Cardiac Assessment in Non Cardiac Surgery

1. PREOPERATIVE CARDIAC
ASSESSMENT IN
NONCARDIAC SURGERY
Presented by: Sabrina Erriyanti
Resource Person: Dr. dr. Soroy Lardo, SpPD

2. INTRODUCTION

3. INTRODUCTION
◦ Many patients undergoing major noncardiac surgery are at
risk for a cardiovascular event. Identification of increased risk
provides the patient (and surgeon) with information that
helps them better understand the benefit-to-risk ration of a
procedure.
◦ This information may lead to interventions that decrease risk.
◦ In this presentation, initial preoperative cardiac evaluation which
includes an attempt to quantify risk will be reviewed

4. CASE
ILLUSTRATION

5. Identity
◦ Name : Mrs S
◦ Gender : Female
◦ Age : 80 years old
◦ Address : Kp. Cipedak
◦ Occupation : Housewife
◦ Marital status : Married
◦ Date of admission: 25/05/2017

6. Primary survey
Airway Clear, cervical spine stable
Breathing Breathing spontaneously, able to articulate. RR 20/min
Circulation HR 82/min; BP 163/65; CRT < 2”; no bleeding seen
Disability Fully alert, GCS 15
Environment Well-covered, warm. There were no injuries visible on the
patient.

7. Secondary survey
◦ Chief complaint
Left hip pain since 1 week before presentation

8. o Present illness history
◦ 1 week before presentation  on her way to the bathroom from her bed 
suddenly slipped and fell down  Hit the floor in a sitting position
◦ Since then  pain in her left hip (+), with a VAS score of 6; difficulty moving
left leg (+)  immobilized for 1 week
◦ The patient’s children were afraid to lift their mother from the bed  did not
take her to the hospital; asking for help from nearest neighbour  brought to
Gatot Soebroto Army Hospital
◦ Head trauma (-), chest trauma (-), abdominal trauma (-), massive blood loss (-),
loss of consciousness (-), vomiting (-).
 Patient did not immediately sought treatment at Gatot Soebroto
Indonesian Central Army Hospital Emergency Department.

9. o Past illness history
◦ Hypertension (+)  did not routinely take medicine
◦ DM (+)  did not routinely take medicine
◦ Asthma and allergy (-)
◦ History of prior surgery (-)
◦ Previous trauma at the hip (-)
◦ History of osteoporosis unknown.

10. o Family history
◦ Hypertension (-)
◦ DM (-)
◦ Asthma and allergy (-)
o Social history
◦ Medical fee payment method  BPJS
◦ History of smoking (-)

11. Physical examination
General Examination
Anthropometrics Body weight 50 kg, body height 165 cm. IMT 18
Skin Within normal limits. Good turgor, brown skin
Head Within normal limits. No deformities, no wounds.
Eyes
Pale conjunctiva (-); icteric sclera (-)
Pupils round; diameter of 3mm/3mm; direct light reflex (+);
consensual light reflex (+)
Neck
Lymph nodes not palpable; JVP not increased; no midline shift
of trachea
Chest
Inspection: Symmetrical expansion, no deformities
Palpation: Symmetrical expansion; tactile fremitus left=right
Percussion: Resonant lung sounds over all lung fields
Auscultation: Vesicular lung sounds +/+; crackles -/-,
wheezing -/-

12. Heart
Inspection: Apical heartbeat not visible
Palpation: Apical heartbeat not palpable
Percussion: Left heart border at 5th
ICS at left mid-clavicular
line; Right heart border at lower right sternal border; Cardiac
waist at 3rd
ICS at left parasternal line.
Ausculation: Heart sounds 1 and 2 normal; gallop (-); murmur
(-)
Abdomen
Inspection: Flat; wounds (-); spider nevi (-)
Palpation: Soft, liver and spleen not palpable, pain on palpation
(-)
Percussion: Tympani over all abdominal fields; shifting
dullness (-)
Auscultation: Bowel sounds (+) at all regions, normal
Extremities
Warm; edema -/-; cyanosis -/-
Palpation of brachial arteries +/+; radial arteries +/+; dorsalis
pedis artery +/+; posterior tibial arteries +/+
Lymph nodes Not palpable

13. Local examination of wound
Look Open laceration (-)
Deformity (+), angulation (-), external rotation (-).
Active bleeding (-)
Feel Pain on palpation (+), neurovascular disease (-),
sensory examination (N)
Palpation of dorsalis pedis artery ++/++; posterior
tibial arteries ++/++
CRT < 2”
Move ROM limited due to pain

