preop. assessment of patients with cardiac disease;anesthesia and surgery risk,scores. annotated bibliography

1. Raccomandazioni per la valutazione
preoperatoria dei pazienti adulti per
chirurgia non cardiaca:
blocco I con enfasi sulle condizioni
caCrladudioi aMecllonhi e
Libero professionista
2011-2012

3. Prediction is very difficult,
especially about the future.
—Niels Bohr

4. Cardiovascular risk?
• major cardiovascular complications
(MACE,event)
– cardiac arrest, non-fatal & fatal
–myocardial infarction, non fatal & fatal
– heart failure,
– clinically relevant arrhythmias,
– stroke

5. Clinical steps
Assessment,preop visit
Detection of clinical conditions:clinical risk factors
Exercise capacity
Preop testing
Surgery risk
Prediction of risk

7. Foundations:ESA 2010
• 1)Guidelines for pre-operative cardiac risk assessment
and perioperative cardiac management in non-cardiac
surgery
– The Task Force for Preoperative Cardiac Risk Assessment and
Perioperative Cardiac Management in Non-cardiac Surgery of
the European Society of Cardiology (ESC) and endorsed by
the European Society of naesthesiology (ESA)
– European Journal of Anaesthesiology 2010, 27:92–
137
• Republished with permission from Eur Heart J. 2009;
22:2769–2812
• Aim:individualized patient assessment

8. ESA 2011
• European Journal of Anaesthesiology:
• October 2011 - Volume 28 - Issue 10 - p 684–722
• Guidelines
• Preoperative evaluation of the adult patient
undergoing non-cardiac surgery: guidelines from the
European Society of Anaesthesiology
• De Hert, Stefan; Imberger, Georgina; Carlisle, John;
Diemunsch, Pierre; Fritsch, Gerhard; Moppett, Iain;
Solca, Maurizio; Staender, Sven; Wappler, Frank;
Smith, Andrew; the Task Force on Preoperative
Evaluation of the Adult Noncardiac Surgery Patient of
the European Society of Anaesthesiology

9. Foundations :
• Perioperative cardiac evaluation, monitoring,
and risk reduction strategies in noncardiac
surgery patients
– Erik J. Bakker, Niels J.C. Ravensbergen and Don
Poldermans
– Current Opinion in Critical Care 2011,17:409–415

10. Foundations :
• ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for
Noncardiac Surgery: Executive Summary: A Report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to
Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac
Surgery):Developed in Collaboration With the American Society of
• Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of
Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society
for Vascular Medicine and Biology, and Society for Vascular Surgery.
• Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E,Fleischmann KE, Freeman WK, Froehlich
JB, Kasper EK, Kersten JR,Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL,Antman
EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V,Halperin JL, Hiratzka LF, Hunt SA, Lytle
BW, Md RN, Ornato JP, Page RL,Riegel B, Tarkington LG, Yancy CW.
• Circulation 2007; 116:1971–1996.
• Aim:creating a risk profile

11. ESA 2011
• The potential legal implications may be an area of
concern.
• It cannot be overemphasised that guidelines may
not be appropriate for all clinical situations.
• The decision whether or not to follow a
recommendation from a guideline must be made
by the responsible physician on an individual basis,
taking into account both the specific conditions of
the patient and the available resources.
• Therefore, deviations from guidelines for specific
reasons remain possible and certainly should not
be interpreted as a basis for claims of negligence.

12. • Specific conditions and available resources……
• What if resources are scarce????
• Decision not to follow a
guideline……documentare perché!!!

13. Rischio in anestesia:risk factors
paziente
anestesia
chirurgia
Ambiente….sala
operatoria
..organization
anestesista
chirurgo

14. Limitazioni della lettura
• Non si parla del rischio tecnico,legato alle attrezzature o alle diverse
tecniche di anestesia
• La lettura è piuttosto focalizzata alla valutazione preoperatoria,con
excursus nella dinamica operatoria (presunta almeno….),escludendo
malattie rare ,gravidanza e includendo:
– Malattie cardiovascolari
– Malattie resp(fumo,COPD,OSA…)
– Mal.renali
– Diabete
– Obesità
– Disordini coagulativi
– Anemia e tecniche di conservazione del sangue
– Anziano
– Alccolismo
– Allergia
• Ci si limita alla chir.noncardiaca

15. Altri argomenti della lettura(se ci sarà
tempo)
• Trattamento della terapia in corso in caso di:
– Antitrombotici e anest.locoregionale;
– Erbe e similari
– Psicotropici
– Ponte perioperatorio della terapia anticoagulante
• Tests preop
• Valutazione delle vie aeree
• Informazione del paziente

16. Aim of preop evaluation
• 1) identify those patients for whom the perioperative period
may constitute an increased risk of morbidity and mortality,
aside from the risks associated with the underlying disease.
– Specialist assessment(cardiologist)
– Identify patients with excessive risk
• 2)help us to design perioperative strategies that aim to reduce
additional perioperative risks.
– Optimization??? initiation, continuation, or optimization of
cardiovascular medication) and interventional cardiovascular
treatment strategies (CABG???)
• 3)identification of the most appropriate testing and avoidance
of unnecessary testing
– 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;

17. Come può la visita preop modificare il
trattamento?
Valutaz cardiaca
preop
Stratificazione
del rischio
cardiaco
Conduzione
periop
preop
Terapia medica
Indicazione
chirurgica
Terapia chirurgica
intraop
Tipo di anestesia
Anestetici
monitoraggio
postop
Monitoraggio
Terapia medica
Follow up

18. • HOW, WHEN AND BY WHOM SHOULD
PATIENTS BE EVALUATED PREOPERATIVELY?
Preoperative evaluation of the adult patient
undergoing non-cardiac surgery: guidelines from
the European Society of Anaesthesiology 2010

19. Preop assessment
• tools to screen patient history and physical status (such as
questionnaires, either paper-based or electronic-based, to be
filled by the patient alone or in conjunction with a health
professional; interviews by either medical or non-medical
health professionals);
• timing of preoperative assessment (including studies looking
at preoperative interventions aimed at improving patient
outcome); smoking cessation,
– alcohol abstinence,
– optimisation of medical condition
– weight loss
• professional qualification necessary to perform the
preoperative evaluation (nurse, physician assistant,family
physician/general practitioner, surgeon, anaesthesia trainee
or anaesthesia specialist).

20. Medical optimization
• Reduce mortality and morbidity after major vascular
surgery (level of evidence: 3)
• Smoking cessation has definitely shown to be
beneficial (level of evidence: 1þ) even if an optimal
duration has not been identified (level of evidence:
2þ)
– (the majority of studies put it between 4 and 8 weeks (level of evidence: 1-
1þ2),
• Short lasting alcohol abstinence (1 week) has not been
shown to be beneficial (level of evidence: 2)whereas
longer (1 month) abstinence has demonstrated
positive effects (level of evidence: 1)

21. Percentage of newly diagnosed comorbidities
Dawson J, Vig S, Choke E, et al. Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair.
Eur J Vasc Endovasc Surg 2007; 33:100–104
St George's Vascular Institute, London, UK.
comprehensive assessment to identify
comorbidities,

22. Optimization
Dawson J, Vig S, Choke E, et al. Medical optimisation can reduce morbidity and mortality associated with
elective aortic aneurysm repair. Eur J Vasc Endovasc Surg 2007; 33:100–104
Cardiology referral
44%
Pneumologist
referral 32%
Renal referral 16%
55% resulted in a change
in management (75%
change in medications,
23% referred for CABG or
coronary stent, 2.5
referred for pacemaker
63% resulted in a change
of management
23% resulted in a change
of management (50%
drug change, 50%
planned peri-operative
dialysis).

23. Risk factors
Dawson J, Vig S, Choke E, et al. Medical optimisation can reduce morbidity and
mortality associated with elective aortic aneurysm repair. Eur J Vasc Endovasc Surg
2007; 33:100–104
• an abnormal echocardiogram was associated
with postoperative pneumonia (OR 6.9, 95% CI 1.6e29, P ¼ 0.01)
and death (OR 7.9, 95% CI 1.15e54, P ¼ 0.036).
• Pre-operative intervention by a renal physician was associated
with a reduction in post-operative renal
impairment (OR 0.12, 95% CI 0.03e0.45, P ¼ 0.002)
• pre-operative intervention by a cardiologist was associated
with a reduction in respiratory complications (OR
0.7, 95% CI 0.05e0.99, P ¼ 0.049).

24. SMOKING

25. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.
• Five trials examined the effect of smoking intervention on
postoperative complications.
• Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for
developing any complication; and 0.70 (95% CI 0.51 to 0.95)
for wound complications.
• Exploratory subgroup analyses showed a significant effect
of intensive intervention on any complications; RR 0.42
(95% CI 0.27 to 0.65) and on wound complications RR 0.31
(95% CI 0.16 to 0.62).
• For brief interventions the effect was not statistically
significant but CIs do not rule out a clinically significant
effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication,
RR 0.99 (95%CI 0.70 to 1.40) for wound complications).

26. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.

27. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.

28. A U T H O R S ’ C O N C L U S I O N S Cochrane
Database Syst Rev. 2010 Jul 7
Implications for practice
• The results of this updated reviewindicate that preoperative smoking
intervention is beneficial for changing smoking behaviour
perioperatively and in the long term, and for reducing the
incidence of complications.
• Exploratory subgroup analyses of two smaller trials suggest that intensive
intervention over a period of four to eight weeks before surgery and including
NRT,may support smoking cessation and reduce postoperative morbidity.
• Six trials testing brief interventions, on the other hand, increased smoking cessation
• at the time of surgery but failed to detect a statistically significant effect on
postoperative morbidity.
• Based on this evidence, intensive interventions for 4-8 weeks before surgery, and
including NRT, appear relevant for patients scheduled to undergo surgery 4 weeks or
more after diagnosis.
• We suggest that smokers scheduled for surgery less than 4 weeks after diagnosis, like
all smokers, be advised to quit and offered effective interventions, including
behavioural support and pharmacotherapy.

29. ALCOHOL

30. Postoperative outcome following anorectal surgery in alcohol
users;withdrawal vs continuous drinking
Tonnesen H, Rosenberg J, Nielsen HJ, Rasmussen V, Hauge C, Pedersen IK, Kehlet H. Effect of preoperative abstinence on
poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999 May 15;318(7194):1311-6.
elective colorectal surgery.
Withdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with
continuous drinking
% No alcohol X 1
month
Continuous
drinking
Any Ko 31 73
Major Ko 12,5 42
Minor Ko 25 58
Secondary surg 12,5 42
Myocardial ischaemia and arrhythmias occurred less often in the intervention
group; there were also significantly fewer episodes of sudden hypoxaemia
heart rate and plasma concentrations of catecholamines and interleukin 6, was
significantly smaller in the intervention group,

31. Conclusions from Tonnesen H, Rosenberg J, Nielsen HJ, Rasmussen V,
Hauge C, Pedersen IK, Kehlet H.
Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers:
randomised controlled trial. BMJ. 1999 May 15;318(7194):1311-6.
• One month of preoperative alcohol
abstinence reduces postoperative
morbidity in alcohol abusers.
• The mechanism is probably reduced
preclinical organ dysfunction and
reduction of the exaggerated response to
surgical stress.

