A critical role of the consultant is to communicate the severity and stability of the patient's cardiovascular status and to determine if the patient is in the best reasonable medical condition, given the context of the surgical illness.
  • Preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and nature of the surgical illness. A careful history and cardiovascular examination are crucial. In addition, the consultant must evaluate the cardiovascular system within the framework of the patient's overall health. Ancillary studies may be minimal, but should include review of the electrocardiogram
  • In this way, the separation of MI into the traditional 3 and 6 month intervals has been avoided. Although there are no adequate clinical trials on which to base form recommendations it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgery.
  • Cardiac complications are two to five times more likely to occur with emergency surgical procedures than with elective operations. In addition, the magnitude of the surgical procedure influences the cardiac risk. Major vascular procedures represent the highest risk, as well as those with prolonged duration and large fluid shifts.
  • Test of choice is exercise ECG testing. Provides estimate of functional capacity, Detects myocardial ischemia through ECG changes and hemodynamic response
  • Preoperative invasive monitoring in an intensive care setting can be used to optimize and even augment oxygen delivery in patients at high risk
  • Further evaluation regarding the optimal strategy for surveillance and diagnosis of perioperative MI is required before one method is advocated. In patients without evidence of CAD, surveillance should be restricted to patients who develop perioperative signs of cardiovascular dysfunction. In patients with known or suspected CAD undergoing surgical procedures associated with a high incidence of cardiovascular morbidity, ECGs at baseline, immediately after the surgical procedure, and daily on the first 2 days postoperatively appear to be the most cost-effective strategy.
  • Koshy

    1. 1. PREOPERATIVE EVALUATION OF CARDIAC PATIENT (For Non-Cardiac Surgery) Dr Thomas Koshy Additional Professor Sree Chitra Tirunal Institute for Medical Sciences and Technology Trivandrum
    2. 2. The risk <ul><li>Low risk: Patients without clinical evidence of heart disease have a low risk of MI (0.15%) </li></ul><ul><li>High risk: Perioperative MI is associated with a 40-70% mortality rate </li></ul>
    3. 3. Magnitude of the problem <ul><li>25 million patients undergo noncardiac surgery each year in the United States </li></ul><ul><li>3 million patients have clinical evidence or multiple risk factors for CAD </li></ul><ul><li>4 million patients are > 65 years old </li></ul><ul><li>Nearly 1/3 of surgical patients are at risk for cardiovascular complications </li></ul><ul><li>Coronary heart disease is the most frequent cause of perioperative cardiac mortality and morbidity after noncardiac surgery </li></ul>
    4. 4. THE CASE <ul><li>Adult with DM – elective non-cardiac surgery </li></ul><ul><li>Adult with systemic HT– elective non-cardiac surgery </li></ul>
    5. 5. 52 year old school teacher from Kottayam <ul><li>large frontal meningioma </li></ul><ul><li>inf wall MI 2 years back </li></ul><ul><li>On atenelol and sorbitrate </li></ul>
    6. 6. The questions <ul><li>Can these patient reasonably have noncardiac surgery </li></ul><ul><li>Is there a need for further testing </li></ul><ul><li>Any drugs to be started </li></ul><ul><li>Keep him in ICU before surgery </li></ul><ul><li>How many ECGs in post op </li></ul><ul><li>Role of intraop NTG </li></ul><ul><li>Would coronary revascularization improve the long-term prognosis from a cardiac standpoint and protect the patient from adverse events during the necessary noncardiac surgery? </li></ul>
