The document discusses various methods of assessing cardiac risk for patients undergoing surgery. It describes several cardiac risk indices, including the Goldman Multifactorial Cardiac Risk Index, Eagle's Cardiac Risk Index, Detsky's Cardiac Risk Index, and the Revised Cardiac Risk Index. It also discusses the American College of Cardiology Cardiac Risk Classification and factors that can affect cardiac risk, such as coronary artery disease, diabetes, hypertension, and the type of surgery. The document provides guidelines for stratifying cardiac risk based on the invasiveness and risk level of the surgical procedure. It further discusses ways to minimize risk, such as through the use of beta blockers, lipid-lowering agents, and a2-adre

1. Cardiac Risk Stratification
Presenter: Dr S. N. Bhagirath
Moderator: Dr Sharanu Patil

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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