Preoperative Cardiac Risk Assessment: Approach & Guidelines By, Liam Morris, MD., FACC (02/03/18)
CPG : Clinical Practice Guidelines GDMT : Guidelines Directed Medical Therapy GWC : Guideline Writing Committee ERC : Evidence Review Committee RCT : Randomized Clinical Trials MACE : Major Adverse Cardiac Events (Death and Nonfatal MI) ACS : Acute Coronary Syndrome
Definitions Emergency procedure : One in which Life or a Limb is threatened, < 6 hours Urgent Procedure : One in which Life or a Limb is threatened, typically between 6 and 24 hours Time sensitive procedure : 1 6 weeks (Oncologic procedures) Elective procedure : The procedure could be delayed up to 1 year
Low Risk procedure : Combined surgical and patient characteristics predict a MACE or MI of less than 1% (Plastic Surgery, Cataract Surgery) Elevated Risk procedure : Risk of MACE of greater than or equal to 1%
Functional Capacity METs : Metabolic Equivalents, where 1 MET is the resting or basal Oxygen consumption of a 40 year old, 70 kg man Classification: Excellent : > 10 METs Good : 7 10 METs Moderate : 4 6 METs Poor : < 4 METs (Slow Ballroom Dancing, Golfing & Walking at 2 3 mph)
Key Point Walking up a flight of Stairs Heavy house work Walking at 4 mph > 4 METs
Stepwise Approach Step 1 Determine the Urgency of Surgery - if EMERGENT; Determine the clinical risk factors that may influence perioperative management, and proceed to Surgery with appropriate monitoring and management strategies based on clinical assessment
Step 2 If Urgent or Elective; Determine if the patient has an ACS
STEMI UA/NSTEMI Decompensated Heart Failure (Peri partum Cardiomyopathy) Significant Arrhythmias Severe Valvular Heart Disease (2 D ECHO preoperatively in Moderate to severe Valvular Heart Disease if not performed in the last year, or if there is a change in clinical status)
When your back is against the wall Reasonable to proceed to Surgery if; a) Asymptomatic + Severe AS (Class II A) b) Asymptomatic + Severe MS (Class II B) c) Asymptomatic + Severe AI (Class II A) d) Asymptomatic + Severe MR (Class II A) (Swan - Ganz Catheter Placement, TEE)
Pulmonary Vascular Disease Increased perioperative risk; a) WHO Group 1 Pulmonary HTN b) Pulmonary Artery Systolic Pressures of > 70 mmhg c) Moderate (or greater) RV Dilatation/Dysfunction d) Pulmonar Vascular Resistance > 3 Wood Units e) NYHA Class III or IV Heart Failure (due to Pulmonary HTN) (Pulmonary HTN Specialist, Right Heart Catheterization)
Step 3 Estimate the Risk; NSQIP Risk Calculator RCRI Score a) Low Risk for MACE (0 0r 1 risk factor) b) Elevated Risk for MACE (greater than or equal to 2 risk factors) 1) High Risk Type of Surgery (Vascular surgery, Intraperitoneal and Intrathoracic surgeries) 2) H/O Ischemic Heart Disease (H/O MI, Pathological Q Waves on EKG, + Stress Test, Nitrate Therapy or Angina) 3) History of Heart Failure 4) H/O Cerebrovascular Disease 5) Diabetes Mellitus requiring treatment with Insulin 6) Preoperative Serum Creatinine of > 2 mg/dl
Step 4 If the patient has Low Risk (o or 1 Risk factor) of MACE (< 1%), proceed with Surgery
Step 5 If the patient has elevated risk of MACE (greater than or equal to 1%), then determine the Functional Capacity. If greater than or equal to 4 METs, proceed with Surgery.
Step 6 If Functional Capacity is poor (< 4 METs), then consult with the patient to determine if further testing would impact patient decision making. If Yes, then perform a Pharmacological Cardiac Stress Test (especially if Functional Capacity cannot be determined) If normal, proceed to Surgery with GDMT If abnormal, consider Coronary Angiography & Revascularization based on the extent of the abnormal Stress Test
Step 7 If testing does not impact decision making or care, to proceed to Surgery with GDMT or explore non invasive therapies
Preoperative EKG Class IIA : Reasonable for H/O Heart Disease, PAD, CVA (LOE: B) Class III : Routine testing is not useful for asymptomatic patients undergoing Low Risk Surgery (LOE: B)
Preoperative ECHO Class II A : a) Dyspnea of unknown origin (LOE: C) b) Heart Failure patients with worsening Dyspnea or change in clinical status (LOE: C) Class III : Routine Echocardiography is not recommended
Preoperative Stress Testing DSE (Dobutamine Stress ECHO) or MPI (Myocardial Perfusion Imaging) a) Moderate to large areas of Myocardial Ischemia is associated with increased risk of perioperative MI and/or Death b) A normal study has a very high negative predictive value c) The presence of an old MI is of little predictive value for perioperative MI or cardiac death
Preoperative Coronary Revascularization Class I : Revascularization is recommended in circumstances in which it is indicated according to CPGs (LOE: C) a) If Evaluation recommends Surgical revascularization (CABG) Go for it! b) Percutaneous Revascularization should be considered for 1) Left Main Disease in poor surgical candidates 2) Unstable CAD 3) NSTEMI/STEMI consider POBA/BMS Class III : Routine Revascularization before non cardiac surgery is not recommended (LOE: B)
