This document provides information on preoperative assessment and cardiac risk assessment (PAC) for patients undergoing non-cardiac surgery. It discusses how cardiovascular complications are a major cause of death following non-cardiac surgeries. The aims of PAC are to identify life-threatening cardiac conditions, order appropriate tests, stratify surgical risks, and implement optimal medical and interventional strategies. The document outlines guidelines for risk assessment and provides details on the history, examination, investigations, medications, and risk indices used to evaluate cardiac patients for non-cardiac surgery. It emphasizes stratifying risk based on surgery type, identifying underlying cardiac conditions, and optimizing medical management to reduce perioperative cardiovascular risks.
PAC OF CARDIAC PATIENTS FOR NON-CARDIAC SURGERY,.pptx
1. PAC OF CARDIAC PATIENTS FOR
NON-CARDIAC SURGERY,
CARDIAC RISK ASSESSMENT
Presented by:
Pooja Pandeya
1st year Resident
Department of Anesthesiology
2. INTRODUCTION
• Cardiovascular complications: 25-50% deaths following non-cardiac
surgeries
• Major Adverse Cardiac Event (MACE): composite term Includes
Acute Myocardial Syndrome, stroke, cardiovascular death, coronary
revascularization and heart failure
• By 2030, 20% individuals aged >75 years will undergo surgery each
year
3. GUIDELINES FOR RISK ASSESSMENT
• ACC/ AHA Task force report 2014
• ESC/ESA 2022 guidelines
• CCS 2019 guidelines
4. DEFINITIONS
• Emergency procedure: Life or limb threatened if not in the operating room
(<6hrs)
• Urgent procedure: Limited time for clinical evaluation (6-24 hrs)
• Time sensitive procedure: 1 to 6 weeks to allow for an evaluation and
significant changes in management will negatively affect outcome
• Elective procedure: Could be delayed for up to 1 year
• Low-risk procedure: <1% risk of MACE
• Elevated risk procedure: >1% risk of MACE
5. AIMS OF PAC
• Identification potentially life-threatening cardiac disease
• Order appropriate tests only
• Stratifications of risks
• Implementation most appropriate medical and interventional
cardiovascular treatment strategies
6. HISTORY
• Chest pain
• SOB
• Easy fatigability
• Palpitations
• Orthopnea, PND
• Syncope
• Relation of symptoms with activity level
• Hemoptysis
12. CARDIAC AND SURGICAL RISK CALCULATORS
• ACS NSQIP MICA Surgical Risk Calculator
• 21 patient-specific variables for prediction of several groups of
outcomes
• https://riskcalculator.facs.org/RiskCalculator/
16. DIABETES MELLITUS
• Accelerate progression of atherosclerosis CAD
• Require Insulin Higher risk
• Duration of disease
• End organ dysfunction
• Autonomic neuropathy silent ischemia
17. HYPERTENSION
• Look for LVH, end organ damage
• JNC -8
• 180/110 mmHg Evidence
• Optimize VS risk of delaying surgery
18. METABOLIC SYNDROME
• High BP + Dyslipedemia + FBS + Central obesity
• Cardiovascular + Pulmonary + Renal Complication + Wound infection
19.
20. INVESTIGATIONS
• 12-lead ECG
• Tropinin I, CK-MB, LDH-1: h/o recent unstable angina
• Echocardiography
• Exercise stress test
• Pharmacological stress test
• Coronary Angiography
21.
22. ECG
• Left ventricular hypertrophy
• Abnormal Q waves
• Known CAD or other structural heart disease (except for low-risk surgical
procedures)
• Asymptomatic patients with clinical risk factors (except for low-risk procedures)
23. ECHOCARDIOGRAPGY
• Regional wall motion abnormalities, wall thickness, valvular function,
EF
• Dyspnea of unknown origin
• Current or prior heart failure with worsening dyspnea
• Valvular stenosis or regurgitation with no echocardiography studies
within 1 year, or worsening clinical status
• Aortic stenosis poor prognosis in noncardiac surgical patient
• Modify perioperative hemodynamic goals and therapy
24. EXERCISE STRESS TEST
• Sensitivity = 70% -80%
• Specificity = 60% -75% for identifying CAD
• Positive exercise stress test risk for ischemia associated with
increased heart rate
• Greatest risk Ischemia after mild exercise
• Ability to exercise No further testing
25. PHARMACOLOGICAL STRESS TEST
• High-risk patients who either are unable to exercise or have
contraindications to exercise
• Dobutamine Regional wall motion abnormality
26. CORONARY ANGIOGRAPHY AND PCI
• Patients with restricted physical activity in whom functional capacity
difficult to determine
• Not recommended for elective surgeries
(an important aspect because non-invasive and invasive testing are not only associated with patient discomfort and financial burden, but also with morbidity and mortality related to the test procedure, false test results, and postponement of required surgery
Hemoptysis in mitral stenosis increase PAH rupture of vessels
One metabolic equivalent (MET) is defined as the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml O2 per kg body weight x min
1 L O2 = 5kcal
BP: White coat syndrome
Medical history or conditions including the presence of PO2 less than 60; PCO2 greater than 50; K below 3; HCO3 under 20; BUN over 50; serum creatinine greater than 3; elevated SGOT; chronic liver disease; or the state of being bedridden (3 points)
Class I (0 to 5 points): correlates with a 1.0% risk of cardiac complications during or around noncardiac surgery.
Class II (6 to 12 points): correlates with a 7.0% risk of cardiac complications during or around noncardiac surgery.
Class III (13 to 25 points): correlates with a 14% risk of cardiac complications during or around noncardiac surgery.
Class IV (26 to 53 points): correlates with a 78% risk of cardiac complications during or around noncardiac surgery.
High risk type surgeries: open intraperitoneal , intrathoracic, vascular surgeries
Risk of death, MI or cardiac arrest
Ischemic heart disease: previous MI, abnormal exercise ECG, chest pain, use of nitrates, Q waves
CHF: s3 gallop rhythm, PND, pulmonary edema, crackles in chest
American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Myocardial Infarction and Cardiac Arrest (MICA)
ECG Qwaves
Joint National Committee
TAG >200 mg/dl and LDL >100 mg/dl
Abdominal circumference >90cm for male , >80 cm for female
Radionucleotide ventriculography
CLAUDICATION
dipyridamole/adenosine/regadenoson 1498 myocardial perfusion imaging (MPI) with thallium-201 and/or technetium99m and rubidium-82. Dipyridamole, adenosine, or regadenoson is administered as a coronary vasodilator to assess flow heterogeneity and the presence of a redistribution defect.
Patients with acute STEMI
Non STEMI and unstable angina
Angina unresponsive to medical therapy
May be considered:
Undergoing high risk surgery
Undergoing intermediate surgery
Dabigatran: Thrombin/ IIa inhibitor
Fondaparinux: Activates antithrombin neutralize Xa
Rivoroxaban: Xa inhibitor
Apixaban Xa inhibitor