This document provides information on preoperative assessment and cardiac risk assessment (PAC) for patients undergoing non-cardiac surgery. It discusses how cardiovascular complications are a major cause of death following non-cardiac surgeries. The aims of PAC are to identify life-threatening cardiac conditions, order appropriate tests, stratify surgical risks, and implement optimal medical and interventional strategies. The document outlines guidelines for risk assessment and provides details on the history, examination, investigations, medications, and risk indices used to evaluate cardiac patients for non-cardiac surgery. It emphasizes stratifying risk based on surgery type, identifying underlying cardiac conditions, and optimizing medical management to reduce perioperative cardiovascular risks.

1. PAC OF CARDIAC PATIENTS FOR
NON-CARDIAC SURGERY,
CARDIAC RISK ASSESSMENT
Presented by:
Pooja Pandeya
1st year Resident
Department of Anesthesiology

2. INTRODUCTION
• Cardiovascular complications: 25-50% deaths following non-cardiac
surgeries
• Major Adverse Cardiac Event (MACE): composite term  Includes
Acute Myocardial Syndrome, stroke, cardiovascular death, coronary
revascularization and heart failure
• By 2030, 20% individuals aged >75 years will undergo surgery each
year

3. GUIDELINES FOR RISK ASSESSMENT
• ACC/ AHA Task force report 2014
• ESC/ESA 2022 guidelines
• CCS 2019 guidelines

4. DEFINITIONS
• Emergency procedure: Life or limb threatened if not in the operating room
(<6hrs)
• Urgent procedure: Limited time for clinical evaluation (6-24 hrs)
• Time sensitive procedure: 1 to 6 weeks to allow for an evaluation and
significant changes in management will negatively affect outcome
• Elective procedure: Could be delayed for up to 1 year
• Low-risk procedure: <1% risk of MACE
• Elevated risk procedure: >1% risk of MACE

5. AIMS OF PAC
• Identification potentially life-threatening cardiac disease
• Order appropriate tests only
• Stratifications of risks
• Implementation most appropriate medical and interventional
cardiovascular treatment strategies

6. HISTORY
• Chest pain
• SOB
• Easy fatigability
• Palpitations
• Orthopnea, PND
• Syncope
• Relation of symptoms with activity level
• Hemoptysis

7. DUKES ACTIVITY STATUS INDEX

8. EXAMINATION
• Pallor, edema, cyanosis, neck veins
• BP (different positions)
• Pulse
• RR
• Precordium
• Apex beat
• Heart sound and murmur
• Lung bases
• Bruits

9. NYHA CLASSIFICATION

10. GOLDMAN MULTIFACTORIAL CARDIAC RISK INDEX

11. REVISED CARDIAC RISK INDEX SCORING (RCRI)

12. CARDIAC AND SURGICAL RISK CALCULATORS
• ACS NSQIP MICA Surgical Risk Calculator
• 21 patient-specific variables for prediction of several groups of
outcomes
• https://riskcalculator.facs.org/RiskCalculator/

15. 9/16/2023 Nams 16

16. DIABETES MELLITUS
• Accelerate progression of atherosclerosis  CAD
• Require Insulin  Higher risk
• Duration of disease
• End organ dysfunction
• Autonomic neuropathy  silent ischemia

17. HYPERTENSION
• Look for LVH, end organ damage
• JNC -8
• 180/110 mmHg  Evidence
• Optimize VS risk of delaying surgery

18. METABOLIC SYNDROME
• High BP + Dyslipedemia + FBS + Central obesity
• Cardiovascular + Pulmonary + Renal Complication + Wound infection

20. INVESTIGATIONS
• 12-lead ECG
• Tropinin I, CK-MB, LDH-1: h/o recent unstable angina
• Echocardiography
• Exercise stress test
• Pharmacological stress test
• Coronary Angiography

22. ECG
• Left ventricular hypertrophy
• Abnormal Q waves
• Known CAD or other structural heart disease (except for low-risk surgical
procedures)
• Asymptomatic patients with clinical risk factors (except for low-risk procedures)

23. ECHOCARDIOGRAPGY
• Regional wall motion abnormalities, wall thickness, valvular function,
EF
• Dyspnea of unknown origin
• Current or prior heart failure with worsening dyspnea
• Valvular stenosis or regurgitation with no echocardiography studies
within 1 year, or worsening clinical status
• Aortic stenosis  poor prognosis in noncardiac surgical patient
• Modify perioperative hemodynamic goals and therapy

24. EXERCISE STRESS TEST
• Sensitivity = 70% -80%
• Specificity = 60% -75% for identifying CAD
• Positive exercise stress test  risk for ischemia associated with
increased heart rate
• Greatest risk  Ischemia after mild exercise
• Ability to exercise No further testing

25. PHARMACOLOGICAL STRESS TEST
• High-risk patients who either are unable to exercise or have
contraindications to exercise
• Dobutamine  Regional wall motion abnormality

26. CORONARY ANGIOGRAPHY AND PCI
• Patients with restricted physical activity in whom functional capacity
difficult to determine
• Not recommended for elective surgeries

29. BETA BLOCKER
• Chronic use  continue
• RCRI >3  May consider  Not on day of surgery

30. STATIN THERAPY
• Continue if currently taking
• Vascular surgery  may start
• Elevated risk procedure

33. REFERENCES
• 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation
and Management of Patients Undergoing Noncardiac Surgery
• Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC. Clinical
Anesthesia. 8th ed.
• Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 7th ed
• Stoelting’s Anesthesia And co existing Disease –7 th edition
• For Professionals | Heart Foundation

34. THANK YOU