Dr. Brijesh Savidhan discusses strategies for evaluating cardiac risk in patients undergoing non-cardiac surgery. The goals are to identify patients at risk, evaluate the severity of underlying heart disease, and stratify surgical risk. A thorough history, physical exam, electrocardiogram, and assessment of functional capacity are recommended. For higher-risk patients, stress testing and evaluation of left ventricular function may be considered to guide management and minimize perioperative complications. Overall, a multidisciplinary approach is important to optimize cardiac status, determine the safest location and timing of surgery, and develop an anesthesia plan tailored to each patient's cardiac condition.

1. Dr Brijesh Savidhan
Department of Anaesthesiology
Travancore Medical College

2. Goals :
 To identify patients at risk - history, physical
examination & ECG.
 To evaluate the severity of underlying cardiac
disease - further cardiac tests.
 Stratify the extent of risk , determine the need
for preoperative interventions, additional
intra/post op monitoring, change in medical
therapy to minimize risk of peri operative
complications.

3.  Optimal location and timing for surgery,
alternative strategies and optimal management
 Communication between anaesthesiologist,
surgeon ,other consultants
 Plan the mode of anaesthesia appropriate to the
cardiac status
Promote pt engagement, shared decisions, provide
clear understandable information about periop
risks

4.  Major hemodynamic stress,
 Changes in cholinergic activity,
 Changes in catecholamine activity,
 Body temperature fluctuations, O2 consumption
 Pulmonary function altered,
 Fluid shifts, blood loss, electrolyte imbalance
 Pain.
 Effects of anaesthetic agents

5.  The initial history, physical examination, and
electrocardiogram assessment should focus on
identification of potentially serious cardiac
disorders.
 In addition it is essential to define disease
severity, stability, and prior treatment.

6.  GA & CNB Alters SVR,PVR,SV,CO
 Induction of GA  MAP by 20-30% ,tracheal
intubation  the BP by 20-30 mm Hg, and most
anesthetic agents  cardiac output by 15% by dose
dependent depression of contractility
 obtundation of baroreceptors, sympathetic
depression/stimulation

7.   arrythmogenic threshold for epinephrine
 May trigger bradycardia other dysrrythmias
 Cardiotoxicity, anaphylaxis, supply-demand
mismatch
 Pulmonary related issues

8.  Other factors that help determine cardiac risk-
functional capacity, age, co morbid conditions
(e.g., DM, PVD, renal dysfunction, and COPD).
 The type of surgery (vascular procedures and
prolonged, complicated thoracic, abdominal,
and head and neck procedures ) are considered
higher risk.
 The presence of anemia may also place a patient
at higher perioperative risk.

9.  Numerous risk indices have been developed
over the years on the basis of multivariate
analyses.
 In addition to CAD and HF, a history of CVD,
preoperative elevated creatinine greater than 2
mg/dl, insulin treatment for DM, and high-
risk surgery have all been associated with
increased periop cardiac morbidity.
( By Lee et al in 1999 in Revised Cardiac Risk
Index).

10. Evaluation of cardiac risk :
The cornerstone of preoperative cardiac
evaluation includes :-
- review of history ,
- physical examination,
- diagnostic tests,
- knowledge about the planned surgical
procedure.

11. History :
1) Risk factors : Age, HTN, DM, Dyslipidemias,
Smoking, Family history etc
2) Angina : Stable/ unstable, present medications.
3) Previous MI : details
4) CHF:
5) Dysrhythmias : Palpitations.
6) Associated CVS disease : Carotid, cerebral, aortic,
PVD.
7) Presence of pacemaker/ ICD.

12. Valvular Heart disease :
1) Dyspnea, Orthopnea, PND.
2) Embolic events.
3) Hemoptysis.
4) Heart failure, palpitations.
Prior cardiac evaluation :
1) Non invasive tests.
2) Angiography/ Stenting.
Medications :
1) Details.
2) Effectiveness.

13. Physical examination :
1) General examination :
Cyanosis, pallor, dyspnea during
conversation or with minimal activity, poor
nutritional status, obesity, skeletal deformities,
tremor & anxiety are just a few of the clues
of underlying disease or CAD.
2) Vitals : Pulse, BP , Respiration. Also pulse pressure

14. 3) Cardiovascular examination :
JVP, pedal edema ,
Displaced apical impulse (cardiomegaly),
S3 gallop ( increased LVEDP ),
S4 ( decreased compliance),
Apical systolic murmur ( Papillary muscle
dysfunction ),
Presence of murmurs,
Pulmonary edema.

15.  The metabolic equivalent, or MET- the ratio of a
person's working metabolic rate relative to the
resting metabolic rate.
 One MET represents the oxygen consumption of a
resting adult-40 yr old 70kg (3.5 ml/kg/min).

16.  In the RCRI by Lee et al functional status was
not independently associated with risk.
 If pts reduce exertion because of cardiac
symptoms but still meet a 4-MET threshold,
clinicians will underestimate risk.
 Conversely, non cardiac functional limitations
(e.g., knee or back pain) may falsely
overestimate cardiac risk.

17. Functional capacity is classified as :
 poor (<4 METS),
 moderate (4–7METS),
 good (7–10METS) ,
 Excellent(>10 METS)
based on evaluation of the pts daily activity.
Measurements on a treadmill inducing ischemia at
low-level exercise (<5 MET or heart rate <100 /min)
identifies a high-risk group,
whereas the achievement of more than 7 MET (or
heart rate >130 / min) without ischemia identifies a
low-risk group.