    7. 7. Factors increasing cardiac risk <ul><li>Disease condition(severity and stability)-CAD, CHF, Arrhythmias, Valvular diseases, Pulm vascular disease </li></ul><ul><li>Age </li></ul><ul><li>Type of Surgery </li></ul><ul><li>Functional capacity </li></ul><ul><li>Comorbid conditions: DM, Renal dysfn, CVA </li></ul>
    8. 8. Purpose of Preoperative Evaluation <ul><li>Evaluate patient’s current medical status </li></ul><ul><li>Provide clinical risk profile </li></ul><ul><li>Decision on further testing </li></ul><ul><li>Recommend management of cardiac risk over entire perioperative period </li></ul><ul><li>Treatment of modifiable risk factors </li></ul><ul><li>NOT SIMPLY TO GIVE MEDICAL CLEARANCE </li></ul>
    9. 9. Roles of Clinicians <ul><li>Cardiologist </li></ul><ul><li>Anaesthesiologist </li></ul><ul><li>Surgeon </li></ul>
    10. 10. Role of the Cardiologist <ul><li>Review available patient data, history and physical examination </li></ul><ul><li>Determine if further testing is needed to define cardiovascular status </li></ul><ul><li>Recommend treatment to improve medical condition </li></ul><ul><li>Participate in postoperative medical management </li></ul>
    11. 11. General Approach to the Patient <ul><li>History – angina, recent or past MI, CHF, symptomatic arrhythmias, presence of pacemaker or ICD </li></ul><ul><li>Physical Examination – general appearance, rales, elevated JVP, carotid and other arterial pulses, S 3 gallop, murmurs </li></ul><ul><li>Comorbid Diseases </li></ul><ul><ul><li>Pulmonary </li></ul></ul><ul><ul><li>Diabetes Mellitus </li></ul></ul><ul><ul><li>Renal Impairment </li></ul></ul><ul><ul><li>Hematologic Disorders </li></ul></ul><ul><li>Ancillary Studies - ECG, blood chemistries, chest X-ray </li></ul>
    12. 12. Clinical Predictors of Increased Perioperative Cardiovascular Risk <ul><li>Major (cardiac risk > 5%) </li></ul><ul><ul><li>Unstable coronary syndromes </li></ul></ul><ul><ul><li>Decompensated CHF </li></ul></ul><ul><ul><li>Significant Arrhythmias </li></ul></ul><ul><ul><li>Severe valvular disease </li></ul></ul><ul><li>Intermediate (cardiac risk< 5%) </li></ul><ul><ul><li>Mild angina pectoris </li></ul></ul><ul><ul><li>Prior MI </li></ul></ul><ul><ul><li>Compensated or prior HF </li></ul></ul><ul><ul><li>Diabetes Mellitus (particularly taking insulin) </li></ul></ul><ul><ul><li>Renal insufficiency </li></ul></ul><ul><li>Minor (cardiac risk < 1%) </li></ul><ul><ul><li>Advanced Age. </li></ul></ul><ul><ul><li>Abnormal ECG. </li></ul></ul><ul><ul><li>Rhythm other than sinus. </li></ul></ul><ul><ul><li>Low functional capacity. </li></ul></ul><ul><ul><li>History of stroke. </li></ul></ul><ul><ul><li>Uncontrolled systemic </li></ul></ul><ul><ul><li>hypertension </li></ul></ul>
    13. 13. Unstable coronary syndromes (major clinical predictor) <ul><li>Acute (<7 days) or Recent MI (7 days-1 month) </li></ul><ul><li>Unstable or severe angina </li></ul><ul><li>(Canadian class III or IV) </li></ul>
    14. 14. Significant Arrhythmias (major clinical predictor) <ul><li>High grade atrioventricular block </li></ul><ul><li>Symptomatic ventricular arrhythmias in the presence of underlying heart disease </li></ul><ul><li>Supraventricular arrhythmias with uncontrolled ventricular rate </li></ul>
    15. 15. Type of Surgery <ul><li>Urgency (cardiac compl 2 to 5 times more) </li></ul><ul><li>High surgical risk : </li></ul><ul><ul><ul><li>Emergent major operations, particularly in the elderly </li></ul></ul></ul><ul><ul><ul><li>Aortic and other major vascular surgery </li></ul></ul></ul><ul><ul><ul><li>Peripheral vascular surgery </li></ul></ul></ul><ul><ul><ul><li>Anticipated prolonged surgical procedures </li></ul></ul></ul><ul><ul><ul><li>associated with large fluid shifts and/or </li></ul></ul></ul><ul><ul><ul><li>blood loss. </li></ul></ul></ul>
