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Preoperative Evaluation of Cardiac
Patients Undergoing Non-cardiac
Surgery
Moderator: Prof. Dr Baburaja
Shrestha
22 Dec,20...
• 1-5 % of unselected pts have perioperative
cardiac morbiditya
• Pre-op Approach
clinical risk indices
pre-op cardiac tes...
Cardiac disease
• Structural heart disease
• Coronary artery disease
• Valvular heart disease
• Cardiomyopathies
• Heart f...
Perioperative cardiac morbidity
• 1-5% of unselected pts
• Myocardial infarction
• Heart failure
• Arrhythmias
• Sudden Ca...
Goals
• Define risks
• Determine if further testing beneficial
• Appropriate anesthetic plan
• Peri-op ?beta blockade, int...
History
• Symptoms, h/o cardiac disease
• Associated co-morbidities: peripheral vascular disease,
cerebrovascular disease,...
• Indicators of disease severity: PND, orthopnea, dyspnea,
angina
• recent change in symptoms?
• Drug therapy & compliance...
Physical examination
• General appearance provides invaluable evidence of patient’s
overall status
• Assessment of vital s...
Risk Stratification
• Risk indices range from ASA-PS grading to
Goldman to revised cardiac risk index
Goldman’s cardiac risk index
Risk factors Points
Third heart sound, raised JVP 11
Recent myocardial infarction (within 6 m...
Interpretation of scores of Goldman’s cardiac
risk index
Points Risk of cardiovascular
complications
0-5 1%
6-12 7%
13-25 ...
Detsky cardiac risk index
Risk Points
Age older than 70 years 5
Myocardial infarction within six months 10
Myocardial infa...
Class Points Cardiac risk
I 0 to 15 Low
II 20 to 30 Moderate
III 31 + High
Interpretation of scores of Detsky cardiac index
Revised Cardiac Risk Index
SIX independent predictors,1999
Clinical variable Points
High-risk surgery 1
H/o Ischemic heart...
Clinical Predictors of Increased Perioperative
Cardiovascular Risk
• Major
- Unstable coronary syndromes
Acute or recent M...
• Intermediate
- Mild angina pectoris (Canadian class I or II)
- Previous MI by history or pathological Q waves
- Compensa...
ACC/AHA cardiac evaluation
guidelines
• Step 1- determine urgency/emergency
if emergency- risk reduction, ↑peri-op
monitor...
• Postpone surgery in ACUTE, RECENT MI (with
symptoms,+ve stress test)
• Step 3- determination of surgical risk/severity
l...
Disease specific
Hypertension
• Two or more readings > 140/90
• PAC an opportunity to identify pts with HTN &
initiate therapy
• Degree of ...
• Evaluate to identify causes of HTN, end organ
damage, therapy and compliance
• Order ECG, BUN,Creatinine
electrolytes if...
Coronary Artery Disease
• History, Physical exam & ECG
• RISK FACTORS as imp. as symptoms since CAD
can be insidious
• Cla...
• Enquiry abt type, duration,
precipitating/relieving factors of chest
discomfort
• Dyspnea with CAD risk factors >> furth...
PERIOPERATIVE RISK OF EVENTS
• Patients With No Prior History Of MI Have A Low Risk Of Perioperative
MI (0.1%-0.6%)
• Pati...
• Taken together,data suggest that <60 days
(recent MI) should elapse after a MI before
noncardiac surgery in the absence ...
Greatest risk
• Extensive 3-vessel disease
• Left main disease
• Ventricular dysfunction
• Residual ischemia remaining fro...
Heart failure
• Symptoms- SOB, fatigue,orthopnea,PND,
cough,periph. edema,recent wt gain
• Signs- S3/S4, tachycardia, rale...
NYHA Heart Failure Classification
Class Description
1
No limitation of physical activity - ordinary physical activity does...
• Decompensated HF >> postpone surgery
• Correlation betwn HF and BNP levels
BNP > 100pg/ml >> heart failure
N-terminal pr...
