Pre operative cardiac assessment dr sadany-1

 Introduction
 Pre-operative evaluation
 Risk reduction
 Specific conditions

 Cardiac patient has a potential source of
complications during surgery
 The risk of peri-operative complications
depends on the condition of the patient prior
to surgery, the prevalence of co-morbidities,
and the magnitude and duration of the
surgical procedure.

 Within the next 20 years, the acceleration in
ageing of the population will have a major
impact on peri-operative patient management.
 It is estimated that elderly people require
surgery four times more often than the rest of
the population.

 An emergency procedure:
It is one in which life or limb is threatened if
not in the operating room where there is time
for no or very limited or minimal clinical
evaluation (within <6 hours).
 An urgent procedure:
It is one in which there may be time for a
limited clinical evaluation, usually when life or
limb is threatened if not in the operating
room (between 6 and 24 hours).

 Time-sensitive procedure:
It is one in which a delay of >1 to 6 weeks to
allow for an evaluation and significant
changes in management will negatively affect
outcome. (oncologic procedures).
 An elective procedure:
It is one in which the procedure could be
delayed for up to 1 year.

 Every operation elicits a stress response.
 This response is initiated by tissue injury and
mediated by neuroendocrine factors, and may
induce tachycardia and hypertension.
 Fluid shifts in the peri-operative period add
to the surgical stress leading to myocardial
O2 imbalance.

 Recently surgical interventions have been
divided into two categories :
1. Low-risk (<1%)
 Operations without significant fluid shifts
and stress (plastic and cataract).
2. High-risk(≥ 1%)
 Operations including supra-inguinal
vascular, intra-peritoneal, or intra-thoracic.

 Major predictor:
1. Unstable coronary syndromes: unstable or
severe angina or recent MI
2. Decompensated HF
3. Significant arrhythmias
4. Severe valvular disease.

 Intermediate predictors:
1.History of ischemic heart disease
2.History of HF
3.History of cerebrovascular disease
4.Diabetes mellitus requiring treatment
with insulin
5.Preoperative serum creatinine >2.0
mg/dL

 Minor predictor:
1. Advanced age (greater than 70 years).
2. Abnormal ECG (LV hypertrophy, left bundle-
branch block, ST-T abnormalities).
3. Rhythm other than sinus.
4. Uncontrolled systemic hypertension.

1. Myocardial infarction.
2. Pulmonary edema.
3. Ventricular fibrillation .
4. Primary cardiac arrest.
5. Complete heart block.
6. Undergoing supra-inguinal vascular, intra-
peritoneal, or intra-thoracic surgery.
 A patient with 0 or 1 predictor(s) of risk would have
a low risk of MACE.
 Patients with ≥2 predictors of risk would have
elevated risk.

 Coronary Artery Disease CAD
Mortality rate (%)MI rate (%)Timing (days)
14.232.80 -30
11.518.731-60
10.88.461-90
9.95.991-180

Patient’s age
 Adults aged > 55 years have a growing
prevalence of CVD, CVS, and diabetes
mellitus.
 Adults aged > 65 years have a higher
reported incidence of acute ischemic stroke.
 Aged > 70 years have more postoperative
complications, increased length of
hospitalization, and inability to return home
alone after hospitalization.

Heart failure
 Survival after surgery for those with a LVEF ≤
29% is significantly worse than for those with
a LVEF >29%.
 In a meta-analysis using individual patient
data, patients with HF and preserved LVEF
had a lower all-cause mortality rate than that
of those with HF and reduced LVEF (the risk
of death did not increase notably until LVEF
fell below 40%)

 Functional capacity is measured in metabolic
equivalents (METs).
 One MET equals the basal metabolic rate.
 1 MET represents metabolic demand at rest.
 Climbing two flights of stairs demands 4
METs
 Strenuous sports such as swimming
represents >10 METS

 Class I
 Patients who have a need for emergency non-
cardiac surgery should proceed to the
operating room and continue peri-operative
surveillance and postoperative risk
stratification and risk factor management.
(Level of Evidence: C)
 Emergency surgery

 Patients with active cardiac conditions should
be evaluated and treated per American Chest
Coleuge/American Heart Association
ACC/AHA guidelines and, if appropriate,
consider proceeding to the operating room.
(Level of Evidence: B)
 Decompensated Active
management

 Patients undergoing low risk surgery are
recommended to proceed to planned surgery.
(Level of Evidence: B)
Low surgery proceed to surgery
 Patients with poor (less than 4 METs) or
unknown functional capacity and no clinical
risk factors should proceed with planned
surgery. (Level of Evidence: B)
Poor function + No risk proceed to
surgery