    16. 16. Type of Surgery <ul><li>Intermediate surgical risk: </li></ul><ul><ul><li>Carotid endarterectomy </li></ul></ul><ul><ul><li>Head and neck surgery </li></ul></ul><ul><ul><li>Intraperitoneal and intrathoracic </li></ul></ul><ul><ul><li>Orthopedic surgery </li></ul></ul><ul><ul><li>Prostate surgery </li></ul></ul>
    17. 17. Type of Surgery <ul><li>Low surgical risk : </li></ul><ul><ul><li>Endoscopic procedures </li></ul></ul><ul><ul><li>Superficial procedures </li></ul></ul><ul><ul><li>Cataract surgery </li></ul></ul><ul><ul><li>Breast surgery </li></ul></ul>
    18. 18. Functional capacity <ul><li>Expressed in metabolic equivalent (MET)levels </li></ul><ul><li>Oxygen consumption (VO2) of 70Kg, 40-yr-old man in resting state is </li></ul><ul><li>3.5 ml/kg/mt or 1 MET </li></ul>
    19. 19. Functional capacity <ul><li>>10 METS - Excellent 7-10 METS - Good </li></ul><ul><li>4-7 - Moderate <4 - Poor </li></ul><ul><li>Patients with a low functional capacity (less than 4 Mets) have a worse prognosis than patients with a good functional capacity </li></ul>
    20. 20. Assessment of Functional capacity <ul><li>Can you take care 1 MET </li></ul><ul><li>of yourself? </li></ul><ul><li>Eat, dress, or use </li></ul><ul><li>the toilet? </li></ul><ul><li>Walk indoors around </li></ul><ul><li>the house? </li></ul><ul><li>Walk a block or two on </li></ul><ul><li>level ground at 2-3 mph </li></ul><ul><li>or 3.2 -4.8 km/h? </li></ul><ul><li>Do light work around 4 MET </li></ul><ul><li>the house like dusting </li></ul><ul><li>or washing dishes? </li></ul><ul><li>Climb a flight of stairs or walk 4 MET </li></ul><ul><li>up a hill? </li></ul><ul><li>Walk on level ground at 4 mph </li></ul><ul><li>or 6.4 km/h? </li></ul><ul><li>Run a short distance? </li></ul><ul><li>Do heavy work around the house </li></ul><ul><li>like scrubbing floors or lifting or </li></ul><ul><li>moving heavy furniture? </li></ul><ul><li>Participate in moderate </li></ul><ul><li>recreational activities like </li></ul><ul><li>golf, bowling, dancing, doubles </li></ul><ul><li>Tennis, or throwing a baseball </li></ul><ul><li>or football? </li></ul><ul><li>Participate in strenuous sports 10 MET </li></ul><ul><li>like swimming, singles tennis, </li></ul><ul><li>football, basketball, or skiing? </li></ul>
    21. 21. Indications for further testing <ul><li>No further testing required </li></ul><ul><li>Coronary revascularization within 5 years and no recurrent symptoms. </li></ul><ul><li>Benign Coronary evaluation within 2 years and no change in symptoms. </li></ul>
    22. 22. Stepwise Approach to Preoperative Cardiac Assessment <ul><li>AMERICAN COLLEGE OF CARDIOLOGY </li></ul><ul><li>AMERICAN HEART ASSOCIATION </li></ul><ul><li>ALGORITHM </li></ul><ul><li>FOR </li></ul><ul><li>FURTHER TESTING TO CONFIRM </li></ul><ul><li>THE DIAGNOSIS AND EXTENT OF </li></ul><ul><li>CORONARY ARTERY DISEASE </li></ul>Circulation 2002;105:1257-68 and J Am Coll Cardiol 2002;39:542-53
    23. 23. Major clinical predictors
    24. 24. Intermediate predictors
    25. 25. Minor predictors
    26. 26. Further Non-invasive testing <ul><li>if 2 or more of following present: </li></ul><ul><ul><li>Intermediate clinical predictors (Canadian Class I or II angina, prior MI based on history or pathological Q waves, compensated or prior HF, or diabetes) </li></ul></ul><ul><ul><li>Poor functional capacity (<4 METs) </li></ul></ul><ul><ul><li>High surgical risk procedure (emergency major surgery*, aortic repair or peripheral vascular, prolonged surgical procedures with large fluid shifts or blood loss) </li></ul></ul><ul><ul><li>* Emergency major operations may require immediately proceeding to surgery without sufficient time for noninvasive testing or preoperative interventions. </li></ul></ul>