19. ECG :
 Preop resting ecg - readily available, inexpensive, easy
to perform.
 12 lead ecg reasonable in pts with known CAD, sig:
arrythmias, PVD, CVD, structural ht disease(class IIa-
LOE B)
 Metabolic & electrolyte disturbances, medications,
intracranial disease, pulmonary disease can alter ECG.

20.  Prognostic significance of
numerous abnormalities has been identified in
studies, including arrhythmias, pathological Q-
waves, LVH, ST depressions , QTc interval
prolongn, and bundle-branch blocks
 Ecg taken within 1-3 mnths adeq for stable pts

21. Risk Indices:
1) ASA.
2) NYHA/CCS.
3) Goldman ( 1977).
4) Detsky (1997 ).
5) ACC / AHA .
6) ACP.
7) RCRI-Lee ( 1999 ).
8) Cooperman ( 1978 ).
9) Larsen( 1987 ).
10) Pedersen ( 1990 ).
11) Vanzetto ( 1996 ).

22. Classification of Recommendations
 Class I: Conditions for which there is evidence, general agreement, or both that
a given procedure or treatment is useful and effective.
 Class II: Conditions for which there is conflicting evidence, a divergence of
opinion, or both about the usefulness/efficacy of a procedure or treatment
 Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
 Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
 Class III: Conditions for which there is evidence, general agreement, or both
that the procedure/treatment is not useful/effective and in some cases may be
harmful.
Level of Evidence
 Level of Evidence A: Data derived from multiple randomized clinical trials
 Level of Evidence B: Data derived from a single randomized trial or
nonrandomized studies
 Level of Evidence C: Consensus opinion of experts

23. 2014…
ACC/AHA guidelines on
perioperative cardiovascular
evaluation and management

24. Life or limb is
threatened if
not in
operating room
within
24 hours
Delay of 1-6
weeks for
further
evaluation
would
negatively
affect outcome
Delay for up
to 1 year
Life or limb is
threatened if
not in operating
room within
6 hours
Emergent Urgent
Time-
Sensitive
Elective

25.  Low risk procedure – combined surgical and
patient characteristic predict a risk of major
adverse cardiac event (MACE) of death or MI
<1%- cataract, plastic surgery
 Elevated risk procedure- all procedures with
risk>= 1% of MACE. Risk by less invasive
techniques(endovascular) &  in case of
emergency procedures.
Previous classification of mild, intermediate, high
risk discarded

26. CAD
 Incidence of morbidity depends on- cardiac
markers to signs of ischaemia
 Isolated Trop I + 2% 30 day mortality
 Post op MI rates durn frm MI to surgery
 Modified by presence & type of coronary
revascularisn

27.  60 days after MI before non cardiac Sx- in the
absence of revascularisn
 Recent MI(<6months)- 8 fold in periop
mortality
 Age>65 overall risk for MACE in non cardiac
Sx

28.  Pts with clinical ht failure- peripheral edema,
jugular venous distension, rales, S3, CXR with
pulmonary vascular redistribution, pulmonary
edema- significant risk
 Original CRI- S3,JVD. modified CRI- h/o
HF,PE,PND O/E b/l rales, S3,CXR(PVR)
 30 day mortality 50 to 100% higher in pts with
CHF

29. Step 1:
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30. Step 2:
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GDMT-Guideline directed medical therapy

31. Step 3:

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33. Step 4:

34. Step 5:
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35. Step 6:

36. Step 7:
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37.  Assessment of LV function
 Exercise Stress Testing for Myocardial Ischemia and
Functional Capacity
 Pharmacological Stress Testing
 Noninvasive
 Radionuclide
 DSE
 Special Situations

38. LV fn
 reasonable for patients with dyspnea of unknown origin,
h/o HF to undergo preop evaluatn of LV fn.(class IIa-
LOE B)
 Sig:(<30%) LVEF- independent contributor to periop
outcome- survival significantly worse
 Though data related to DD ltd- asctd with sig:rate of
MACE, prolongd hospital stay, higher post op ht failure
 Prospctve cohort study(vascular surgery)- 2005 pts on
role of echo in preop pts- LV dysfn (EF<50%) in 50 % pts
of whom 80% asymptomatic- 30 day cardiovascular
event -23% in pts with asymptomatic LV dysfn

39.  pts with excellent (>10 METs) fnl capacity- reasonble
to forgo further exercise tstng with cardiac imaging
and proceed to Sx (classIIa-LOE B)
 pts with  risk and unknown fnl capacity/moderate-
good fnl capacity, reasonble to perform exercise testng
if it will change Mx(class IIb-LOE B)

40. Reasonable (Class IIa) for patients at elevated risk and have
poor FC (either DSE or pharm stress MPI) (LOE=B)
Pts with PAH , with periop risk, should undergo a thorough preop
risk assessment including an assessment of fnl capacity,
hemodynamics, and echocardiography that includes evaluation of
RV function. (class IIa) and optimisation of PAH & RV status.
Despite lack of RCT on use of periop DSE/MPI several meta-
analysis has estd clinical utility of pharmacological stress
testing in the preop evaluatn of patients undergoing
noncardiac surgery.

41.  presence of moderate to large areas of myocardial
ischemia is associated with increased risk of
perioperative MI and/or death.
 A normal study has a very high negative predictive
value.
 Routine preoperative coronary angiography is not
recommended. (LOE: C)

45. THANK YOU