 It is probably recommended that patients
with poor (less than 4 METs) or unknown
functional capacity and ≥ 2 clinical risk
factors consider testing if it will change
management.(Level of evidence:B)
Poor function + ≥ 2 risk factors Non-
invasive test

 It is probably recommended that patients
with poor (less than 4 METs) or unknown
functional capacity and < 2 clinical risk
factors proceed with planned surgery with
heart rate control. (Level of Evidence: B)
Unknown function + Low-Risk Proceed
with HR control

 Pre-operative non-invasive testing aims at
providing information on three cardiac risk
markers:
1.LV dysfunction
2.Myocardial ischaemia
3.Heart valve abnormalities

 LV function is assessed at rest, and various
imaging modalities:
1. Echocardiography
2. Thallium imaging
3. Radionuclide angiography
 For myocardial ischaemia detection, exercise
ECG and non-invasive imaging techniques
may be used.
 Echocardiography is preferred for evaluation
of valve disease.

LevelClassRecommendations
BIIaPreoperative resting 12-lead electrocardiogram (ECG) is
reasonable for patients with known coronary heart
disease, significant arrhythmia, peripheral arterial
disease, cerebrovascular disease, or other significant
structural heart disease, except for those undergoing
low-risk surgery
BIIbPreoperative resting 12-lead ECG may be considered for
asymptomatic patients without known coronary heart
disease, except for those undergoing low-risk surgery
BIIIRoutine preoperative resting 12-lead ECG is not useful
for asymptomatic patients undergoing low-risk surgical
procedures

CIIa1. It is reasonable for patients with dyspnea
of unknown origin to undergo
preoperative evaluation of LV function.
2. It is reasonable for patients with HF with
worsening dyspnea or other change in
clinical status to undergo preoperative
evaluation of LV function.
CIIbReassessment of LV function in clinically
stable patients with previously documented
LV dysfunction may be considered if there
has been no assessment within a year.
BIIIRoutine preoperative evaluation of LV
function is not recommended

BIIaFor patients with elevated risk and excellent (>10 METs)
functional capacity, it is reasonable to forget further exercise
testing with cardiac imaging and proceed to surgery.
B
B
C
IIb
IIb
IIb
1. For patients with elevated risk and unknown functional
capacity, it may be reasonable to perform exercise testing to
assess for functional capacity if it will change management.
2. For patients with elevated risk and moderate to good (≥4
METs to 10 METs) functional capacity, it may be reasonable
to forget further exercise testing with cardiac imaging and
proceed to surgery
3. For patients with elevated risk and poor (<4 METs) or
unknown functional capacity, it may be reasonable to
perform exercise testing with cardiac imaging to assess for
myocardial ischemia if it will change management.
BIIIRoutine screening with noninvasive stress testing is not useful

CIIaIt is reasonable for patients who are at an
elevated risk for non-cardiac surgery and have
poor functional capacity (<4 METs) to undergo
noninvasive pharmacological stress testing
(either dobutamine stress echocardiogram
[DSE] or pharmacological stress myocardial
perfusion imaging [MPI]) if it will change
management.
BIIIRoutine screening with non-invasive
pharmacological stress testing is not useful for
patients undergoing low-risk non-cardiac
surgery.

BIIBCardiopulmonary exercise
testing may be considered for
patients undergoing elevated
risk procedures in whom
functional capacity is unknown

 Cardiopulmonary exercise testing (CPET)
provides a global assessment of the
integrated response to exercise involving the
pulmonary, cardiovascular, and skeletal
muscle systems.
 CPET is a programmed exercise test on either
a cycle ergometer or a treadmill during which
inspired and expired gases are measured
through a facemask or a mouthpiece.
 This test provides information on oxygen
uptake and utilization.

 The thresholds for classifying patients as low
risk are usually taken as VO2 >15 mL/kg/
min and AT > 11 mL/kg/min
 A VO2 < 12 mL/kg/min was associated with a
13-fold higher rate of mortality.

 CLASS I
 Coronary revascularization before non-
cardiac surgery is useful in patients with
stable angina who have significant left
main coronary artery stenosis. (Level of
Evidence: A)
cardiac surgery is useful in patients with
stable angina who have 3-vessel disease.
(Survival benefit is greater when LVEF is
less than 50%) (Level of Evidence: A)

 Coronary revascularization before noncardiac
surgery is useful in patients with stable
angina who have 2-vessel disease with
significant proximal LAD stenosis and either
EF less than 50% or demonstrable ischemia
on noninvasive testing. (Level of Evidence: A)
cardiac surgery is recommended for patients
with high-risk unstable angina or non–St
segment elevation MI. (Level of Evidence: A)

cardiac surgery is recommended in patients
with acute ST-elevation MI. (Level of
Evidence: A)

C
B
B
I
I
I
1. Elective non-cardiac surgery should be
delayed 14 days after balloon angioplasty
2. Elective non-cardiac surgery should be
delayed 30 days after BMS implantation
3. Elective non-cardiac surgery should
optimally be delayed 365 days after drug-
eluting stent (DES) implantation.
CIIaIn patients in whom non-cardiac surgery is
required, a consensus decision among treating
clinicians as to the relative risks of surgery and
discontinuation or continuation of anti-platelet
therapy can be useful.