32. ESA 2010 Recommendations
• (1) Preoperative standardised questionnaires may be helpful in improving
anaesthesia valuation in a variety of situations (grade of recommendation: D).
• (2) If a preoperative questionnaire is implemented,great care should be
taken in its design (grade of recommendation: D), and a computer-based version
should be used whenever possible (grade of recommendation:C).
• (3) Preoperative evaluation should be carried out with sufficient time
before the scheduled procedure to allow for the implementation of any
advisable preoperative intervention aimed at improving patient outcome
(grade of recommendation: D).
• (4) Preoperative assessment should at least be completed by an
anaesthetist (grade of recommendation:D), but the screening of patients could be
carried out effectively either by trained nurses (grade of recommendation: C) or
anaesthesia trainees (grade of recommendation: D).
• (5) A pharmacy personnel member may usefully be included in preoperative
assessment, in order to reduce discrepancies in postoperative drug orders
(grade of recommendation: C).
• (6) There is insufficient evidence to recommend that the preferred model is
that a patient should be seen by the same anaesthetist from preoperative
assessment through to anaesthesiaadministration (grade ofrecommendation: D).

33. Wijeysundera, D N, AustinPC, Beattie WS, Hux JE, Laupacis A A
Population-Based Study of Anesthesia Consultation Before Major
Noncardiac Surgery .Arch Intern Med. 2009;169(6):595-602
• Background: In single-center studies, consultation byan anesthesiologist days to weeks before surgery was associated
• with reduced patient anxiety, case cancellations on the day of surgery, and duration of hospitalization.
• Nonetheless, the impact of anesthesia consultation on outcomes in the population remains unclear.
• Methods: We used population-based, linked, administrative databases to conduct a cohort
study of patients,aged 40 years and older, who underwent selected elective intermediate-to
high-risk noncardiac surgical procedures in Ontario, Canada, between April 1, 1994, and
March 31, 2004. Propensity-score methods were used to construct a matched-pairs cohort that resolved important
differences between patients who underwent consultation and those who did not. We then determined
• the association of consultation (within 60 days before surgery) with hospital length of stay and postoperative mortality
• (30-day and 1-year) rates within the matched
• pairs. Results: Of the 271 082 patients in the entire cohort, 39%(n=104 716) underwent
anesthesia consultation. The proportion of patients who underwent consultation
increased from 19% in 1994 to 53% in 2003. Within the matched-pairs (n=180
254), consultation was associated with reduced mean hospital length of stay (8.17
days vs 8.52 days; difference, −0.35 days; 95% confidence interval [CI], −0.27 to
−0.43; P.001). Consultation was not associated with reduced mortality at 30 days
(relative risk, 1.04; 95% CI, 0.96 to 1.13; P=.36) or 1 year (relative risk, 0.98; 95% CI,
0.95 to 1.02; P=.20).
• Conclusions: Preoperative anesthesia consultation is associated
• with reduced length of stay but not with reduced
• mortality. Future research should evaluate the costeffectiveness
• of the increasing use of anesthesia
• consultation.

34. Single center results:
• preoperative anesthesia consultation clinics showed measurable benefits in several single-center studies.
• They were associated with reduced patient anxiety,3
• Reduced case cancellations on the day of surgery,4,5
• Reduced duration of hospitalization,5,6
• Reduced hospital costs.6
• 3. Klopfenstein CE, Forster A, Van Gessel E. Anesthetic assessment in an outpatient
• consultation clinic reduces preoperative anxiety. Can J Anaesth. 2000;
• 47(6):511-515.
• 4. Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce
• operating room cancellations and delays. Anesthesiology. 2005;103(4):
• 855-859.
• 5. van Klei WA, Moons KG, Rutten CL, et al. The effect of outpatient preoperative
• evaluation of hospital inpatients on cancellation of surgery and length of hospital
• stay. Anesth Analg. 2002;94(3):644-649.
• 6. Pollard JB, Garnerin P, Dalman RL. Use of outpatient preoperative evaluation to
• decrease length of stay for vascular surgery. Anesth Analg. 1997;85(6):1307-
• 1311.

35. OUTCOME OF PATIENTS (WITH AND
WITOUT CARDIAC RISK)AFTER
NONCARDIAC SURGERY

36. Magnitude of risk of major
perioperative cardiac events
• Patients experiencing an MI after noncardiac
surgery have a hospital mortality rate of 15%–
25%(5–8)
• nonfatal perioperative MI is an independent risk
factor for cardiovascular death and nonfatal MI
during the 6 months following surgery (hazard ratio
18; 95% confidence interval [CI] 6–57)(9 )
• Patients who have a cardiac arrest after
noncardiac surgery have a hospital mortality rate
of 65%(10)
• nonfatal perioperative cardiac arrest is a risk
factor for cardiac death during the 5 years
following surgery(11)

37. Outcomes of major perioperative cardiac events in patients
undergoing noncardiac surgery: prospective cohort studies with samples >300 patients,no
restrictions as to the type of surgery (e.g., vascular surgery) and that required patients to have at least 1
measurement of a cardiac enzyme or biomarker after surgery.(5–8,12–14 )
Poise I 8351 patients. 190 centers in 23 countries 2007-2008
5%
Gilbert 2035 pts in 2 teaching canadian
Hospitals
1999 2,4% 1,8% 6,4%

38. Occurrence of major periop cardiac events in
patients at risk and without risk
• 1.7%,with a cardiovascular cause 0,5%.Major Dutch University
Boersma,2005,108.000 pts,1991-2000
• 2.1% Lee
• 3.9% (95% CI 3.3%–4.6%) pooled data from praevious table)
• Vs
• 5% of unselected patients (mortality 11.6%)(Poise 1 )
– Characteristics and short-term prognosis of perioperative myocardial infarction in patients
undergoing noncardiac surgery: a cohort study.
Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, Garutti I, Leslie K, Rao-Melacini P, Chrolavicius S,
Yang H, Macdonald C, Avezum A, Lanthier L, Hu W, Yusuf S; POISE (PeriOperative ISchemic Evaluation)
Investigators. Ann Intern Med. 2011 Apr 19;154(8):523-8
• Vs
– 6,4 %unselected patients ,death 2,4%
– Gilbert K, Larocque BJ, Patrick LT. Prospective evaluation of cardiac risk indices for
patients undergoing noncardiac surgery. Ann Intern Med 2000;133:356-9

39. Differences in incidences
• Patient selection
• Surgery selection(major…????)
• Endpoint MI definition
• …..organization,skills…….

40. Magnitude of the problem
• Ageing of population
• Elderly people requirement for surgery are 4
times +> general population
• Rising frequency of interventions with age
• Incresing number of elderly patients with
comorbidities
• Number of affected individuals higher in
countries with high cardiovascular
morbidity(Central-east Europe)

41. Pathophysiology of perioperative
cardiac events
• Cardiac death
• etiology???
–Ischemia?
–Arrhythmia?
–pre-existing cardiomyopathy ?

42. Pathophysiology of perioperative
cardiac events:Cardiac arrest
• only 1 study examined the cause of cardiac arrest in patients undergoing
noncardiac surgery.
• Sprung and colleagues
– Sprung J, Warner ME, Contreras MG, Schroeder DR, Beighley CM, Wilson GA, et al.
Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery:
a study of 518 294 patients at a tertiary referral center. Anesthesiology 2003;99:259-69
– evaluated 223 cases of perioperative cardiac arrest that occurred between
the start of anesthesia and discharge from the recovery room in patients
undergoing noncardiac surgery at a single centre from 1990 to 2000.
– A committee of staff anesthesiologists, anesthesia chief residents, certified
nurse anesthetists and recovery room nurses reviewed all cases and judged
the probable cause of each cardiac arrest.
– dominant causes:cardiac causes (e.g., MI) and bleeding .
– Confidence in these conclusions will require a multicentre study of all cardiac
arrests that occur in the postoperative period (i.e., from the start of surgery to
30 days after surgery).

43. Sprung J, Warner ME, Contreras MG, Schroeder DR, Beighley CM, Wilson
GA, et al. Predictors of survival following cardiac arrest in patients
undergoing noncardiac surgery: a study of 518 294 patients at a tertiary
referral center. Anesthesiology 2003;99:259-69

44. Autopsy findings
• 50-90% associated with plaque rupture and
thrombus
• Remaining cases associated with DO2/VO2
mismatch
– Dawood Int J Cardiol 1996,57:37-44
– Cohen MC Cardiovasc Pathol 1999,8,133-39

45. of periop MI …
from:Perioperative cardiac events in patients
undergoing noncardiac surgery: a review of the
magnitude of the problem, the
pathophysiology of the events
and methods to estimate and communicate risk
P.J. Devereaux, Lee Goldman, Deborah J. Cook,
Ken Gilbert, Kate Leslie, Gordon H. Guyatt

46. Preoperative cardiac risk assessment
• Risk estimate
Patient • Acceptance /refusal
info
• Periop management
• Choice of surg.technique
• Postop
care;location,intensity…
Decision
making
improv
e
overall
patient
outco
me

47. independent predictors
of adverse perioperative cardiac outcome
•Active cardiac conditions
• High risk surgical procedure
• Poor exercise tolerance

48. I marcatori clinici
condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie:
• 1)instabilità coronarica;per esempio un MI recente o una
angina instabile o severa;
• 2)Insufficienza cardiaca scompensata;NYHA Classe IV o
una insufficienza in peggioramento o di nuova insorgenza;
• 3)aritmie significative;blocco AV di alto grado(Mobitz 2,BAV
3,aritmie ventricolari sintomatiche,aritmie sopraventricolari con ritmo
cardiaco non controllato,tachicardia sintomatica,tachicardia
ventricolare di nuova scoperta.
• 4)malattia valvolare severa,cioè stenosi aortica serrata o
stenosi mitralica sintomatica.
– Active Cardiac Conditions for Which the Patient Should Undergo Evaluation
and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)

49. Intermediate Clinical risk factors
• Ischemic heart disease including mild angina
pectoris (CCS class I or II) or prior MI by history or
pathologic Q wave
• Compensated or prior heart failure (HF)
• Diabetes mellitus
• Renal insufficiency (preoperative creatinine >2.0
mg/dL [177 μmol/L])
• Cerebrovascular disease
– (See RCRI)
– Careful assessment of the patient status,which may necessitate
noninvasive testing

50. Obese patients
• 2009 AHA scientific advisory
• Increased risk because:
– Heart failure (Myocardial steatosis)
– Sleep apnea +/- pulmonary hypertension
– Dvt
– Pulmonary embolism
• ????
• Poor exercise tolerance
• Specific tests should be performed only if
the results will change management