MURMURS &
VALVULAR ANOMALIES
Recommendations
• CLASS I
• 1. clinically suspected moderate or greater degrees of
valvular stenosis or regurgitation
• un...
Importance of type of surgery
Cardiac riska stratification for non-cardiac surgery
• High (reported cardiac risk often greater than 5%)
- Emergent major...
Functional capacity
METs
• functional capacity is classified as
Excellent (>10 METs),
Good (7 METs to 10 METs)
moderate (4 METs to 6 METs),
po...
METs
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergo...
Dukes Activity status index
The 12-Lead Electrocardiogram:
Recommendations
CLASS IIa
• ECG reasonable for patients with known coronary heart disease,
...
Stepwise Approach to Preoperative Cardiac
Assessment
Poor
(<4 METs)
6. Intermediate
clinical
predictor
Moderate or
excelle...
 pre op evaluation of cardiac pts for non-cardiac surgery
 pre op evaluation of cardiac pts for non-cardiac surgery
 pre op evaluation of cardiac pts for non-cardiac surgery
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pre op evaluation of cardiac pts for non-cardiac surgery

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pre op evaluation of cardiac pts for non-cardiac surgery

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pre op evaluation of cardiac pts for non-cardiac surgery

  1. 1. Preoperative Evaluation of Cardiac Patients Undergoing Non-cardiac Surgery Moderator: Prof. Dr Baburaja Shrestha 22 Dec,2014
  2. 2. • 1-5 % of unselected pts have perioperative cardiac morbiditya • Pre-op Approach clinical risk indices pre-op cardiac testing
  3. 3. Cardiac disease • Structural heart disease • Coronary artery disease • Valvular heart disease • Cardiomyopathies • Heart failure / Cor pulmonale
  4. 4. Perioperative cardiac morbidity • 1-5% of unselected pts • Myocardial infarction • Heart failure • Arrhythmias • Sudden Cardiac death
  5. 5. Goals • Define risks • Determine if further testing beneficial • Appropriate anesthetic plan • Peri-op ?beta blockade, interventional therapy,
  6. 6. History • Symptoms, h/o cardiac disease • Associated co-morbidities: peripheral vascular disease, cerebrovascular disease, diabetes mellitus, renal impairment, and chronic pulmonary disease • History of surgery, anesthetic course • Use of mechanical devices: ICD/pacemaker/stents/prosthetic valves • Exercise tolerance
  7. 7. • Indicators of disease severity: PND, orthopnea, dyspnea, angina • recent change in symptoms? • Drug therapy & compliance : disease specific; over-the- counter and illicit drugs, herbal and other nutritional supplements; dosages/compliance/side-effects • Alcohol, tobacco use • Bleeding tendencies
  8. 8. Physical examination • General appearance provides invaluable evidence of patient’s overall status • Assessment of vital signs (including measurement of blood pressure in both arms) • Carotid pulse contour and bruits, jugular venous pressure and pulsations, auscultation of the lungs, precordial palpation and auscultation, abdominal palpation, and examination of the extremities for edema and vascular integrity. • The presence of an implanted pacemaker or ICD
  9. 9. Risk Stratification • Risk indices range from ASA-PS grading to Goldman to revised cardiac risk index
  10. 10. Goldman’s cardiac risk index Risk factors Points Third heart sound, raised JVP 11 Recent myocardial infarction (within 6 months) 10 Rhythm other than sinus or >5 premature atrial contractions 7 >5 premature ventricular contractions/min 7 Age >70 yrs 5 Emergency operations 4 Poor general health condition 3 Intrathoracic, intraperitoneal or aortic surgery 3 Severe aortic stenosis 3 Total score 53
  11. 11. Interpretation of scores of Goldman’s cardiac risk index Points Risk of cardiovascular complications 0-5 1% 6-12 7% 13-25 14% 26-53 78%
  12. 12. Detsky cardiac risk index Risk Points Age older than 70 years 5 Myocardial infarction within six months 10 Myocardial infarction before six months 5 Canadian Cardiovascular Society Angina Classification Class III 10 Class IV 20 Unstable angina within six months 10 Alveolar pulmonary edema Within one week 10 Ever 5 Suspected critical aortic stenosis 20 Arrhythmia Rhythm other than sinus or sinus plus atrial premature beats 5 More than five premature ventricular beats 5 Emergency operation 10 Poor general medical status 5