BIIbElective non-cardiac surgery after DES implantation may
be considered after 180 days if the risk of further delay is
greater than the expected risks of ischemia and stent
thrombosis.
B
C
III
III
1. Elective non-cardiac surgery should not be
performed within 30 days after BMS implantation or
within 12 months after DES implantation in patients
in whom dual anti-platelet therapy (DAPT) will need
to be discontinued perioperatively.
2. Elective non-cardiac surgery should not be
performed within 14 days of balloon angioplasty in
patients in whom aspirin will need to be
discontinued perioperatively.

BIBeta blockers should be continued in patients undergoing
surgery who have been on beta blockers chronically.
BIIaIt is reasonable for the management of beta blockers after
surgery to be guided by clinical circumstances, independent
of when the agent was started.
C
B
Iib
IIb
1. In patients with intermediate- or high-risk myocardial
ischemia noted in pre-operative risk stratification tests,
it may be reasonable to begin peri-operative beta
blockers.
2. In patients with 3 or more RCRI risk factors (e.g.,
diabetes mellitus, HF, CAD, renal insufficiency,
cerebrovascular accident), it may be reasonable to begin
beta blockers before surgery.

B
B
Iib
IIb
3. In patients with a compelling long-term
indication for beta-blocker therapy but no
other RCRI risk factors, initiating beta blockers
in the perioperative setting as an approach to
reduce perioperative risk is of uncertain
benefit.
4. In patients in whom beta-blocker therapy is
initiated, it may be reasonable to begin
perioperative beta blockers long enough in
advance to assess safety and tolerability,
preferably more than 1 day before surgery.
BIIIBeta-blocker therapy should not be started on the
day of surgery

BIStatins should be continued in patients currently
taking statins and scheduled for non-cardiac
surgery.
BIIaPerioperative initiation of statin use is reasonable
in patients undergoing vascular surgery.
CIIbPerioperative initiation of statins may be
considered in patients with clinical indications
according to GDMT who are undergoing elevated-
risk procedures.

BIIIAlpha-2 agonists for prevention of
cardiac events are not recommended in
patients who are undergoing non-cardiac
surgery.

B
C
Iia
IIa
1. Continuation of angiotensin-
converting enzyme (ACE) inhibitors or
angiotensin-receptor blockers (ARBs)
perioperatively is reasonable.
2. If ACE inhibitors or ARBs are held
before surgery, it is reasonable to
restart as soon as clinically feasible
postoperatively.

C
C
C
I
I
I
1. In patients undergoing urgent non- cardiac surgery
during the first 4 to 6 weeks after BMS or DES
implantation, DAPT should be continued unless the
relative risk of bleeding outweighs the benefit of the
prevention of stent thrombosis.
2. In patients who have received coronary stents and must
undergo surgical procedures that mandate the
discontinuation of ADP platelet receptor–inhibitor
therapy, it is recommended that aspirin be continued if
possible and the ADP platelet receptor–inhibitor be
restarted as soon as possible after surgery.
3. Management of the perioperative antiplatelet therapy
should be determined by a consensus of the surgeon,
anesthesiologist, cardiologist, and patient, who should
weigh the relative risk of bleeding versus prevention of
stent thrombosis.

BIIbIn patients undergoing non-emergency/non-urgent non-cardiac
surgery who have not had previous coronary stenting, it may
be reasonable to continue aspirin when the risk of potential
increased cardiac events outweighs the risk of increased
bleeding
BIIIInitiation or continuation of aspirin is not beneficial in patients
undergoing elective non-cardiac non-carotid surgery who have
not had previous coronary stenting.
CIIIUnless the risk of ischemic events outweighs the risk of surgical
bleeding, initiation or continuation of aspirin is not beneficial
in patients undergoing elective non-cardiac surgery

 It is recommend the use of ACE inhibitors (or
ARBs in patients intolerant of ACE inhibitors)
and b-blockers as primary treatment in
chronic heart failure patients, to improve
morbidity and mortality.

 In patients with an LV ejection fraction < 35%
who remain severely symptomatic the
addition of a low dose of aldosterone
antagonist should be considered.
 Diuretics are recommended in heart failure
patients with signs or symptoms of
congestion.