    27. 27. When and Which Test (For the cardiologist) No further preoperative testing recommended Preoperative angiography Ex ECG Exercise echo or perfusion imaging‡** Pharmacologic stress imaging (nuclear or echo) Dipyridamole or adenosine perfusion Dobutamine stress echo or nuclear imaging Other (eg, Holter monitor, angiography) Yes Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Borderline or low blood pressure? Marked hypertension? Poor echo window? No Yes Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Marked hypertension? Bronchospasm? II  AV Block? Theophylline dependent? Valvular dysfunction? No No Resting ECG normal? Patient ambulatory and able to exercise?‡ Yes No Yes Yes Indications for angiography? (eg, unstable angina?) Yes Yes No No Testing is only indicated if the results will impact care. 2 or more of the following?†* 1. Intermediate clinical predictors 2. Poor functional capacity (less than 4 METS) 3. High surgical risk
    28. 28. Non Invasive tests <ul><ul><ul><li>Exercise stress testing- Ex ECG </li></ul></ul></ul><ul><ul><ul><li>Nonexercise stress testing: </li></ul></ul></ul><ul><ul><ul><ul><li>Dobutamine stress echocardiography. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Myocardial perfusion imaging </li></ul></ul></ul></ul><ul><ul><ul><li>Ambulatory electrocardiographic monitoring. </li></ul></ul></ul>
    29. 29. Management Options after Noninvasive Testing <ul><li>Intensified medical therapy </li></ul><ul><li>Cardiac catheterization </li></ul><ul><ul><li>Cancel or delay surgery </li></ul></ul><ul><ul><li>Proceed with surgery </li></ul></ul><ul><ul><li>Coronary revascularization prior to surgery </li></ul></ul>
    30. 30. Preop Coronary angiography (Class I indications) <ul><li>High-risk results during noninvasive testing </li></ul><ul><li>Angina pectoris unresponsive to adequate medical therapy </li></ul><ul><li>Most patients with unstable angina </li></ul><ul><li>Nondiagnostic or equivocal noninvasive test in a high-risk patient undergoing a high-risk noncardiac surgical procedure </li></ul>
    31. 31. Preop Coronary angiography (Class II indications) <ul><li>Multiple markers of intermediate-risk during noninvasive testing </li></ul><ul><li>Nondiagnostic or equivocal noninvasive test in a lower-risk patient undergoing a high-risk noncardiac surgical procedure </li></ul><ul><li>Urgent noncardiac surgery in a patient convalescing from acute MI </li></ul>
    32. 32. Preoperative CABG <ul><ul><li>No randomized clinical trials documenting decreased incidence of perioperative cardiac events </li></ul></ul><ul><ul><li>Patients with prognostic high risk coronary anatomy in whom long-term outcome would likely be improved </li></ul></ul><ul><ul><li>Noncardiac elective surgical procedure of high or intermediate risk. </li></ul></ul>
    33. 33. Preoperative CABG <ul><li>Indications are same as those in the nonoperative setting </li></ul><ul><li>Cardiac risk of CABG often exceeds that of noncardiac surgery </li></ul><ul><li>Rarely indicated simply to get a patient through the perioperative period </li></ul>
    34. 34. Preopoperative PTCA <ul><li>No controlled trials </li></ul><ul><li>Several small observational studies suggest that cardiac death is infrequent in patients who have PTCA prior to noncardiac surgery </li></ul><ul><li>Indications are similar to those in nonoperative setting </li></ul>
    35. 35. Preoperative Medical therapy <ul><ul><li>Few randomized trials </li></ul></ul><ul><ul><li>S tudies suggest B-blockers reduce perioperative ischemia and may reduce risk of MI and death </li></ul></ul><ul><ul><li>Alpha-agonists may also reduce cardiac events when administered perioperatively </li></ul></ul>Poldermans D. NEJM 1999;341:1789-1794
    36. 36. Valvular Heart Disease <ul><li>Indications for evaluation/treatment identical to those in nonoperative setting </li></ul><ul><li>Symptomatic stenotic lesions associated with risk of perioperative CHF/shock </li></ul><ul><li>Symptomatic regurgitant lesions usually better tolerated perioperatively </li></ul>