51. CORONARY ARTERY
DISEASE(CAD)

52. Incidenza di mortalità periop in
pazienti con CAD(n=1632) Eagle et al
High risk surgery >=4% Low risk surgery<=4%
Abdominal 4% Urologic 1.8
Vascolar 11.3 Orthopedic 1.2
Thoracic 7.7 Skin 0
Head neck 7.3 Miscellaneous 3

53. Outcome cardiaco per chirurgia
maggiore non cardiaca Eagle et al,Circulation 1997 96
1892-7
N=395
N=582
N=964

54. Circulation. 1997;96:1882-1887.Cardiac Risk of Noncardiac Surgery
Influence of Coronary Disease and Type of Surgery in 3368 Operations
Kim A. Eagle, MD; Charanjit S. Rihal, MD; Mary C. Mickel, MS; David R. Holmes, MD;
Eric D. Foster, MD; Bernard J. Gersh, MBBS; for the CASS Investigators; ; University of
Michigan Heart Care Program
• The Figure illustrates the outcomes of those patients who underwent "high-risk"
noncardiac surgery, that is, combined myocardial infarction or death rate ≥4% in
medically treated patients with known coronary disease. As one can see,
abdominal, vascular, thoracic, and head and neck surgery each had a combined
rate of myocardial infarction and/or death ≥4%. The Figure indicates that
patients undergoing "higher-risk" noncardiac surgery on average had
a lower perioperative risk if they had undergone prior coronary
bypass surgery. For the higher-risk patients overall, postoperative
death was 3.3% in medically treated patients versus 1.7% in those
having had prior coronary bypass surgery (P=.03). Similarly, the rate of
myocardial infarction for high-risk surgical patients was lower if prior coronary
bypass surgery had been performed. In this case, the rate was 2.7% among 582
patients who were being treated medically compared with 0.8% among 964 who
had undergone prior coronary bypass surgery (P=.002). Table 2 indicates, on
average, that patients undergoing the lower-risk operations such as urologic,
orthopedic, breast, and skin operations had very low risks of operative myocardial
infarction or death that were not significantly affected by having had prior bypass
surgery.

56. ATRIAL FIBRILLATION ,(AF),HEART
INSUFFICIENCY-FAILURE(HF),AORTIC
STENOSIS(AS),CORONARY
ISCHEMIA(IHD,ISCHEMIC HEART
DISEASE)…

57. AF

58. Importance of AF
• Death rates are doubled
by AF, independently of
other known predictors
of mortality.
• Only antithrombotic
therapy has been
shown to reduce AF-related
deaths

59. Circulation. 2011 Jul 19;124(3):289-96. Mortality and readmission of patients
with heart failure, atrial fibrillation, or coronary artery disease undergoing
noncardiac surgery: an analysis of 38 047 patients.van Diepen S, Bakal JA,
McAlister FA, Ezekowitz JA.
consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or
AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta,
Canada.

60. 30 day periop mortality stratified by admission and type of surgery
Circulation. 2011 Jul 19;124(3):289-96. Mortality and readmission of patients with heart failure, atrial
fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047
patients.van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA.
consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD
(n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September
31, 2006, in Alberta, Canada.
18
16
14
12
10
8
6
4
2
0
HF non isch
HF isch
CAD
AF

61. Circulation. 2011 Jul 19;124(3):289-96. Mortality and readmission of patients with heart
failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an
analysis of 38 047 patients.van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA.
• 3 principal findings
• 1) patients with HF or AF are at substantially higher risk of
postoperative mortality than patients with CAD, and this
risk is higher than previously appreciated by perioperative
cardiac risk prediction models
• 2) patients with HF undergoing routine minor surgical
procedures are not low risk, as highlighted by the 4% risk of
mortality within 30 days of purportedly minor outpatient
surgical procedures,such as a colonoscopies,
bronchoscopies, and cystoscopies.
• 3)mortality rates are particularly high for those patients
undergoing surgery within 4 weeks of an incident diagnosis
of HF or AF and further highlighted by the risk carried by a
recent HF rehospitalization on postoperative mortality.

62. • Camm AJ, Kirchhof P, Lip GY, et al. Guidelines
for the management of atrial fibrillation: the
Task Force for the Management of Atrial
Fibrillation of the European Society of
Cardiology (ESC). Eur Hear J 2010; 31:2369–
2429

63. HF=EF(???)

64. Patients with HF (suspected or known)
• preoperative evaluation by a specialist to assess the severity
of the disease and to ensure optimal medical therapy.
• stress echocardiography + serum concentrations of brain
natriuretic peptide (BNP) or
• its inactive precursor N-terminal pro-B-type natriuretic
peptide (NT-proBNP) for risk stratification.
• Multiple long-term medications, including angiotensin-converting
enzyme (ACE) inhibitors, angiotensin-II-receptor
blockers,b-blockers, aldosterone antagonists, diuretics…
– associated side-effects (mostly electrolyte disturbances,renal
insufficiency, and intraoperative therapy-resistant hypotension).
– As there is evidence that the perioperative use of ACE inhibitors, b-blockers,
statins, and aspirin improves outcome in patients with LV
dysfunction undergoing major vascular surgery, perioperative
continuation of such therapy is recommended in this patient
population

65. EF preop e outcome cardiaco
postop.(Franco et al,J Vasc Surg 10;656:1989)
EF>55%
N=50
EF 35-55%
N=20
EF 20-35%
N=15
MI 19% 15% 20%
Morte 0 0 13%

66. A comparison of data
Perioperative mortality and 30 days readmission rate for patients
with HF operated for noncardiac surgery
Preoperative evaluation at the Internal
Medicine Preoperative
Assessment Consultation and T
reatment (IMPACT)
Center at the Cleveland Clinic

67. Left ventricular function and postoperative outcome :%
Flu WJ, van Kuijk JP, Hoeks SE, Kuiper R, Schouten O, Goei D, Elhendy A, Verhagen HJ, Thomson IR, Bax JJ, Fleisher LA, Poldermans D.
Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery. Anesthesiology. 2010
Jun;112(6):1316-24.
50
45
40
35
30
25
20
15
10
5
0
Normal LV function
asympt isolated
diastolic LV
function
asympt sist LV
dissfunction
symptomatic
HeartFailure
%

68. Operative mortality
Hammill BG,Curtis,LH,Bennett-Guerrior E,O’Connor,CM,Jollis JC,Schulman KA,Hernandez AF.Impact of heart failure on patients
undergoing major noncardiac surgery.Anesthesiology 2008;108:559-67
HF CAD normal
total 8 3,1 2,4
> Knee amput 25.8 18 16
<knee amput 12.8 10.4 7.2
Carotid endarterec tomy 2,5 1,2 0,9
Colon cancer resection 11.9 6.3 5.4
Hip replacement 8.4 3.9 2.8
Knee replacement 0.9 0.4 0.3
Laparoscopic
5.6 2.1 1.8
cholecystectomy
Lower extremity bypass 8.1 3.7 4.1
Open AAA repair 10.3 5.8 4.8
Other abdominal cancer
11.8 4.3 4.9
resections
Pulmonary cancer
resection
10.2 6.0 4.1
Spinal fusion 3.8 2.1 1.3

69. 30 day readmission
Hammill BG,Curtis,LH,Bennett-Guerrior E,O’Connor,CM,Jollis JC,Schulman KA,Hernandez AF.Impact of heart failure on patients
undergoing major noncardiac surgery.Anesthesiology 2008;108:559-67
HF CAD normal
total 17.1 10.8 8.1
> Knee amput 25.2 21.6 18.9
<knee amput 24.1ns 23.4ns 19.9 ns
Carotid endarterectomy 15.2 10.8 8.7
Colon cancer resection 18 13.2 10.5
Hip replacement 16.6 10.3 8.8
Knee replacement 9.9 6.2 4.7
Laparoscopic
16.4 10.1 8.4
cholecystectomy
Lower extremity bypass 27.2 18.2 16.2
Open AAA repair 14.8 10.3 11.4
Other abdominal cancer
17.3 12.6 11.8
resections
Pulmonary cancer
resection
17.4 15.5 11.3
Spinal fusion 13.3 9.4 7.7

70. Conclusion from the study of Hammil et al
• Heart Failure patients :
–mortality risk 63%
–Readmission risk 51%

71. Periop cardiovascular events are associated
World J Surg. 2011 Nov;35(11):2411-6.Increased aortic stiffness can predict perioperative
cardiovascular outcomes in patients undergoing noncardiac, nonvascular surgery.
Biteker M, Duman D, Dayan A, Ilhan E
• Impaired elastic properties of the aorta
are associated with increased
Periop.Cardiovasc.Event rates in patients
undergoing noncardiac, nonvascular
surgery
• Aortic distensibility and strain(echo)
• Diabetes mellitus
• LVEF

72. Insomma…..
• Insuff cardiaca e FA prognosi
peggiore della ischemia
miocardica!!

73. Valvular heart
disease…….
AORTIC STENOSIS(AS)

74. Severe valvular disease
(part of the active cardiac conditions)
• stenosis is severe when:
• Mitral stenosis is symptomatic
• Aortic stenosis:
– Mean pressure gradient > 40 mmHg
– Area< 1cm2
– Symptomatic

75. Monin J-L, Lancellotti P, Monchi M, et al. Risk score for predicting outcome in
patients with asymptomatic aortic stenosis. Circulation 2009; 120: 69–75
3 parameters were
independent
predictors of outcome:
female sex, serum BNP,
and peak
aortic-jet velocity at
baseline.
Risk score was calculated according to the following formula:
Score[=peak velocity (m/s)x 2]+(natural logarithm of BNP x1.5)+1.5 (if female sex).

77. HYPERTENSION AS A RISK FACTOR

78. • its importance as a clinical risk
factor is still debated……………..

79. Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, Brill S,
Tarnopolski A, Ovadia L, Gurman GM: The dilemma of immediate
preoperative hypertension: to treat and operate, or to postpone
surgery? J Clin Anesth 2003; 15: 179-83
• There is a great deal of debate regarding a trigger to delay or cancel a
surgical procedure in a patient with poorly or untreated hypertension
• In the absence of end-organ changes, such as renal
insufficiency or left ventricular hypertrophy with strain, it
would seem appropriate to proceed with surgery.
• A randomized trial of treated hypertensive patients without known
CAD who presented the morning of surgery with an elevated diastolic
blood pressure was unable to demonstrate any difference in outcome
between those who were actively treated versus those in whom
surgery was delayed.
• In contrast, a patient with a markedly elevated blood pressure and the new
onset of a headache should have surgery delayed for further evaluation and
potential treatment..

80. Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P.
Hypertension, admission blood pressure and perioperative
cardiovascular risk. Anaesthesia 1996;51:1000-1004.
• A retrospective case-controlled study which
found that a history of hypertension was an
important predictor for perioperative cardiac
death but not admission blood pressure.
• The study implies that end-organ damage
resulting from hypertension is the likely villain
in this group of patients.

