ACC AHA Guidelines on Perioperative Cardiac Assesement

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ACC AHA Guidelines on Perioperative Cardiac Assesement

  1. 1. Overview • Drafted out by American College of Cardiology (ACC) and American Heart Association (AHA) initially in 1980 then revised again in 2002, 2007 and 2011. • Comprising almost 20 topics relating to cardiac issues for patients undergoing non cardiac surgery. • Eg : preoperative noninvasive evaluation of LV function; preoperative resting 12-lead ECG; noninvasive stress testing before non-cardiac surgery; reoperative coronary revascularization; betablocker therapy; statin therapy; preoperative ICU monitoring; use of volatile anesthetic agents; prophylactic Nitroglycerin, maintenance of normothermia; glucose control; use of pulmonary artery catheters; intraoperative and postoperative ST-segment monitoring; surveillance for perioperative myocardial infarction; and the tissue of when patients with cardiac stents can safely undergo elective surgery
  2. 2. Purpose • Quick reference for decision making • lower the risk of surgery • evaluation of the patient’s current medical status • make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire preoperative period • provide a clinical risk profile can be of use in making treatment decisions that may influence short- and long-term cardiac outcomes
  3. 3. GOALS – IDENTIFICATION OF PATIENTS WITH UNSTABLE CARDIOVASCULAR CONDITION – IDENTIFICATION OF PATIENTS WITH KNOWN AND SYMPTOMATIC Coronary Heart Disease (CHD) – IDENTIFICATION OF PATIENTS AT RISK OF CHD » » » » » PVD HTN DM SMOKING HYPERCHOLESTROLEMIA
  4. 4. CLASSIFICATION OF RECOMMENDATIONS
  5. 5. CLASS 1 CLASS II A CLASS II B CLASS III SHOULD REASONABLE MAYBE CONSIDERED SHOULD NOT Benefit >>> Risk LEVEL A Multiple (3-5) population risk LEVEL B Limited (2-3) population risk LEVEL C Very limited (1-2) population risk BENEFIT >> RISK BENEFIT > RISK RISK > BENEFIT
  6. 6. PREOPERATIVE CARDIAC EVALUATION • Evaluation History taking • to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent or past MI, decompensated HF, significant arrhythmias, and severe valvular disease • history of a pacemaker or implantable cardioverter defibrillator • Accurate recording of current medications used, including herbal and other nutritional supplements, and dosages .
  7. 7. • Determine ASA status , surgery classification and functional capacity. Status State Class 1 No organic, physiologic, biochemical, or psychiatric disturbance. Class 2 Mild to moderate systemic disturbance that may or may not be related to the reason for surgery Eg : Essential HTN, DM, Morbid Obesity, Anemia Class 3 Severe systemic disturbance that may or may not be related to the reason for surgery, (does limit activity) Eg ; Uncontrolled HTN, DM with vascular complications, COPD with func. Limitation, angine pectoris, Hx of MI Class 4 Severe systemic disturbance that is life-threatening with or without surgery Eg : CHF, advanced pulmonary, renal/hepatic dysfunction Class 5 Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort) Eg : Uncontrolled hemorrhage from ruptured abdominal aneurysm, cerebal trauma, pulmonary embolism. Emergency (E) Any patient in whom an emergency operation is required
  8. 8. Risk Stratification 5 FACTORS FOR RISK STRATIFICATION – Recency Of Coronary Revascularization – Recency Of Last Favourable Cardiac Evaluation – Presence Of Comorbidities-clinical Predictors – Functional Status – Risk Of Proposed Surgery
  9. 9. 1-CORONARY REVASCULARISATION • Complete coronary surgical revascularization -5 yrs • PCI-- > 6months-5 yrs • No recurrent Symptoms or signs of ischemia • Clinical status is stable No further cardiac testing is necessary
  10. 10. 2-Coronary evaluation • Past 2 years • Invasive/non invasive tech – Favorable – No definite change or new symptom No further cardiac testing is necessary
  11. 11. 3-Clinical predictors • Major – Unstable coronary syndromes • recent MI with evidence for ischemia ( >7 days & < 30days) • unstable or severe angina – Decompensated CHF – Significant arrhythmia • high grade AV block • symptomatic ventricular arrhythmia • supraventricular arrhythmia with uncontrolled rate – Severe valvular disease
  12. 12. • Intermediate – Mild angina pectoris (Canadian class I or II) – Prior MI by history or pathological Q waves – Compensated or prior CHF – Diabetes mellitus – Renal impairment (creatinine > 2mg per dL) – Anemia – Pulmonary Disease (obstructive/restrictive)