14. Laboratory
Results
Complete blood count
25/05 30/05
Hb 10.1 9.6
Ht 31 30
Leucocyte 8.160 8440
Thrombocyte 380.000 493.000
MCV 83 84
MCH 27 27
MCHC 32 32
PT 9.8/10.8 (1.10x) -
APTT 32.3/34.5 (1.07x)
-
Blood urea 76 -
Blood creatinine 1.6 -
SGOT 21 -
SGPT 13 -
Random blood glucose 369 286
Electrolytes 138/4.1/104 -
ESR - 58
Total Cholesterol - 191
Triglyceride - 130
HDL - 45
LDL - 120
Uric Acid - 5.1

15. ELECTROCARDIOGRAPHY
Sinus rhythm, normoaxis, QRS rate 100 beats/min, normal P-wave, PR
interval 0.16 s, QRS duration 0.08 s, and no ST-T changes, PAC (+)

16. X-ray examination (1)
Comminuted fracture at collum with extension to diaphysis of
proximal left femur

17. X-ray examination (2)
Cardiomegaly with aortic elongation and calcification of the aorta

18. Echocardiography
• LVH (-)
• EF 55%
• Global
normokinetic
• TAPSE 1.8 cm
• MR mild, AR
mild, TR mild
• Low probability
of pulmonary
hypertension
• Grade 1 diastolic
dysfunction

19. Working diagnosis
1. Closed fracture intertrochanter femur
sinistra
2. DM type 2, underweight, uncontrolled

20. Management
1. Skin traction
2. Tramadol 3 x 100 mg IV
3. Ranitidin 2 x 50 mg IV
4. Pro elective bipolar hemiarthroplasty

21. Prognosis
◦ Ad vitam : Bonam
◦ Ad functionam : Dubia ad bonam
◦ Ad sanactionam : Dubia ad bonam

22. Follow up 30/05/17
S No complaints
O
Fully alert, stable hemodynamics
Local examination of right ankle
•L  Wound clean, odor (-), pus (-)
•F  Pain on palpation (-), arterial pulsations popliteal artery ++/++; dorsal
pedal artery ++/++; posterial tibial artery ++/++, sensory function (N)
•M  limited ROM
A
1. Closed fracture intertrochanter femur sinistra
2. DM type 2, underweight, uncontrolled
P
1. Tramadol 3 x 100 mg IV
2. Ranitidin 2 x 50 mg IV
3. Novorapid 3x10 IU SC
4. Levemir 1x8 IU SC
5. Pro elective bipolar hemiarthroplasty, electively (02/05)

23. RESUME
◦ A 80 year old woman was admitted to emergency room with chief
complaint of left hip pain since 1 week before presentation. This
complaint was started after she slipped on her way to the
bathroom from her bed and fell down in a sitting position 1 week
before presentation. From hip x-ray examination, there was a
comminuted fracture at collum with extension to diaphysis of
proximal left femur. In the ward, patient was then prepared to
undergo bipolar hemiarthroplasty. Therefore, a preoperative
assessment from cardiologist, pneumologist and anesthesiologist
was planned.

24. PERIOPERATIV
E EVALUATION
Cardiac Assessment for Non-Cardiac Surgery

25. Pre-operative Evaluation
• A patient’s age is an important consideration, given that adults (those >55 years
of age) have a growing prevalence of CVD which increase overall risk for MACE
when they undergo noncardiac surgery.
• More postoperative complications, increased length of hospitalization, and inability
to return home after hospitalization were also more pronounced older adults >70
years of age

26. Perioperative Cardiac Physiology
◦ Cardiac effects of general anesthesia
Changes in the arterial and central venous pressure, CO, varying
heart rhythms  ↓ systemic vascular resistance, ↓ myocardial
contractility, ↓ SV, ↑ myocardial irritability
Induction of general anesthesia lowers systemic arterial pressures by
20-30%, tracheal intubation increases the blood pressure by 20-30
mm Hg, and agents such as nitric oxide lower cardiac output by
15%.

27. ◦ The use of fentanyl, sufentanil, or alfentanil results in less
myocardial depression compared to inhaled anesthetics.
 still cause venodilation, thus reducing preload and, hence,
depressing cardiac output (sensitive for patients with CHF)
◦ Cardiac effects of regional anesthesia
Epidural and spinal anesthetics cause arteriodilation and
venodilation by blocking sympathetic outflow, ↓ preload, and, ↓
reducing CO

28. Stress Response due to surgery
◦ Every operation elicits a stress response  initiated by tissue injury
and mediated by neuroendocrine factors  induce tachycardia and
hypertension  ↑ myocardial oxygen demand
◦ Surgery also causes alterations in the balance between
prothrombotic and fibrinolytic factors, resulting in
hypercoagulability and possible coronary thrombosis (elevation of
fibrinogen and other coagulation factors, increased platelet
activation and aggregation, and reduced fibrinolysis) 
proportionate to the extent and duration of the intervention.
◦ All these factors may cause myocardial ischaemia and heart
failure.