81. Forrest plot for a meta-analysis of the risk of perioperative
cardiovascular complications in hypertensive and normotensive patients.
Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br
J Anaesth 2004; 92:570–83

82. SITE AND EXTENT OF
SURGERY:SURGERY
CONTRIBUTION…

83. La stratificazione chirurgica degli interventi dal punto di vista
del rischio cardiaco (ASA/AHA);
surgical risk estimates
• rischio di MI o morte cardiaca superiore al 5%:
– chirurgia vascolare maggiore(aortica) e quella periferica;
• a rischio intermedio ,compreso fra 1 e 5%:
la chirurgia intraperitoneale ed intratoracica
endoarterectomia carotidea
chirurgia della testa e del collo
chirurgia ortopedica maggiore
chir prostatica.
• rischio minore,inferiore all’1% :
– procedure endoscopiche(urol/ortop),
– superficie corporea
– chirurgia per cataratta
– Chir mammaria.
ESA 2010

84. Trapianti?????vedi il registro
olandese ….
Da :Priebe,BJA 2011

85. Noordzij PG, Poldermans D, Schouten O, et al. Postoperative mortality in The
Netherlands: a population-based analysis of surgery-specific risk in adults.
Anesthesiology 2010; 112:1105–1115.
• .
• 3.7 million surgical procedures
• 102 hospitals in The Netherlands during 1991-2005.
• Patients older than 20 yr who underwent an elective, nonday
case, open surgical procedure were enrolled.
• Patient data included main (discharge) diagnosis, secondary diagnoses, dates of admission and discharge, death
during admission, operations, age, sex, and a limited number of comorbidities classified according to the
International Classification of Diseases 9th revision Clinical Modification.
• The main outcome measure was postoperative all-cause mortality. Univariable and multivariable logistic regression
analyses were applied to evaluate the relationship between type of surgery and the main outcome.
• RESULTS:
• Postoperative all-cause death was observed in 67,879 patients (1.85%).
• In a model based on a classification into 11 main surgical categories, breast surgery was associated with lowest
mortality (adjusted incidence, 0.07%), and vascular surgery was associated with highest mortality (adjusted
incidence, 5.97%). In a model based on 36 surgical subcategories, the adjusted mortality ranged from 0.07% for
hernia nuclei pulposus surgery to 18.5% for liver transplant. The c-index of the 36-category model was 0.88,
which was significantly (P < 0.001) higher than the c-index that was associated with the simple surgical classification
(low vs. high risk) in the commonly used Revised Cardiac Risk Index (c-index, 0.83).
• CONCLUSIONS:
• This population-based study provided a detailed and contemporary overview of postoperative mortality for the entire
surgical spectrum, which may act as reference standard for surgical outcome in Western populations

86. trapianti
milza
Fegato
pancreas
stomaco
Esofago
intestino

87. Severe(cardiac death,MI,alveolar pulm.edema,cardiac arrest,non fatal
ventric.tachycardia or fibrillation) and serious cardiac complications(
unstable angina,CHF without pulm edema)
Kumar R, McKinney WP, Raj G, Heudebert GR, Heller HJ, Koetting M, et al. Adverse cardiac events
after surgery: assessing risk in a veteran population. J Gen Intern Med 2001;16:507-18
Surgery Complications:severe Serious
aortic 24% 32%
carotid 8.3% 10%
Vasc periph. 11.8% 14.7%
Intrabdominal &
intrathoracic
9% 13.1%
Head,neck,major
orthopedic,neurosurg
2.9% 3.3%
Ophtalmic,maxillo
facial,plastic,low risk
orthopedic,
0.27% 1.1%

88. FUNCTIONAL
CAPACITY

89. MET: equivalenti energetici
1 MET is defined as 3.5 mL O2 uptake/kg per min, which is the resting oxygen uptake in a sitting position)
indice delle possibilità energetiche per varie attività
• scaletta dei MET :risposta a domande semplici,quali:
• sei in grado di avere cura di te stesso?mangiare,bere,usare la toilette(MET 1)?;
• puoi camminare in casa (MET 2) ;
• puoi camminare 100-200m in piano alla velocità di 3-4.5 Km/h?(Met 3);
• puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti?(MET 4);
• puoi salire una rampa di scale o in salita?o camminare in piano a 6,5 Km/h o
correre per una breve distanza?(Met 5).
• Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o
muovere mobilio pesante(Met 6-7)?
• Puoi partecipare a attività ricreative leggere come giocare a golf,a
bocce,ballare,giocare a tennis in doppio,o lanciare la palla a baseball o
calcio(MET 8-9)?
• Puoi partecipare a sport pesanti come il nuoto,tennis in
singolo,calcio,pallacanestro o sci?(Met 10).

90. Reilly DF, McNeely MJ, Doerner D, et al. Self-Reported Exercise Tolerance
and the Risk of Serious Perioperative Complications. Arch Intern
Med. 1999; 159: 2185-2192.
• Division of General Internal Medicine, University of Washington Medical Center, Seattle 98195-6330, USA.
dreilly@u.washington.edu
• To determine the relationship between self-reported exercise tolerance and serious perioperative complications.
• 600 consecutive outpatients referred to a medical consultation clinic at a tertiary care medical center for
preoperative evaluation before undergoing 612 major noncardiac procedures.
• Patients were asked to estimate the number of blocks they could walk and
flights of stairs they could climb without experiencing symptomatic limitation.
Patients who could not walk 4 blocks and climb 2 flights of stairs were
considered to have poor exercise tolerance.
• All patients were evaluated for the development of 26 serious complications that occurred during hospitalization.
• RESULTS:
• Patients reporting poor exercise tolerance had more perioperative complications (20.4% vs 10.4%; P<.001).
Specifically, they had more myocardial ischemia (P = .02) and more cardiovascular (P = .04) and neurologic (P =
.03) events. Poor exercise tolerance predicted risk for serious complications independent of all other patient
characteristics, including age (adjusted odds ratio, 1.94; 95% confidence interval, 1.19-3.17). The likelihood of a
serious complication occurring was inversely related to the number blocks that could be walked (P = .006) or
flights of stairs that could be climbed (P = .01). Other patient characteristics predicting serious complications in
multivariable regression analysis included history of congestive heart failure, dementia, Parkinson disease, and
smoking greater than or equal to 20 pack-years.
• CONCLUSION:
• Self-reported exercise tolerance can be used to predict in-hospital perioperative risk, even when using relatively
simple and familiar measures.
• Comment in

91. 25
20
15
10
5
0
good exercise tolerance
poor exercise tolerance
Reilly DF, McNeelyMJ, Doerner D, et al. Self-Reported
Exercise Tolerance and the Risk of Serious Perioperative
Complications. Arch InternMed. 1999; 159: 2185-2192.

92. Br J Anaesth. 2011 Oct 5. Validity of the 6 min walk test in prediction
of the anaerobic threshold before major non-cardiac surgery.
Sinclair RC, Batterham AM, Davies S, Cawthorn L, Danjoux GR.
• Source
• Department of Anaesthesia, The James Cook University Hospital, Middlesbrough, UK.
• For perioperative risk stratification, a robust, practical test could be used where cardiopulmonary exercise testing (CPET) is unavailable. The aim of
this study was to assess the utility of the 6 min walk test (6MWT) distance to discriminate between low and high anaerobic threshold (AT) in patients
awaiting major non-cardiac surgery.
• METHODS:
• /st>In 110 participants, we obtained oxygen consumption at the AT from CPET and recorded the distance walked (in m) during a 6MWT. Receiver
operating characteristic (ROC) curve analysis was used to derive two different cut-points for 6MWT distance in predicting an AT of <11 ml O(2) kg(-1)
min(-1); one using the highest sum of sensitivity and specificity (conventional method) and the other adopting a 2:1 weighting in favour of sensitivity.
In addition, using a novel linear regression-based technique, we obtained lower and upper cut-points for 6MWT distance that are predictive of an AT
that is likely to be (P≥0.75) <11 or >11 ml O(2) kg(-1) min(-1).
• RESULTS:
• /st>The ROC curve analysis revealed an area under the curve of 0.85 (95% confidence interval, 0.77-0.91). The optimum cut-points were <440 m
(conventional method) and <502 m (sensitivity-weighted approach). The regression-based lower and upper 6MWT distance cut-points were <427
and >563 m, respectively.
• CONCLUSIONS:
• /st>Patients walking >563 m in the 6MWT do not routinely require CPET; those walking <427 m should be referred for further evaluation. In
situations of 'clinical uncertainty' (≥427 but ≤563 m), the number of clinical risk factors and magnitude of surgery should be incorporated into the
decision-making process. The 6MWT is a useful clinical tool to screen and risk stratify patients in departments where CPET is unavailable.
• Test robusto pratico: se in 6 min cammina > 563 mt è ok

93. When exercise capacity is unclear
• cardiopulmonary exercise testing may be
performed
• Wilson et al. [7]
– 847 patients,infra-abdominal surgery.
– An anaerobic threshold of less than 11 ml/kg/min
was associated with a relative risk (RR) of 6.8
[95%confidence interval (CI) 1.6–29.5] of in-hospital
mortality.

94. • Low exercise tolerance is
associated with poor
perioperative outcome.
• Older P, Smith R, Courtney P, Hone R. Pre-operative evaluation of cardiac failure and
ischemia in elderly patients by cardiopulmonary exercise testing. Chest 1993; 104: 701–4
• Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for peri-operative
management of major surgery in the elderly. Chest 1999; 116: 355–62
• Win T, Jackson A, Sharples L, et al. Cardiopulmonary exercise tests and lung cancer surgical
outcome. Chest 2005; 127:1159–65
• Murray P, Whiting P, Hutchinson SP, Ackroyd R, Stoddard CJ,Billings C. Pre-operative shuttle
walking testing and outcome after oesophagogastrectomy. Br J Anaesth 2007;99: 809–11
• Carlisle J, Swart M. Mid-term survival after abdominal aortic aneurysm surgery predicted
by cardiopulmonary exercise testing. Br J Surg 2007; 94: 966–9
• Crawford RS, Cambria RP, Abularrage CJ, et al. Pre-operative functional status predicts peri-operative
outcomes after infrainguinal bypass surgery. J Vasc Surg 2010; 51: 351–9

95. Cardiac tests
•Incremental shuttle
walk test( ISWT) I
•Cardiopulmonary
exercise testing

96. Integrated assessment of cardiopulmonary function
• Cardiopulmonary exercise testing (CPET)
• 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 most commonly used data from this test are :
• O2 consumption at peak exercise (VO2peak) and at anaerobic
threshold (VO2AT),defined as the point when metabolic
demands exceed oxygen delivery, and anaerobic metabolism
begins to occur.