  13. 13. • Minor – Advanced age – abnormal ECG (LVH, LBBB, ST-T change) – Rhythm other than sinus – Low functional capacity – History of stroke – Uncontrolled systemic hypertension
  14. 14. Functional Capacity • Functional capacity can be expressed as metabolic equivalents (METs); the resting or basal oxygen consumption (Vo2) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min, or 1 MET.
  15. 15. Duke’s Activity Status Index • 1 MET – Can you take care of self? – Eat, dress, use toilet? – Walk indoors in house? – Walk a block or two on level at 2-3 mph? – Do light housework like dusting or dishes? • 4 METs 1 MET = 3.5 ml/kg/mt VO2 • 4 METs Climb a flight of stairs, walk up hill? Walk on level at 4 mph? Run a short distance? Heavy housework Golf, bowling, dancing, doubles tennis Swimming, singles tennis football, basketball, skiing • >10 METs >10 METs-Excellent 7-10 good 4-7 moderate ≤4 poor
  16. 16. Classification of surgeries according to Risk. • High (reported cardiac risk > 5%) • emergent major operations, esp. in elderly • aortic and other major vascular procedures • peripheral vascular procedures • anticipated prolonged procedure with large fluid shift/blood loss
  17. 17. • Intermediate (reported cardiac risk < 5%) – carotid endarterectomy – head and neck – intraperitoneal & intrathoracic – orthopedic – prostate
  18. 18. • Low (reported cardiac risk < 1%) – endoscopic procedures – superficial procedure – cataract – breast
  19. 19. 9 step algorithm
  20. 20. 9 step algorithm
  21. 21. 9 step algorithm 9 step algorithm
  22. 22. Cardiac Conditions that Need Evaluation and Treatment Before Surgery Condition Unstable coronary syndromes Examples Unstable or severe angina (CCS class III, IV) , Recent MI Decompensated HF Significant Arrhythmias High Grade AV Block, Mobitz II AV Block, 3rd Degree AV block, Symptomatic Ventricular Arrhythmias, Supraventricular Arrhytmias with HR > 100 bpm at rest, Symptomatic Bradycardia, Newly Recognized VT Severe Valvular Disease Severe aortic stenosis, Symptomatic Mitral Stenosis (dyspnea on exertion, exertional presyncope or HF)
  23. 23. • Class IIA • It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms‡ proceed to planned surgery. • It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for vascular surgery consider testing if it will change management. • It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control. • It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.
  24. 24. • Class IIB • Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors∥ who are scheduled for intermediate risk surgery. • Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors∥ who are scheduled for vascular or intermediate risk surgery.
  25. 25. PREOP TESTING • ECG • DETECT LVH,BBB & CONDUCTION DEFECT • PREVIOUS MI • BASELINE FOR INTRA AND POST OP COMPARISON • INCREASED PERIOP RISK • ST DEPRESSION MORE THAN .5 MM • LVH WITH STAIN PATTERN • LBBB
  26. 26. • EXERCISE STRESS TEST • STRONGEST DETERMINANT OF RISK AND NEED FOR INVASIVE MONITORING • LEAD SELECTION • ECG CRITERIA – – – – 1 M M OF J POINT DEPRESSION 2MM OF ST DEPRESSION AT 80 MS FROM J POINT ST ELEVATION NON ECG RESP • LOW ACHIEVED HR • SYSTOLIC HYPOTENSION • INABILITY TO EXERCISE FOR MORE THAN 3 MIN
  27. 27. PHARMACOLOGICAL STRESS TEST • Two Categories – Dobutamine Stress Echo-incr. Mvo2 – New/Incr In Rwma – More Than 5/16 Lt Ventricular Segm Involvement – Dipyridamole Thallium-mimics Coronary Art Dialatation Resp Associated With Exercise – Infarcted Area-fixed Defect – Ischemic Area-reversible Defect
  28. 28. ECHOCARDIOGRAPHY – LVEF – RWMA – Valvular Abn – Cong Cardiac Defects
  29. 29. CORONARY ANGIOGRAPHY • Non Invasive Testing-high Risk Of Adverse Outcome • Angina Unresponsive To adequate Medical Therapy • Unstable Angina-intermediate And High Risk Sx • High Clinical Predictor In High Risk Sx
  30. 30. PERIOP THERAPY • BETA BLOCKERS – CVS EFFECTS • • • • ↓ HR-(diastolic Time) ↓ Contractility Plaque Stabilization- ↓ Shear Forces Antiarrythmic Effect – ELIGIBILITY CRITERIA • CLINICAL -ANY 2 – – – – – AGE>65 HTN CHR SMOKER SER CHOLESTROL>240 mg/dl DM • CARDIAC RISK INDEX CRITERIA – – – – – HIGH RISK SX PROCEDURE IHD CVA DM CRF
  31. 31. OTHER THERAPIES • Alpha-2 Adrenergic Agonist • Regional Anesthesia – Epidural

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