29. Initial Preoperative Evaluation
◦ The physician should inquire about symptoms such as :

30. Pre Operation Evaluation
(Stepwise Approach)
◦ Step 1 : urgent surgery
◦ Step 2 : active or unstable cardiac conditions
◦ Step 3 : risk of surgical procedure
◦ Step 4 : functional capacity of patient
◦ Step 5 : patient with poor functional capacity consider risk of surgical
procedure
◦ Step 6 : consider cardiac risk factors
◦ Step 7 : consider non invasive testing
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

31. Step 1
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
SURGERY

32. SURGERY
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
Step 2

33. Determine the risk of the surgical
procedure
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
Step 3

34. Glance LG, Lustik SJ, Hannan EL, Osler TM, Mukamel DB, Qian F et al. The Surgical Mortality Probability Model:
derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg 2012;255:696–702.

35. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
Consider the functional capacity
of the patient
◦ Can be expressed in metabolic equivalents
(1 MET = 3.5 mL O2 uptake/kg per min 
the resting oxygen uptake in a sitting
position).
◦ Indicators of functional status include the
following:
- Can take care of self, such as eat, dress, or use the
toilet (1 MET)
- Can walk up a flight of steps or a hill or walk on
level ground at 3 to 4 mph (4 METs)
- Can do heavy work around the house such as
scrubbing floors or lifting or moving heavy
furniture or climb two flights of stairs (between 4
and 10 METs).
- Can participate in strenuous sports such as
swimming, singles tennis, football, basketball, and
skiing (>10 METs)

36. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
In patients with a poor functional capacity
consider the risk of the surgical procedure

37. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management
Cardiac risk factors

38. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement
Consider non-invasive testing. Noninvasive testing can also be
considered prior to any surgical procedure for patient counselling,
change of peri-operative management in relation to type of surgery
and anaesthesia technique

39. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

40. Risk Models
◦ Risk models estimate the risk based on information obtained from the history,
physical examination, electrocardiogram, and type of surgery.
◦ We use either the revised cardiac risk index (RCRIrevised cardiac risk index (RCRI), also referred to as the Lee
index, or the American College of Surgeons’ National Surgical Quality
Improvement Program risk (ACS-NSQIP) model calculator  The RCRI is
simpler. The ACS-NSQIP calculator is more complex
◦ For patients at low risk (<1 percent), no further testing is indicated.
◦ For patients at higher risk, caregivers need to ask the question whether further
cardiovascular testing will change management and hopefully improve the
outcome

41. Comparison of the RCRI, NSQIP, MICA, and ACS-NSQIP

42. RCRI

43. Further Cardiac Testing
◦ In patients with known or suspected heart disease (ie, cardiovascular disease, significant
valvular heart disease, symptomatic arrhythmias), we perform further cardiac evaluation
(echocardiography, stress testing, or 24-hour ambulatory monitoring) only if it is
indicated in the absence of proposed surgery.

44. PERIOPERATIVE
MONITORING
Cardiac Assessment for Non-Cardiac Surgery

45. 1. ECG (Electrocardiography)
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

46. 2. TOE (Trans Oesophageal Echocardiography)
◦ Rapidly available, relatively non-
invasive, more versatile,
comprehensive information
◦ MI can be identified as
abnormalities in wall motion and
thickening
◦ Recommended if acute and
severe hemodynamic instability or
life-threatening abnormalities
develop during or after surgery
◦ Determine cause of hypotension,
hypovolemia, low EF, embolism,
MCI, tamponade and dynamic
LVOT obstruction
◦ Useful in OR in pt with severe
valvular lesions
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

47. 3. Right Heart Catheterization
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

48. 4. Disturbed Glucose Metabolism
◦ DM promotes atherosclerosis,
endothelial dysfunction, platelet
activation, pro-inflammatory
cytokines
◦ 50% if patient with type 2 DM die of
CVD
◦ DM + surgery longer
hospitalization, greater use of
healthcare resources, higher
perioperative mortality; HbA1C
associated with worse outcomes in
surgical and critical care pt
◦ Surgical stress  increase pro-
thrombotic state
◦ Critical illness dysglycemia
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement

49. 5. Anaemia
◦ Can contribute in MI especially in pre-existing CAD
◦ Transfusion during emergency surgery according to clinical needs
◦ Elective surgery – symptom guide approach

50. CONCLUSION

51. 1. All patients scheduled to undergo noncardiac surgery should
have an assessment of the risk of a cardiovascular perioperative
cardiac event.
2. The patient’s functional status is an important determinant of
risk. Identification of risk factors is derived from the history and
physical examination, the type of proposed surgery influences
the risk of perioperative cardiac event
3. For patients with known or suspected heart disease, we only
perform further cardiac evaluation if it is indicated in the
absence of proposed surgery.
4. In this patient, according to the algorithm, it was
concluded that the patient had moderate risk for
cardiovascular event for surgery.

52. THANK YOU