  13. 13. Class Points Cardiac risk I 0 to 15 Low II 20 to 30 Moderate III 31 + High Interpretation of scores of Detsky cardiac index
  14. 14. Revised Cardiac Risk Index SIX independent predictors,1999 Clinical variable Points High-risk surgery 1 H/o Ischemic heart disease 1 H/o Congestive heart failure 1 H/o cerebrovascular disease 1 Insulin treatment for diabetes mellitus 1 Pre-operative serum creatinine level >2.0 mg/dl (180 mcgmol/L) 1 Risk class Points Risks of complications (%) I. Very low 0 0.4 % II. Low 1 0.9 % III. Moderate 2 7.0 % IV. High 3+ 11.0 % Interpretation of risk score
  15. 15. Clinical Predictors of Increased Perioperative Cardiovascular Risk • Major - Unstable coronary syndromes Acute or recent MI with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina (Canadian class III and IV) - Decompensated heart failure - Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate - Severe valvular disease
  16. 16. • Intermediate - Mild angina pectoris (Canadian class I or II) - Previous MI by history or pathological Q waves - Compensated or prior heart failure - Diabetes mellitus (particularly insulin dependent) - Renal insufficiency • Minor - Advanced age - Abnormal ECG (left ventricular hypertrophy, left bundle-branch block, ST-T abnormalities) - Rhythm other than sinus (eg, atrial fibrillation) - Low functional capacity (eg, inability to climb one flight of stairs with a bag of groceries) - History of stroke - Uncontrolled systemic hypertension (ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
  17. 17. ACC/AHA cardiac evaluation guidelines • Step 1- determine urgency/emergency if emergency- risk reduction, ↑peri-op monitoring • Step 2 any active cardiac condition? Acute MI,Unstable angina, CHF, severe valvular disease, significant arrhythmias STILL ? Benefits > risks (lifesaving procedure)
  18. 18. • Postpone surgery in ACUTE, RECENT MI (with symptoms,+ve stress test) • Step 3- determination of surgical risk/severity low risk surgery without active cardiac condition can proceed • STEP 4- Pts functional capacity asymptomatic/excellent functional capacity>> proceed to surgery • Step 5 – poor functional status – Further invasive test only “if it will change the management
  19. 19. Disease specific
  20. 20. Hypertension • Two or more readings > 140/90 • PAC an opportunity to identify pts with HTN & initiate therapy • Degree of end-organ damage, morbidity & mortality correlate with disease duration and severity • IHD most common end organ damage associated • HTN with LVH have higher peri-op risk than non HTN (Barash,7th edn)
  21. 21. • Evaluate to identify causes of HTN, end organ damage, therapy and compliance • Order ECG, BUN,Creatinine electrolytes if on diuretics • LVH and strain pattern>> futher evaluation • Dyspnea/heart failure >> ECHO • Little association between SBP <180 mm Hg or DBP <110 mm Hg and peri-op outcomes • In the absence of end-organ changes (eg renal insufficiency/ LV strain) the benefits of optimizing BP must be weighed against the risks of delaying surgery
  22. 22. Coronary Artery Disease • History, Physical exam & ECG • RISK FACTORS as imp. as symptoms since CAD can be insidious • Classic risk factors (age, gender,smoking,↑cholesterol) NOT direct/independent risk to peri-op cardiac event
  23. 23. • Enquiry abt type, duration, precipitating/relieving factors of chest discomfort • Dyspnea with CAD risk factors >> further IHD investigations
  24. 24. PERIOPERATIVE RISK OF EVENTS • Patients With No Prior History Of MI Have A Low Risk Of Perioperative MI (0.1%-0.6%) • Patients With A History Of Prior MI Are At A Significantly Higher Risk (2.8%-7%). • MI Within 3 Mnths.-37% Increase In Events • MI Within 3-6 mnths.-16% Increase In Events • MI Greater Than 6 Mnths.-4% Increase In Events
  25. 25. • Taken together,data suggest that <60 days (recent MI) should elapse after a MI before noncardiac surgery in the absence of a coronary intervention • Recent MI also independent risk factor for peri-op stroke (8 fold mortality)