 It has been concluded that the perioperative
use of ACE inhibitors, b-blockers, statins,
and aspirin is independently associated with a
reduced incidence of in-hospital mortality in
patients with LV dysfunction who are
undergoing major non-cardiac vascular
surgery.

 In hypertensive patients with concomitant IHD
who are at high risk of cardiovascular
complications, peri-operative administration
of b-blockers is recommended.
 In patients with hypertension, anti-
hypertensive therapy should be continued up
to the morning of surgery.

 In patients with severe hypertension (SBP >
180 mmHg and/or DBP > 110 mmHg), the
potential benefits of delaying surgery to
optimize the pharmacological therapy should
be weighed against the risk of delaying the
surgical procedure.

CIIt is recommended that patients with clinically
suspected moderate or greater degrees of valvular
stenosis or regurgitation undergo preoperative
echocardiography if there has been either:
1) no prior echocardiography within 1 year or
2) a significant change in clinical status or physical
examination since last evaluation.
CIFor adults who meet standard indications for valvular
intervention (replacement and repair) on the basis of
symptoms and severity of stenosis or regurgitation,
valvular intervention before elective non-cardiac
surgery is effective in reducing perioperative risk.

 Elevated-risk elective non-cardiac surgery
with appropriate intra-operative and
postoperative hemodynamic monitoring is
reasonable to perform in patients with
asymptomatic severe aortic stenosis (AS)
Class IIa (Level of Evidence: B)

 Maintain normal sinus rhythm
 Avoid bradycardia or tachycardia(60-90)
 Avoid hypotension
 Optimize intravascular fluid volume to
maintain venous return and left ventricular
filling

 Elevated-risk elective non-cardiac surgery
using appropriate intra-operative and
postoperative hemodynamic monitoring may
be reasonable in asymptomatic patients with
severe mitral stenosis if valve morphology is
not favorable for percutaneous mitral balloon
commissurotomy. Class IIb (Level of Evidence:
C)

 Patients with mitral stenosis who meet standard
indications for valvular intervention (open mitral
commissurotomy or percutaneous mitral balloon
commissurotomy) should undergo valvular
intervention before elective non-cardiac surgery.
 If valve anatomy is not favorable for
percutaneous mitral balloon commissurotomy, or
if the non-cardiac surgery is an emergency, then
non-cardiac surgery may be considered with
invasive hemodynamic monitoring and
optimization of loading conditions.

 Avoid sinus tachycardia or AF(60-90 beat /
minute).
 Avoid marked increase in central blood
volume.
 Avoid vasoactive drugs or use it cautiously.
 Avoid hypoxemia and/or hypercarbia that
may exacerbate pulmonary hypertension and
evoke right ventricular failure.

 Proceed with non-cardiac surgery:
1. In asymptomatic patients with severe
AR/MR and preserved LV
function(mortality< 0.2%)
 Proceed cautiously with non-cardiac
surgery if so necessary in:
1. Asymptomatic with EF < 30%
2. Symptomatic
 Optimize pharmacological therapy
(Nefidipine or hydralazine)

 Avoid bradycardia (keep above 80
beat/min)
 Avoid increases in systemic vascular
resistance
 Minimize myocardial depression (if
occurred it is treated by vasodilator with
inotrope)

 Prevent bradycardia (keep above 80
beat/min)
 Prevent increases in systemic vascular
resistance
 Minimize drug-induced myocardial
depression
 In severe MR, monitor the magnitude of
regurgitant flow with a pulmonary artery
catheter and/or echocardiography
 Maintenance of intravascular fluid volume

 Symptomatic patients should undergo mitral
valve surgery even if they have a normal
ejection fraction.
 Mitral valve repair is preferred to mitral valve
replacement because it restores valve
competence, maintains the functional aspects
of the mitral valve apparatus, and avoids
insertion of a prosthesis.

 Patients with an ejection fraction
of less than 30% or left ventricular
end-systolic dimension more than
55 mm do not improve with mitral
valve surgery

 Cardiac patient has a potential source of
complications during surgery
 Revised cardiac risk index is the most reliable
risk assessment.
 Emergency operation has a higher morbidity
and mortality.
 b-blockers reduce peri-operative myocardial
ischaemia.
 Peri-operative use of ACE inhibitors, b-
blockers and statins reduce mortality.

 Postpone only patients with severe
hypertension (> 180/110)
 Avoid hypotension and treat it aggressively in
severe AS.
 Avoid sinus tachycardia or AF in severe MS
 In AR minimize myocardial depression (treat
by vasodilator with inotrope)
 In MR prevent increases in systemic vascular
resistance

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