99. CPET as a risk predictor:
• low risk: VO2peak >15 mL/kg/min and VO2AT >11mL/kg/min. (=
4/5 METs )
• pulmonary lobectomy or pneumonectomy:VO2peak <20mL/kg/min was a
predictor of pulmonary complications, cardiac complications, and mortality;
VO2peak <12 mL/kg/min was associated with a 13-fold higher rate of
mortality
– . Brunelli A, Belardinelli R, Refai M, Salati M, Socci L, Pompili C, Sabbatini A. Peak oxygen consumption during cardiopulmonary exercise test
improves risk stratification in candidates to major lung resection. Chest 2009; 135:1260–1267.
• 187 elderly ,major abdominal surgery;overall mortality 5.9%.
• Patients who had a VO2AT <11mL/kg/min mortality 18% ;VO2AT
>11mL/kg/min mortality 0.8% (risk ratio 24,95% CI 3.1–183).
• Older P, Smith R, Courtney P, Hone R. Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise
testing. Chest 1993; 104:701–704.
• signs of myocardial ischaemia during testing: mortality 42% for patients
whose VO2AT <11 mL/kg/min and only 4% for those whose VO2AT was >11
mL/kg/min(

100. prognostic information in heart failure patients
• Normal: HR increases
fairly linearly with VO2
until max HR reached; O2
pulse increases linearly
until a plateau occurs
• Heart disease: HR vs. VO2
curve shifts leftward and
up; O2 pulse reaches an
early plateau
– SV limitation requires
higher HR for any level of
work

101. Anaerobic Threshold
• Estimation of the onset of metabolic acidosis
• Occurs at approximately 40-50% VO2max in
normal individuals
– low (early) AT suggests problems in O2 delivery, muscle
oxidative capacity, or both
• More important is whether it occurs, rather than
at what %VO2max
– indicates test is at least close to maximal exercise
– not under voluntary control, not affected by
psychological factors

102. Anaerobic Threshold
• Direct measurement requires measuring
lactate levels in blood
– requires frequent blood sampling; impractical
• Noninvasive assessment using gas exchange
parameters
– buffering of lactate by bicarbonate produces
disproportionate increase in VCO2
– “V-slope method”

103. Anaerobic Threshold: V-Slope Method

104. Ventilatory Response to Exercise
• Normal resting VE: 5-10 L/min
– higher suggests anxiety, low suggests either equipment
problems or is of no significance
• Normally, there is adequate ventilatory reserve
during exercise
– MVV = predicted maximum VE
– peak VE close to or above predicted max VE indicates a
ventilatory limitation
– early in exercise, increase in VE due to increase in VT; later
mainly from increase in RR

105. Ventilatory Response to Exercise
• Normal subjects reach
only about 75% MVV
with predicted
VO2max
• Lung disease: curve
shifts up and left, and
MVV is reduced

106. QUINDI FIN QUI ABBIAMO VISTO:

107. Fattori che determinano il rischio
cardiaco periop
• Marcatori clinici
• Intervento chirurgico
• Capacità funzionale

108. Condizioni associate ad alto rischio per
complicanze cardiovascolari
perioperatorie
• Presenza dei fattori predittivi di aumentato
rischio cardiovascolare periop
• Scarsa capacità funzionale(<4 MET)
• Chirurgia ad alto rischio (rischio
cardiovascolare periop > 5%)

109. Allora ,se rimuoviamo i pazienti con il
rischio + alto………..
• ‘major clinical predictors’ or ‘active cardiac
conditions’.( AHA/ACC And ESC algorithms )
which have the highest specificity for an adverse
cardiac outcome, effectively reduces both the
disease prevalence and the risk of a cardiac event
in the remaining population.
• It is from this population, with a reduced pre-test
probability, that we now need to effectively
discriminate patients at increased cardiovascular
risk.

110. Cardiac evaluation and care algorithm for patients undergoing noncardiac surgery, based on
active cardiac conditions, known cardiovascular disease, and cardiac risk factors in patients
aged 50 years or older.
Freeman W K , Gibbons R J Mayo Clin Proc. 2009;84:79-90

112. Recommendations
• (1) If active cardiac disease is suspected in a
patient scheduled for surgery, the patient
should be referred to a cardiologist for
assessment and possible treatment (grade of
recommendation: D).
• (2) In patients currently taking b-blocking or
statin therapy, this treatment should be
continued perioperatively (grade of
recommendation: A).

113. PREDICTIVE
INDICES,SCORES,….

114. Preoperative cardiac risk assessment:Clinical indices
• generic indices
• Lee
• Goldman
• Larsen
• Gilbert
• estimate a patient’s risk through determination of how many predictors of risk
(e.g., history of angina, diabetes, emergent surgery) the patient has.
• Bayesian risk indices
• Kumar
• Detsky
• modify the hospital’s average cardiac event rate for a specific surgery (pretest
probability) through use of a patient’s individual index score (likelihood ratio),
which is based on how many predictors of risk (e.g., history of angina,
diabetes) the patient has; this results in an estimate of the patient’s risk of a
perioperative cardiac event (posttest probability).

115. Decision tools
• American College of Physicians (ACP) and American College
of Cardiology/American Heart Association (ACC/AHA),
– algorithmic approaches that make direct recommendations
about whether to pursue cardiac testing.
– These tools are designed to be widely applicable to potential
candidates for noncardiac surgery.
• risk score or index
– which the user must interpret and translate into perioperative
recommendations.
– The physician must also assure that the index is appropriate to
the patient being evaluated by considering the original study’s
patient selection criteria, the setting in which the rule was
validated (eg, referral center), and which outcomes the rule
predicts.

116. Critical Elements for Risk Stratification in
Patients Undergoing Noncardiac Surgery
• Risk-assessment tool must be accurate
• Predicts perioperative events (positive likelihood ratio 10)
• Predicts absence of perioperative events (negative likelihood
ratio 0.2)
• Risk-assessment tool must influence outcome
• Identifies subgroups in which surgery should be cancelled or
treatment changed
• Identifies subgroups that do or do not benefit from proven
therapy to reduce risk
• Risk-assessment tool must have a favorable harms–benefit
tradeoff

117. Risk factor Definition (Goldman) points Definition (Detsky) point
s
CAD MI within 6 months 10 MI within 6 months 10
MI > 6 months ago 5
class III angina 10
class IV angina 20
unstable angina within 6 months 10
CHF S3 gallop or JVD 11 pulmonary edema within 1 week
Ever
10
5
Rhythm rhythm other than sinus or PACs
on last ECG prior to surgery
7 rhythm other than sinus or sinus
+ PACs on last ECG
5
> 5 PVCs/minute at any time
before surgery
7 > 5 PVCs/minute at any time 5
Valvular disease important aortic stenosis 3 suspected critical aortic stenosis 20
General medical
status
pO2 < 60 or PCO2 >50 or K+ < 3.0 or HCO3 < 20
or BUN > 50 or Cr > 3.0 or signs of chronic liver
disease or bedridden from noncardiac causes
3 same as Goldman 5
Age > 70 5 70 5
Surgery type intraperitoneal, intrathoracic or
aortic
3 emergency surgery 10

118. Goldman index Detsky index
• Class I < 15,
• Class II = 20-30
• Class III > 30
points
• Class I < 5,
• Class II = 6-12
• Class III = 13-25
• Class IV >25 points.
Cardiac risk estimate Goldman DEtsky
low low
<30 <15
Cardiac risk estimate
high >25 >30

119. Goldman index
Class Point
Prob. of life-threatening
complications
I 0-5 0.7
II 6-12 5
III 13-25 11
IV >25 22

120. Revised cardiac risk index(RCRI)
Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker
DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L: Derivation and
Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major
Noncardiac Surgery. Circulation 1999; 100: 1043-1049
• High risk surgery
• intraperitoneal, intrathoracic or suprainguinal vascular procedures
• Ischemic heart disease
(MI,+stress test results,current complaint of chest pain or nitrate
use,ECG with pathological Q waves)
• H/O CHF
(pulm edema,parox,noct.dyspnea,S3 gallop or pulm.rales on physical
examination,RX with pulmonary vascular resistance )
• H/O Cerebrovascular disease:
(Stroke ,TIA)
• Insulin therapy for DM
• Preop Cr>2.0mg/dl
1 point each

122. Preoperative cardiac risk stratification:
Revised Cardiac Risk Index:estimated risk of a major
cardiac event according to the Lee index predictors
Class Number
of predictors
Major cardiac
events, % *
All cardiac
events, % **
I 0 0.4
(0.1-0.8)
0.5
(0.05-1.5)
II 1 1.0
(0.5-1.4)
0.9
(0.3-2.1)
III 2 2.4
(1.3-3.5)
6.6
(3.9-10.3)
IV ≥3 5.4
(2.8-7.9)
11.0
(5.8-18.4)
•*Major cardiac events = cardiac arrest, MI (fatal or non-fatal)
•**All cardiac events = cardiac arrest, MI (fatal or non-fatal), pulmonary edema, or complete heart block.
Lee TH. Circulation. 1999;100:1043-9.
Bertges,
Vasc
surg.
2.6
6.7,
11.6,
18.4
Cardiovasc
ular
Death
0.3
0.7
1.7
3.6

123. Performance (and limitations) of RCRI
• moderately well in distinguishing patients at low compared
to high risk for all types of non-cardiac surgery
• less accurate in patients undergoing only vascular non-cardiac
surgery.
• RCRI did not predict all-cause mortality well, but this is
expected, as it does not capture risk factors for noncardiac
causes of perioperative mortality.
• Only one third of perioperative deaths are due to cardiac
causes.
• The original RCRI risk prediction model did not take
mortality into account
• Emergency surgery not included

124. Risk factors and severity of disease
• RCRI : dichotomous risk factors vs a continuum of severity
• as the severity of a risk factor increases, there is a proportional
‘semi-logarithmic’ increase in patient risk:Risk factor thresholds: their
existence underscrutiny. Br Med J 2002; 324: 1570–6
• Seattle Heart Failure Model:Levy WC, Mozaffarian D, Linker DT, et al. The Seattle heart failure
• model: prediction of survival in heart failure. Circulation 2006;113: 1424–33
• A 50-yr-old female with heart failure of ischaemic aetiology,NYHA grade 2, and an
ejection fraction of 55% has an expected 1 yr mortality of 12% and a mean life
expectancy of 6.2 yr.
• A 75-yr-old male with heart failure of ischaemic aetiology, NYHA grade 3, and an
ejection fraction of 30% has an expected 1 yr mortality of 21% and a mean life
expectancy of 3.9 yr.
• Despite this difference in risk, the RCRI would allocate an equal risk score to both
these patients.
• Thus, the risk associated with the diagnosis of heart failure in the individual patient
has been replaced 0by a generic risk factor describing the risk associated with the
diagnosis of heart failure in a population.