  26. 26. Greatest risk • Extensive 3-vessel disease • Left main disease • Ventricular dysfunction • Residual ischemia remaining from previous MI • Mortality rates exceed 50%
  27. 27. Heart failure • Symptoms- SOB, fatigue,orthopnea,PND, cough,periph. edema,recent wt gain • Signs- S3/S4, tachycardia, rales, ↑JVP,ascites,hepatomegaly • Identification and grading
  28. 28. NYHA Heart Failure Classification Class Description 1 No limitation of physical activity - ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath 2 Slight limitation of physical activity - comfortable at rest, but ordinary physical activity results in tiredness, heart palpitations, or shortness of breath 3 Marked or noticeable limitations of physical activity - comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath 4 Severe limitation of physical activity - unable to carry out any physical activity without discomfort. Symptoms also present at rest. If any physical activity is undertaken, discomfort increases.
  29. 29. • Decompensated HF >> postpone surgery • Correlation betwn HF and BNP levels BNP > 100pg/ml >> heart failure N-terminal pro-BNP < 300 pg/ml virtually excludes acute HF! • ECG,CXR,electrolytes,urea/creat & possible BNP indicated • ECHO for LVEF, Ventricular performance & diastolic function
  30. 30. MURMURS & VALVULAR ANOMALIES
  31. 31. Recommendations • CLASS I • 1. clinically suspected moderate or greater degrees of valvular stenosis or regurgitation • undergo preop echo if 1) no prior echocardiography within 1 year or 2) significant change in clinical status or physical examination since last evaluation • 2. for indications of valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk (15). (LOE: C)
  32. 32. Importance of type of surgery
  33. 33. Cardiac riska stratification for non-cardiac surgery • High (reported cardiac risk often greater than 5%) - Emergent major operations, particularly in the elderly - Aortic and other major vascular surgery - Peripheral vascular surgery - Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss • Intermediate (reported cardiac risk generally less than 5%) - Carotid endarterectomy - Head and neck surgery - Intraperitoneal and intrathoracic surgery - Orthopedic surgery - Prostate surgery • bLow (reported cardiac risk generally less than 1%) - Endoscopic procedures - Superficial procedure - Cataract surgery - Breast surgery
  34. 34. Functional capacity
  35. 35. METs • functional capacity is classified as Excellent (>10 METs), Good (7 METs to 10 METs) moderate (4 METs to 6 METs), poor (<4 METs) or unknown. • Periop cardiac and long-term risks are increased in pts unable to perform 4 METs of work during daily activities
  36. 36. METs Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.” http://content/onlinejacc.org/
  37. 37. Dukes Activity status index
  38. 38. The 12-Lead Electrocardiogram: Recommendations CLASS IIa • ECG reasonable for patients with known coronary heart disease, • significant arrhythmia, peripheral arterial disease, cerebrovascular • disease, or other significant structural heart disease, • except for those undergoing low-risk surgery (137–139). • (Level of Evidence: B) • CLASS IIb • ECG may be considered for asymptomatic patients without known coronary heart disease,except for those undergoing low-risk surgery • (Level of Evidence: B) • CLASS III: NO BENEFIT • Routine 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures • (Level of Evidence: B)
  39. 39. Stepwise Approach to Preoperative Cardiac Assessment Poor (<4 METs) 6. Intermediate clinical predictor Moderate or excellent (>4 METs) Intermediate or low surgical risk procedure High surgical risk procedure Low surgical risk procedure 8. Noninvasive testing Consider coronary angiography Subsequent care dictated by findings and treatment results Operating room Postoperative risk stratification and risk factor reduction Low risk High risk Functional capacity Surgical risk Noninvasive testing Invasive testing

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