    37. 37. Hypertension <ul><li>Perioperative swings of pressure often occur in hypertensive patients </li></ul><ul><li>Patients who are adequately treated preoperatively have less marked deviations of blood pressure </li></ul><ul><li>Surges of BP most common during: </li></ul><ul><ul><li>Induction </li></ul></ul><ul><ul><li>Intubation </li></ul></ul><ul><ul><li>Skin incicision </li></ul></ul><ul><ul><li>12 to 24 hours post-op </li></ul></ul>
    38. 38. Preoperative Intensive care <ul><li>Goal </li></ul><ul><ul><li>Optimize and augment oxygen delivery in patients at high risk </li></ul></ul><ul><li>Hypothesis </li></ul><ul><ul><li>Indices derived from pulmonary artery catheter and invasive blood pressure monitoring can be used to maximize oxygen delivery, which leads to reduction in organ dysfunction </li></ul></ul>
    39. 39. Preoperative Intensive care <ul><li>Recommendation: </li></ul><ul><li>Based on scant evidence, preoperative preparation in intensive care unit may benefit certain high risk patients, particularly those with decompensated HF. </li></ul>
    40. 40. Anesthetic Considerations and Intraoperative Management <ul><li>No study clearly demonstrated improved outcome from use of: </li></ul><ul><ul><li>Regional versus general anesthesia </li></ul></ul><ul><ul><li>Pulmonary artery catheter </li></ul></ul><ul><ul><li>Intraoperative Nitroglycerin </li></ul></ul><ul><ul><li>ST-Segment Monitoring </li></ul></ul><ul><ul><li>Transesophageal echocardiography </li></ul></ul><ul><ul><li>Prophylactic placement of intra-aortic balloon counterpulsation device </li></ul></ul>
    41. 41. Intraoperative Nitroglycerine <ul><li>High-risk patients previously taking nitroglycerin who have active signs of myocardial ischemia without hypotension </li></ul>
    42. 42. Anaesthesia <ul><li>Any anesthetic technique that does not effectively eliminate pain will be associated with markedly increased cardiac demands </li></ul><ul><li>Choice should be left to the discretion of the anesthesia care team </li></ul><ul><li>Opiod-based anesthetics popular because of cardiovascular stability, but high doses result in postoperative ventilation </li></ul>
    43. 43. Perioperative Surveillance <ul><li>Patients without evidence of CAD: </li></ul><ul><ul><li>Surveillance restricted to those who develop perioperative signs of cardiovascular dysfunction </li></ul></ul><ul><li>Patients with known or suspected CAD, and undergoing high or intermediate risk procedure: </li></ul><ul><ul><li>ECGs at baseline, immediately after procedure, and daily x 2 days </li></ul></ul><ul><ul><li>Cardiac troponin measurements 24 hours postoperatively and on day 4 or hospital discharge (whichever comes first) </li></ul></ul>
    44. 44. 52 year old school teacher from Kottayam <ul><li>large frontal meningioma </li></ul><ul><li>inf wall MI 2 years back on sorbitrate and atenelol </li></ul><ul><li>Good functional capacity by history 4-7 METS </li></ul>
    45. 45. <ul><li>positive treadmill test , acheived 7 METS </li></ul><ul><li>coronary angiogram tripple vessel disease- LAD - 75% block </li></ul><ul><li>OM 1- 90% block </li></ul><ul><li>RCA - 75% block LVEDP (post angio)-14 </li></ul><ul><li>Cardiologist’s opinion – CABG before surgery </li></ul><ul><li>Functional limitation correlates with perioperative risk </li></ul><ul><li>Anatomical severity is important for long term </li></ul><ul><li>prognosis </li></ul><ul><li>(Braunwald) </li></ul>
    46. 46. Summary <ul><li>Integration of clinical risk factors, surgery specific risk and functional capacity should be utilised to determine the need for further diagnostic evaluation </li></ul><ul><li>Use of beta blockers in high risk patients has been shown to reduce perioperative risk </li></ul><ul><li>Coronary intervention is reserved for patients who warrant intervention independent of non-cardiac surgery </li></ul>

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