125. New York Heart Association functional classification of
heart disease
NYHA
Class 1 No limitations Ordinary activity does not
cause symptoms
Class 2 Slight limitations Comfortable at rest,
ordinary activity causes
symptoms
Class 3 Marked limitations Comfortable at rest, less
than ordi nary activity
causes symptoms
Class 4 Inability to carry on any
physical activity
Symptoms at rest

127. A more subtle classification of surgery and age allowed a better
predictive value: Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW,Schinkel AF,
van Santen M, Simoons ML, Thomson IR, Klein J, van Urk H,Poldermans D. Perioperative cardiovascular mortality
in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med 2005;
118:1134–1141

128. Case 1
A 72 year old male is admitted to the hospital with a left hip
fracture. A preoperative medical evaluation is requested by the
orthopedic surgeon. The injury was suffered after he tripped on a
rug in his home. He is fairly active and walks approximately one
mile daily with rare angina and can climb 2 flights of stairs in his
home without difficulty.
His past medical history is notable for CAD with prior MI and
subsequent CABG x3; hypertension; prior TIA; and recently
diagnosed type 2 diabetes mellitus.
Current medications: aspirin 325 mg qd, simvastatin 20 mg qd,
glyburide 5 mg bid, atenolol 25 mg qd, and lisinopril 10 mg qd.
Vital signs on admission are pulse 84 and blood pressure 162/90.
Cardiopulmonary examination is unremarkable. ECG is notable
for pathologic q waves in leads 1 and avL.

129. Case 1
1) What is the estimated cardiac risk?
“His past medical history is notable for CAD with prior MI
and subsequent CABG x3; hypertension; prior TIA; and
recently diagnosed type 2 diabetes mellitus.”
– RCRI score = 2
– ~5-10% risk of perioperative cardiac
complications

130. RCRI within specialties
• Ackland et al.demonstrated that, in patients undergoing major
orthopedic surgery, a RCRI at least 3 is associated with a 1.7-fold
increase in noncardiac complications (infectious, respiratory, and
neurological) and prolonged hospital stay.
• Bertges et al. ( Vascular Study Group-Cardiac Risk Index (VSG-CRI),
which adds age,smoking, COPD, and beta-blocker use, and predicts
a risk of cardiac complications ranging from 2.6 to 14.3%.) reported
that the RCRI underestimates the risk of cardiac complications in
their cohort of vascular surgery patients.
– Observed event rates were 2.6,6.7, 11.6, and 18.4% in patients with 0,
1, 2, and at least 3 risk factors. This model might be more appropriate
than the RCRI for risk stratification of vascular surgery patients.

131. Arch Intern Med. 2006 Apr 24;166(8):914-20.Predicting medical and
surgical complications of carotid endarterectomy: comparing the risk
indexes.Press MJ, Chassin MR, Wang J, Tuhrim S, Halm EA.
• Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA.
• A multicenter retrospective observational cohort study of 1998 patients undergoing carotid endarterectomy (CEA).
• Complications within 30 days of surgery : death or nonfatal stroke and cardiac, noncardiac medical, minor neurologic, and
wound complications.
• Logistic regression and receiver operating characteristic curve analyses assessed the predictive abilities of the Goldman, Detsky,
Revised Cardiac Risk, and American Society of Anesthesiologists indexes and of 2 CEA-specific risk models (the Halm and Tu
scores).
• RESULTS:
• Death or stroke occurred in 3.2% of patients, cardiac complications in 4.0%,
noncardiac medical complications in 3.2%, minor neurologic complications in 6.9%,
and wound complications in 6.0%.
• All risk models (except the Tu score) significantly predicted cardiac complications
equally well (P<.05). All 6 risk models were equivalent in predicting noncardiac medical complications. Only the Revised
Cardiac Risk Index and the 2 CEA-specific risk models (Halm and Tu scores) predicted death or stroke and minor neurologic and
wound complications. The Halm score was superior in predicting death or stroke compared with the Tu score and the Revised
Cardiac Risk Index (area under the receiver operating characteristic curve, 0.72 vs 0.62 and 0.61, respectively; P<.05). Patients
with cardiac, noncardiac medical, minor neurologic, or wound complications had 3- to 16-fold increased odds of death or
stroke.
• CONCLUSION:
• The Halm score CEA-specific risk model and the generic Revised Cardiac Risk Index predicted a broad range of medical,
neurologic, and surgical complications following CEA
• Tu JV, Wang H, Bowyer B, Green L, Fang J, Kucey D. Risk factors for death or
• stroke after carotid endarterectomy: observations from the Ontario Carotid Endarterectomy
• Registry. Stroke. 2003;34:2568-2573.
• Halm EA, Hannan EL, Rojas M, et al. Clinical and operative predictors of outcomes
• of carotid endarterectomy. J Vasc Surg. 2005;42:420-428

132. Arch Intern Med.
2006 Apr
24;166(8):914-20.
Predicting medical
and surgical
complications of
carotid
endarterectomy:
comparing the risk
indexes.
Press MJ, Chassin
MR, Wang J,
Tuhrim S, Halm
EA.

134. Arch Intern Med. 2006 Apr 24;166(8):914-20.
Predicting medical and surgical complications of carotid endarterectomy:
comparing the risk indexes.
Press MJ, Chassin MR, Wang J, Tuhrim S, Halm EA

135. Gilbert K, Larocque BJ, Patrick LT. Prospective evaluation of cardiac
risk indices for patients undergoing noncardiac surgery. Ann Intern
Med 2000;133:356-9
Existing indices
for prediction
of cardiac
complications
perform better
than chance,
but no index is
significantly
superior.

136. .
Grading of Angina of by the Canadian CardiovascularSociety
• I. "Ordinary physical activity does not cause ... angina," such as walking
and climbing stairs. Angina with strenuous or rapid or prolonged exertion
at work or recreation.
• II. "Slight limitation of ordinary activity." Walking or climbing stairs rapidly,
walking uphill, walking or stair climbing after meals, or in cold, or in wind,
or under emotional stress, or only during the few hours after awakening.
Walking more than 2 blocks on the level and climbing more than one flight
of ordinary stairs at a normal pace and in normal conditions.
• III. "Marked limitation of ordinary physical activity." Walking one to two
blocks on the level and clim-bing one flight of stairs in normal conditions
and at normal pace.
• IV. "Inability to carry on any physical activity without discomfort.- anginal
syndrome may be present at rest."

137. Ann Intern Med. 2010 Jan 5;152(1):26-35.
Systematic review: prediction of perioperative cardiac
complications and mortality by the revised cardiac risk
index.Ford MK, Beattie WS, Wijeysundera DN.
• Source
• Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
• Abstract
• BACKGROUND:
• The Revised Cardiac Risk Index (RCRI) is widely used to predict perioperative cardiac complications.
• PURPOSE:
• To evaluate the ability of the RCRI to predict cardiac complications and death after noncardiac surgery.
• DATA SOURCES:
• MEDLINE, EMBASE, and ISI Web of Science (1966 to 31 December 2008).
• STUDY SELECTION:
• Cohort studies that reported the association of the RCRI with major cardiac complications (cardiac death, myocardial infarction, and nonfatal cardiac
arrest) or death in the hospital or within 30 days of surgery.
• DATA EXTRACTION:
• Two reviewers independently extracted study characteristics, documented outcome data, and evaluated study quality.
• DATA SYNTHESIS:
• Of 24 studies (792 740 patients), 18 reported cardiac complications; 6 of the 18 studies were prospective and had uniform outcome surveillance and
blinded outcome adjudication. The RCRI discriminated moderately well between patients at low versus high risk for cardiac events after mixed
noncardiac surgery (area under the receiver-operating characteristic curve [AUC], 0.75 [95% CI, 0.72 to 0.79]); sensitivity, 0.65 [CI, 0.46 to 0.81];
specificity, 0.76 [CI, 0.58 to 0.88]; positive likelihood ratio, 2.78 [CI, 1.74 to 4.45]; negative likelihood ratio, 0.45 [CI, 0.31 to 0.67]). Prediction of
cardiac events after vascular noncardiac surgery was less accurate (AUC, 0.64 [CI, 0.61 to 0.66]; sensitivity, 0.70 [CI, 0.53 to 0.82]; specificity, 0.55 [CI,
0.45 to 0.66]; positive likelihood ratio, 1.56 [CI, 1.42 to 1.73]; negative likelihood ratio, 0.55 [CI, 0.40 to 0.76]). Six studies reported death, with a
median AUC of 0.62 (range, 0.54 to 0.78). A pooled AUC for predicting death could not be calculated because of very high heterogeneity (I(2) = 95%).
• LIMITATION:
• Studies generally were of low methodological quality, had varied definitions of cardiac events, and were statistically and clinically heterogeneous.
• CONCLUSION:
• The RCRI discriminated moderately well between patients at low versus high risk for cardiac events after mixed noncardiac surgery. It did not
perform well at predicting cardiac events after vascular noncardiac surgery or at predicting death. High-quality research is needed in this area of
perioperative medicine.

138. Computation of the cardiac risk
from: Kumar R, McKinney WP, Raj G, Heudebert GR, Heller HJ, Koetting M, et al. Adverse cardiac events after
surgery: assessing risk in a veteran population. J Gen Intern Med 2001;16:507-18
Preop risk variable points Odds
ratio(OR)
MI < 6 mo 25 4.9
Emerg surgery 15 2.6
MI > 6 mo 10 2.2
Praevious CHF(but > 1
10 1.9
week)
Rythm non sinus 10 1.7

139. 1)Select a point indicating
the selected complication
rate on the the pretest side
of the nomogram
2)Connect this point to a
point on the center column
that reflect the index score
and associated likelihood
ratio
3)Extend this line to intersect
the left post test side of the
nomogram
The point of tintersection
gives the post test
probability,i.e. the risk of
perioperative cardiac
complications
Kumar R, McKinney WP, Raj G, Heudebert GR,
Heller HJ, Koetting M, et al. Adverse cardiac events
after surgery: assessing risk in a veteran
population. J Gen Intern Med 2001;16:507-18
VA nomogram

140. PECULIAR CARDIAC RISK INDICES

141. Burris JM, Subramanian A, Sansgiry S, et al. Perioperative
atrial arrhythmias in noncardiothoracic patients: a review of
risk factors and treatment strategies in the veteran
population. Am J Surg 2010; 200:601–605.
• Department of General Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,
USA.
• Perioperative atrial arrhythmias (PAAs) in noncardiothoracic patients
• The surgical intensive care unit database was queried for patients who developed
PAAs from 2008 to 2009
• 561 patients were admitted to the surgical intensive care unit.
• 354 (63%) had noncardiothoracic surgery, and 30 (8.5%) developed PAAs.
• The mean age of patients with PAAs was 66 ± 7.3 years, compared with 64 ± 11 years for controls (P
= NS), with most patients undergoing general (60%) and vascular (33%) surgery. PAA patients were
more likely to have coronary artery disease (P = .029), cardiomegaly (P = .011), and premature atrial
contractions (P = .016) and to take aspirin (P = .010). On multivariate logistic regression, predictors
of atrial arrhythmias were premature atrial contractions, preoperative hypokalemia, intraoperative
adverse events, and cardiomegaly. Most PAA patients received amiodarone (63%). Ten percent
required electrical cardioversion, and 26% received anticoagulation. PAA patients had significantly
longer intensive care unit lengths of stay (P = .032).
• CONCLUSION:
• Coronary artery disease, cardiomegaly, hypokalemia, and premature atrial contractions were
significantly associated with PAAs in noncardiothoracic patients. Prospective studies are needed to
define treatment guidelines

142. Burris JM, Subramanian A, Sansgiry S, et al. Perioperative atrial
arrhythmias in noncardiothoracic patients: a review of risk factors and
treatment strategies in the veteran population. Am J Surg 2010;
200:601–605.
• predictors of atrial arrhythmias:
– Coronary artery disease
– premature atrial contractions
– preoperative hypokalemia
– intraoperative adverse events
– cardiomegaly.