Timing of Elective Surgery (post PCI) Class I : a) POBA : 2 weeks (LOE: C) b) BMS : 4 weeks (LOE: B) c) DES : 1 year (LOE: B) Class IIB : Elective Surgery after DES may be considered after 180 days if the risk of further delay is greater than the expected risks of Ischemia and Stent Thrombosis (LOE: B)
Perioperative Beta Blocker (BB) Therapy Class I : BBs should be continued perioperatively for those who have been on it chronically (LOE: B) Class II B : BB can be initiated in the following settings; 1) Intermediate or High Risk Myocardial Ischemia prior to the procedure (LOE: C) 2) 3 or more RCRI risk factors (LOE: B)
Timing of Initiation: 2 7 days before the procedure Class III : BB therapy SHOULD NOT BE STARTED ON THE DAY OF SURGERY
Perioperative Statin Therapy Class I : Statins should be continued perioperatively for those who have been on it chronically (LOE: B) Class IIA : Statins can be considered in those undergoing Vascular Surgery (LOE: B)
Perioperative Aspirin (ASA) Therapy Class III : Initiation or continuation of ASA is not beneficial in patients undergoing non cardiac or non carotid surgery, who have not had previous stenting, unless the risk of Ischemic events outweigh the risks of surgical bleeding (LOE: C)
Sample Notes The patient is at Low perioperative risk for major adverse cardiac events (< 1% risk for Death and non fatal MI). No further cardiac testing is indicated at this time. To proceed to Surgery, continue BB and Statin therapy perioperatively. The patient is at Elevated perioperative risk for major adverse cardiac events (greater than or equal to 1% risk for Death and non fatal MI). However, further cardiac testing is unlikely to impact decision making or care, and is therefore not indicated at this time. To proceed to Surgery, continue BB and Statin therapy perioperatively. The patient is at Elevated perioperative risk for major adverse cardiac events (greater than or equal to 1% risk for Death and non fatal MI). To order a Cardiac Stress Test prior to the procedure for further risk stratification.
Question 1 81 Y/O AAM with a H/O CAD S/P CABG (1985), PAD S/P PTA to the Right SFA (2013), DM, HTN, Hyperlipidemia, CKD Stage 4 and CVA (2008) with no residual neurological deficits is about to undergo Cataract Surgery. His Ophthalmologist calls you for Preoperative Evaluation. Low Risk for MACE. Proceed with Surgery
Question 2 56 Y/O WM with a H/O CAD S/P PCI to the LAD (2014), DM, HTN and Hyperlipidemia is about to undergo Right Inguinal Herniorrhaphy. He however, gives a history of worsening chest pain (similar to the pain he experienced prior to his Stent Placement) over the last 2 weeks. Physical Exam reveals a Right Inguinal Hernia without signs of Incarceration. His Surgeon wants to know if he could proceed with the procedure. Unstable Angina the heart comes first!
Question 3 45 Y/O AAF with a H/O DM and HTN who was admitted for elective Hiatal Hernia repair. She develops chest pain soon after admission, and an EKG revealed Lateral ST depressions concerning for Ischemia. Cardiac Enzymes showed an elevated troponin of 2 ng/ml. She wants to go ahead with the planned procedure, and the surgeon seeks your help. NSTEMI Left heart catheterization and possible PCI!!!!
Question 4 65 Y/O WM with a H/O DM (on Metformin), HTN and Hyperlipidemia who was referred to the Cardiology Clinic for Preoperative Evaluation prior to Lumbar Laminectomy. Low Risk for MACE. Proceed with Surgery
Question 5 31 Y/O WM with no significant PMH comes to the ED with C/O intense RLQ Abdominal Pain. He was subsequently diagnosed with Acute Appendicitis. The first year surgical resident calls you for preoperative evaluation. Be Nice!!!!! Proceed to surgery.
Question 6 Dr Gill from the VA Medical Center calls you about a 65 Y/O AAM with a H/O CAD S/P PCI to the LAD (2010), Ischemic Cardiomyopathy (EF of 35% per 2 D ECHO), DM, CKD Stage 3 (Creatinine of 2.1 mg/dl), HTN and Hyperlipidemia who presented for an elective Right Carotid Endarterectomy, and was not cleared by Cardiology. He is asymptomatic from a cardiac standpoint, and can climb a flight of stairs without discomfort. He is currently on ASA, Metoprolol, Lisinopril, Simvastatin and Insulin. Proceed to surgery. Continue ASA, BB and Statin therapy
Question 7 Part 1 75 Y/O WM with a H/O CAD S/P PCI to the LAD (2009), CVA (2010) with residual left sided weakness, DM (requiring Insulin), HTN and Hyperlipidemia who is about to undergo a Left Great Toe Amputation for a chronic non healing ulcer. His functional capacity is extremely limited due to his Stroke. The vascular surgeon would like you to evaluate his cardiac risk prior to the procedure. Cardiac Stress Test
Part 2 The patient however refuses to undergo Bypass Surgery or PCI should the Cardiac Stress Test reveal abnormalities. He just wants this darn toe off. Proceed to Surgery with GDMT
Part 3 He speaks to his wife the next day, and suddenly has a change of heart. He is willing to undergo Coronary Angiography and further therapy for the same should it be indicated. The Cardiac Stress Test reveals a large reversible perfusion defect in the anterior wall and the apex. He subsequently undergoes Coronary Angiography, which reveals critical Left Main Disease. Consult Cardiothoracic Surgery!
Thank You!!!