143. J Vasc Surg. 2010 Sep;52(3):674-83, 683.e1-683.e3. Epub 2010 Jun 8.
The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac
complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients.
Bertges DJ, Goodney PP, Zhao Y, Schanzer A, Nolan BW, Likosky DS, Eldrup-Jorgensen J,
Cronenwett JL; Vascular Study Group of New England.
• Source
• Divisions of Vascular Surgery of University of Vermont College of Medicine, Burlington, Vt 05401, USA. daniel.bertges@vtmednet.org
• Abstract
• OBJECTIVE:
• The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific
model developed from patients within the Vascular Study Group of New England (VSGNE).
• METHODS:
• We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm
repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict
in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of
8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was
used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation
coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant
predictors were converted to an integer score to create a practical cardiac risk prediction formula.
• RESULTS:
• The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia,
1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after
LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI
underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%,
and 18.4% for patients with 0, 1, 2, and >or=3 risk factors. In multivariate analysis of the VSGNE cohort,
independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking
(1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress
test (1.2), long-term beta-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and
creatinine >or=1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate
model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve =
0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72;
EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and >or=6 VSG risk
factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the
validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac
complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG
Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3%
(score of 0-3 to 8) were discernible.
• CONCLUSIONS:
• The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more
accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making

144. The Vascular Study Group of New England Cardiac Risk
Index (VSG-CRI
estimate of RISK in vascular surgery patients
Risk factors Lee RCIR VSG CRI VSG risk factors
0 2.6 3.1%, 0 to 3
1 6.7%, 5.0% 4- 5
2 11.6% 6.8% 6
3 or + 18.4 11.6-14,3 >6

145. VSGNE
The Vascular Study Group of New England Cardiac Risk
Index (VSG-CRI
• independent predictors of adverse cardiac
events for vascular surgery were :
• increasing age (1.7-2.8),
• smoking (1.3),
• insulin-dependent diabetes (1.4),
• coronary artery disease (1.4),
• CHF (1.9),
• abnormal cardiac stress test (1.2),
• long-term beta-blocker therapy (1.4)
• chronic obstructive pulmonary disease (1.6)
• creatinine >or=1.8 mg/dL (1.7).
– Prior cardiac revascularization was protective (OR, 0.8)

146. Head Neck. 2010 Nov;32(11):1485-93.
Incidence and prediction of major cardiovascular complications
in head and neck surgery.
Datema FR, Poldermans D, Baatenburg de Jong RJ
• .
• Source
• Department of Otorhinolaryngology-Head and Neck Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. f.datema@erasmusmc.nl
• Abstract
• BACKGROUND:
• Patients with head and neck squamous cell carcinoma (HNSCC) usually have a history of tobacco and alcohol abuse. These 2
intoxications not only are main oncologic risk factors but also show a strong causal relationship with certain comorbid conditions.
Examples are coronary artery disease, stroke, renal dysfunction, and heart failure, which are all proven major risk factors for an adverse
postoperative outcome after stressful noncardiac surgery. Preoperative identification of these conditions could lead to preventive
measures in patients with HNSCC that undergo extensive surgery. Preventing morbidity and mortality is of medical and economical
importance.
• METHODS:
• All comorbidity of 135 consecutive patients with HNSCC that underwent extensive oncologic and reconstructive surgery as the first form
of treatment between 2001 and 2007 was investigated. Based on these data, a Lee Cardiac Risk Index (LCRI) Score and an overall Adult
Comorbidity Evaluation (ACE-27) severity score were calculated. The predictive value of these scores and the American Society of
Anesthesiologists' (ASA) classification toward major cardiovascular complication development were investigated. Major cardiovascular
complications were defined as: cardiac death, nonfatal myocardial infarction, heart failure, and cardiac arrhythmias. The impact of
these complications on duration of hospitalization, medical costs, and short-term mortality (defined as death within 6 months after
primary tumor diagnosis) were investigated as well. The cardioprotective effect of preoperatively prescribed beta blockers and statins
are discussed.
• RESULTS:
• Twenty-two patients developed 23 major cardiovascular complications (16.3%). In univariate and multivariate analyses, a higher LCRI
score was associated with an increased risk for major cardiovascular complications, as was an age >70 years (all values of p < .01). The
area under the receiver operating characteristics (ROC) curve (AUC) for the multivariate model was 0.84, indicating a good prognostic
value. In univariate and multivariate analysis, a higher ACE-27 score was associated with an increased risk for major cardiovascular
complications, as was as age >70 years (all values of p < .01). The AUC for this model was 0.84, indicating a performance similar to that
of the LCRI score model. No statistically significant results were found for the ASA scores (p = .38). Preoperative beta-blocker use
showed a significant cardioprotective function in univariate analysis, whereas statins did not. The mean duration of hospitalization was
prolonged by 7 days in patients with a major cardiovascular complication. In economic terms, this means a cost increase of at least 3500
euros. None of the patients died during admission because of a major cardiovascular complication. The short-term mortality rate was
11.1%, but no specific cardiovascular cause of death was reported in these patients.
• CONCLUSIONS:
• Prevention of major complication occurrence after extensive HNSCC surgery is of medical and economic importance. Our results show that the ACE-27 and the LCRI are suitable
instruments for preoperative major cardiovascular complication risk assessment. Addition of the variable age >70 years shows an improvement in predictive value of both instruments.
Because of its simplicity we advise the implementation of the LCRI into preoperative HNSCC screening protocols. We advise the exploration of low-dose long-acting beta blockers as a
preventive treatment strategy

147. Indian J Anaesth. 2010 May;54(3):219-25.
Comparative evaluation of ASA classification and ACE-27 index as morbidity
scoring systems in oncosurgeries.
Thomas M, George NA, Gowri BP, George PS, Sebastian P
• .
• Source
• Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India.
• Abstract
• The primary intention of the study was to find out whether Adult Comorbidity Evaluation Index
(ACE-27) was better than the American Society of Anaesthesiologists' (ASA) risk classification
system in predicting postoperative morbidity in head and neck oncosurgery. Another goal was to
identify other risk factors for complications which are not included in these indexes. Univariate and
multivariate analyses were performed on 250 patients to determine the impact of seven variables
on morbidity-ACE-27 grade, ASA class, age, sex, duration of anaesthesia, chemotherapy and
radiotherapy. In univariate analysis ACE-27 index, ASA score, duration of anaesthesia, radiotherapy
and chemotherapy were significant. As both comorbidity scales were significant in univariate
analysis they were analyzed together and separately in multivariate analysis to illustrate their
individual strength. In the first multivariate analysis (excluding ACE-27 grade) ASA class, duration of
anaesthesia, radiotherapy and chemotherapy were significant. The positive predictive value (PPV)
of this model to predict morbidity was 60.86% and negative predictive value (NPV) was 77.9%. The
sensitivity was 75% and specificity 62.2%. In the second multivariate analysis (excluding ASA class)
ACE-27 grade, duration of anaesthesia and radiotherapy were significant. The PPV of this model to
predict morbidity was 62.1% and NPV was 76.5%. The sensitivity was 61.6% and specificity 70.9%.
In the third multivariate analysis which included both ACE-27 grade and ASA class only ASA class,
duration of anaesthesia, radiotherapy and chemotherapy remained significant. In conclusion, ACE-
27 grade and ASA class were reliable predictors of major complications but ASA class had more
impact on complications than ACE-27 grade

148. Comorbidity calculator
• on http://oto.wustl.edu/clinepi/calc.html
(Clinical Outcomes Research Office’s Website).

149. National Surgical Quality Improvement Program(NSQIP)
Circulation. 2011 Jul 26;124(4):381-7..
Development and validation of a risk calculator for prediction of cardiac risk after surgery.
Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Pipinos II, Johanning
JM, Lynch TG, Forse RA, Mohiuddin SM, Mooss AN.
, • Patients who underwent surgery were identified
from the American College of Surgeons' 2007
National Surgical Quality Improvement Program
database, a multicenter (>250 hospitals)
prospective database (211410 patients)
• The cardiac risk calculator provides a risk
estimate of perioperative myocardial infarction or
cardiac arrest and is anticipated to simplify the
informed consent process.
• Its predictive performance surpasses that of the
Revised Cardiac Risk Index

150. Preoperative variables significantly associated with an increased risk
for MI/CA Circulation. 2011 Jul 26;124(4):381-7. Epub 2011 Jul 5.
Development and validation of a risk calculator for prediction of cardiac risk after surgery.
Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Pipinos II, Johanning JM,
Lynch TG, Forse RA, Mohiuddin SM, Mooss AN.
ASA class,
dependent functional
status,
increasing age,
abnormal creatinine
(1.5 mg/dL)
type of surgery
organ-based classification of
is the most appropriate approach for MICA
risk assessment, providing a more precise
estimate of risk.

151. • available online at
http://www.surgicalriskcalcul
ator.com/miorcardiacarrest
• free download.
• When the required input is entered into this calculator for a
given patient, it returns a model-based percent estimate of
MICA
• In the risk calculator, values are entered as 0 and 1 for
absence or presence, respectively, of the significant
predictive factors or as the actual value for continuous
variables

152. • Perioperative Cardiac Risk Calculator
• Full methodology in the paper-
Circulation. 2011 Jul 26;124(4):381-7. Epub 2011 Jul 5.
•
• For accompanying editorial, click here
•
• For excel 2007 or above users, you can download the cardiac risk calculator here.
• For excel 2003 users, you can download the risk calculator here
•
• Iphone version available through the app - 'Calculate' by QxMD

153. Dove lo trovate…….
• Perioperative Cardiac Risk Calculator - Surgical Risk Calculator
• www.surgicalriskcalculator.com/miorcardiacarr... - Traduci questa pagina
• Hai fatto +1 pubblicamente su questo elemento. Annulla
• Full methodology in the paper-. Circulation. 2011 Jul 26;124(4):381-7. Epub 2011 Jul 5. For
accompanying editorial, click here. For excel 2007 or above users , ...
• Development and Validation of a Risk Calculator for Prediction of ...
• circ.ahajournals.org/content/124/4/381.full.pdf - Traduci questa pagina
• Hai fatto +1 pubblicamente su questo elemento. Annulla
• di PK Gupta - 2011 - Citato da 2
26 Jul 2011 – http://www.surgicalriskcalculator.com/miorcardiacarrest for free download.
When the required input is entered into this calculator for a given ...

154. 15

155. • Ricerca Google per “surgery
risk calculator”

156. www.vasgbi.com/riskdets
ky.htmCopia cache -
Simili - Traduci questa
pagina
Detsky and
Goldman
calculators.

161. Calculations of risk scores
Possum e
derivati,EPASS,VBHOM,surgical
apgar,Saps,Apache,Sofa….

162. Risk prediction on line
• Risk prediction in surgery
[http://www.riskprediction.org.uk/p
pindex.php].
• SFAR

163. Surgical Risk scores
• ACPGBI CRC Model - Association of Coloproctology of GB & I Colorectal Cancer Model for
mortality in colorectal cancer
• ACPGBI MBO Model - Association of Coloproctology of GB & I model for mortality
prediction in malignant bowel obstruction
• ACPGBI Lymph Node Harvesting Model - Association of Coloproctology of GB & I model for
determining the number of nodes that should be found in each resection
• St Mark's Lymph Node Positivity Model - calculates the probability of lymph node
metastases in patients undergoing local resection of rectal cancers and for patients whose
nodal harvest was not sufficient to adequately stage the rectal cancer.
• CCF CLC Model - The Cleveland Clinic Colorectal Laparoscopic Conversion Model for
prediction of conversion of lapararoscopic to open surgery in patients undergoing colonic
or rectal surgery for benign or malignant disease.
• CCF IPF Model - The Cleveland Clinic Ileal Pouch Failure Model for prediction of ileal pouch
failure in patients undergoing restorative proctocolectomy.
• CR-POSSUM - Used for predicting mortality in Colorectal Surgery (benign & malignant)
• P-POSSUM - Used for predicting mortality (& morbidity by POSSUM) in General Surgery
• O-POSSUM - Used for predicting mortality in Oesophagogastric Surgery
• Vascular-POSSUM - Used for predicting mortality in Vascular Surgery (all 4 models available
• MUST screening tool (malnutrition)

164. •POSSUM:
• physiological and operative
severity scoring system for
enumeration of morbidity and
mortality

167. • MedCalc: Perioperative Cardiac Evaluation
• Guidelines for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery
American College of Cardiology / American Heart
Association
JACC 1996; 27:910-948; and Circulation 1996;
93:1278-1317.
Pocket Guideline: requires Adobe Acrobat Reader
• Go BACK

168. TABLE 1
Progra
m
informa
tion
Algorith
m
Progra
m Version Size Cost Source
ACC/AH
A1 2002
STAT
Cardiac
Clearanc
e
1.1 97 KB Free
http://w
ww.statc
oder.com
Detsky3 MedRule
s 2.5 324 KB Free
http://pb
rain.hyp
ermart.n
et/
Detsky6 InfoRetri
ever
4.2
(beta) 2.1 MB
Beta is
free;cost
of final
version
unknown
http://w
ww.infop
oems.co
m

169. • STAT Cardiac Clearance (September 10, 2001)
• STAT Cardiac Clearance will help guides clinicians through steps for evaluating patients before they go in for non-cardiac
surgery.
It uses the guidelines set by the American College of Cardiology, the American Heart Association Task Force on
Practice Guidelines and the American College of Physicians.
This item is part of the collection: Tucows Software Library
Identifier: tucows_214418_STAT_Cardiac_Clearance
Date: 2001-09-10
Creator: http://www.statcoder.com/
Rights: Freeware
Publisher: Tucows Inc.
Mediatype: software
Addeddate: 2004-10-17 22:10:26
Publicdate: 2004-10-25 11:45:05
Keywords: palm pilot; palm pilot software; palm pilot downloads; palm; palm os; downloads; palm downloads
•
Individual Files
• Whole Item Format Size clearance.zip ZIP 78.6 KB Image Files Item Image Screenshot of STAT Cardiac Clearance 9.2
KB
Information Format Size tucows_214418_STAT_Cardiac_Clearance_files.xml Metadata [file]
tucows_214418_STAT_Cardiac_Clearance_meta.xml Metadata 1.5 KB
tucows_214418_STAT_Cardiac_Clearance_reviews.xml Metadata 197.0 B

170. STAT Cardiac Clearance (September
10, 2001)

171. Medrules
• Current Medical Therapeutics (September 7, 2000)
• Current Medical Therapeutics is designed for the resident or internist.
All one has to do to utilize the program is simply input the name of an acute medical condition.
Once that is complete, you can view a whole document that will explain the "dos and don'ts" for each condition.
This item is part of the collection: Tucows Software Library
Identifier: tucows_79012_Current_Medical_Therapeutics
Date: 2000-09-07
Creator: http://pbrain.hypermart.net/files/MedRx4.zip
Tucows_rating: 4
Rights: Freeware
Publisher: Tucows Inc.
Mediatype: software
Addeddate: 2004-10-17 22:03:14
Publicdate: 2004-10-26 02:09:43
Keywords: palm pilot; palm pilot software; palm pilot downloads; palm; palm os; downloads; palm downloads
•
Individual Files
• Whole Item Format Size currentmed.zip ZIP 43.7 KB Image Files Item Image Screenshot of Current Medical
Therapeutics 2.3 KB
Information Format Size tucows_79012_Current_Medical_Therapeutics_files.xml Metadata [file]
tucows_79012_Current_Medical_Therapeutics_meta.xml Metadata 1.4 KB

172. Medrules Detsky

173. Infopoems

174. B. M. Biccard* and R. N. Rodseth) British Journal of Anaesthesia 107 (2): 133–
43 (2011
Utility of clinical risk predictors for preoperative
cardiovascular risk prediction
• Summary. Cardiovascular risk prediction using clinical risk factors is integral to both the
• European and the American algorithms for preoperative cardiac risk assessment and
• perioperative management for non-cardiac surgery. We have reviewed these risk factors
• and their ability to guide clinical decision making. We examine their limitations and
• attempt to identify factors which may improve their performance when used for clinical
• risk stratification. To improve the performance of the clinical risk factors, it is necessary
• to create uniformity in the definitions of both cardiovascular outcomes and the clinical
• risk factors. The risk factors selected should reflect the degree of organ dysfunction
• rather than a historical diagnosis. Parsimonious model design should be applied, making
• use of a minimal number of continuous variables rather than creating overfitted models.
• The inclusion of age in the model may assist partly in controlling for the duration of risk
• factor exposure. Risk assignment should occur throughout the perioperative period and
• the risk factors chosen for model inclusion should vary depending on when the
• assignment occurs (before operation, intraoperatively, or after operation).

175. ESA recommendations 2011

176. • With our current approach to risk
stratification, it is true that ‘we are not yet
near the situation where we can give a specific
risk value for an individual’, although this is
what we should strive for”
– B. M. Biccard,R. N. Rodseth. Utility of clinical risk predictors for
preoperative cardiovascular risk prediction.British Journal of Anaesthesia
107 (2): 133–43 (2011)

177. STEND

178. TESTING

179. Io consiglio
• avoid overly aggressive preoperative
investigation.
– The ACC/AHA state in their guideline on
perioperative risk assessment that “intervention is
rarely necessary simply to lower the risk of
surgery unless such intervention is indicated
irrespective of the preoperative context.”

180. Scopi dei test aggiuntivi cardiovascolari
• Fornire una misura obbiettiva di capacità
funzionale
• Identificare una ischemia preop miocardica
importante
• Diagnosticare aritmie cardiache rilevanti
• Stimare il rischio cardiaco periop e definire una prognosi

181. Invasive tests and CABG
• Coronary arteriography has a 0.3% mortality risk.
• Coronary artery bypass grafting (CABG) is associated
with an overall operative mortality risk of 3%.11
• In patients undergoing noncardiac surgery who have
significant coronary artery disease without antecedent
CABG, overall cardiac mortality is 2.4%, compared with
0.5% for those with antecedent CABG.12
• Therefore, performing otherwise unnecessary bypass
grafting simply to lower the risk of a subsequent
surgical procedure incurs an antecedent mortality of
greater than 3% from the CABG, whereas proceeding
directly to the indicated procedure, on average,
produces a 2.4% cardiac mortality.

182. • However, patients who are otherwise candidates for CABG may be first
identified when being evaluated for another surgical procedure. In such
cases, when the intended surgery can be safely delayed, performing the
CABG first is then most logical because the combined mortality of the
procedures will be lowest when the CABG is performed first.
• All of these tools focus exclusively on cardiovascular risk stratification or
preoperative cardiac management (except the decision tool of Steyerburg
et al 7; see below). Interestingly, few or none incorporate such risk factors
as smoking, hypertension, or serum albumin, which are not independent
predictors of major perioperative cardiac events. Two risk factors common
to all algorithms are heart failure and prior myocardial infarction (MI).
Seven of the 8 algorithms incorporate renal insufficiency, signs or
symptoms of current coronary ischemia, and age. In branching algorithms,
factors that may be included in an algorithm may not always be
considered for a particular patient.

183. • intervention is rarely necessary to simply
lower the risk of surgery unless such
intervention is indicated irrespective of the
preoperative context.
• No test should be performed unless it is likely
to influence patient treatment.
• The goal of the consultation is the optimal
care of the patient

184. Noninvasive cardiac testing
• is recommended in patients at increased risk of cardiac
complications in the 2009 ESC guidelines on perioperative care [4].
• ECG is recommended in patients with clinical risk factors or
undergoing intermediate or high-risk surgery.
• Assessment of left ventricular function should be considered in
patients undergoing high-risk surgery.
• Cardiac stress testing is recommended in patients with 3 or + RCRI
risk factors undergoing highrisk surgery and may be considered in
ntermediaterisk surgery and patients with two or less risk factors
undergoing high-risk surgery.
– Multiple options for cardiac stress testing are available, including
exercise electrocardiography, dobutamine stress echocardiography
(DSE), MRI, and nuclear imaging.

186. Dipiridamolo tallio
• the presence of a redistribution defect on
dipyridamole thallium imaging in patients
undergoing peripheral vascular surgery is
predictive of postoperative cardiac events. In
order to increase the predictive value of the
test, several strategies have been suggested.
Lung uptake, left ventricular cavity dilation,
and redistribution defect size have all been
shown to be predictive of subsequent
morbidity.10

187. Dobutamine stress test
• Dobutamine stress echocardiography has been suggested as the best
preoperative test in several recent meta-analyses.11 The appearance of
new or worsened regional wall motion
abnormalities is considered a positive test. The
advantage of this test is that it is a dynamic assessment of ventricular
function. Dobutamine echocardiography has also been studied and was
found to have among the best positive and negative predictive values.
Poldermans et al. demonstrated that the group at greatest risk were those
who demonstrated regional wall motion abnormalities at low heart rates.12
The presence of 5 or more segments of new regional wall motion
abnormalities denotes a high risk group who did not benefit from
perioperative beta blockade in one trial.13 Beattie and colleagues
performed a meta-analysis of stress echocardiography versus thallium
imaging and demonstrate that stress echocardiography has better negative
predicative characteristics.11 A moderate-to-large perfusion defect by
either test predicted postoperative MI and death