Title: Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery
1Guidelines for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery
- ACC/AHA Task Force
- JACC 1996 27910-945
- Circulation 1996 931278-1317
2Objectives
- Understand ACC/AHA guidelines
- Evaluate and accurately manage cardiac patients
undergoing noncardiac surgery - Identify preoperative techniques for assessing
cardiac risk in patients being considered for
noncardiac surgery
3Cardiac Risk Stratification (nonfatal MI and
Death) for Noncardiac Surgical Procedures
- High (Reported cardiac risk often gt5 )
- Emergent major operations, particularly in the
elderly - Aortic and other major vascular
- Peripheral vascular
- Anticipated prolonged surgical procedures
associated with large fluid shifts and / or blood
loss
- Intermediate (risk generally lt5 )
- Carotid endarterectomy
- Head and neck
- Intraperitoneal and intrathoracic
- Orthopedic
- Prostate
- Low (cardiac risk generally lt1 )
- Endoscopic procedures
- Superficial procedures
- Cataract
- Breast
Further preoperative cardiac testing is
generally unnecessary.
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
4Clinical Predictors of Increased Perioperative
Cardiovascular Risk (MI, CHF, Death)
- Major
- Unstable coronary syndromes
- Recent MI ( gt7 days but ?30 days) with evidence
of important ischemic risk by clinical symptoms
or noninvasive study - Unstable or severe angina (Canadian
Cardiovascular Society Class III or IV). May
include stable angina in patients who are
unusually sedentary. - Decompensated congestive heart failure
- Significant arrhythmia
- High-grade atrioventricular block
- Symptomatic ventricular arrhythmias in the
presence of underlying heart disease - Supraventricular arrhythmias with uncontrolled
ventricular rate - Severe valvular disease
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
5Clinical Predictors of Increased Perioperative
Cardiovascular Risk (MI, CHF, Death)
- Intermediate
- Mild angina pectoris (Canadian Cardiovascular
Society Class I or II) - Prior myocardial infarction by history or
pathological waves - Compensated or prior congestive heart failure
- Diabetes mellitus
- Minor
- Advanced age
- Abnormal electrocardiogram (LVH, LBBB, ST-T
abnormalities) - Rhythm other than sinus(eg. atrial fibrillation)
- Low functional capacity (eg. Unable to climb one
flight of stairs with a bag of groceries) - History of stroke
- Uncontrolled systemic hypertension
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
6Grading of Angina of Effortby the Canadian
Cardiovascular Society
- I. Ordinary physical activity does not cause
angina, such as walking and climbing stairs.
Angina with strenuous or rapid or prolonged
exertion at work or recreation. - II. Slight limitation of ordinary activity.
Walking or climbing stairs rapidly, walking
uphill, walking or stair climbing after meals, or
in cold, or in wind, or under emotional stress,
or only during the few hours after awakening.
Walking more than 2 blocks on the level and
climbing more than one flight of ordinary stairs
at a normal pace and in normal conditions. - III. Marked limitation of ordinary physical
activity. Walking one to two blocks on the
level and climbing one flight of stairs in normal
conditions and at normal pace. - IV. inability to carry on any physical activity
without discomfort -- anginal syndrome may be
present at rest.
Circulation 1976 54522-523
7Estimated Energy Requirements for Various
Activities
- 1 MET Can you take care of yourself?
- Eat, dress, or use the toilet?
- Walk indoors around the house?
- Walk a block or two on level ground at 2-3 mph
or 3.2-4.8 km/h? - 4 METs Do light work around the house like
dusting or washing clothes? - MET metabolic equivalent
- 4 METs Climb a flight of stairs or walk up a
hill? - Walk on level ground at 4 mph or 6.4 km/h?
- Run a short distance?
- Do heavy work around the house like scrubbing
floors or lifting or moving heavy objects? - Participate in moderate recreational activities
like golf, bowling, dancing, doubles tennis, or
throwing a baseball or football? - 10 METs Participate in strenuous sports like
swimming, singles tennis, football, baseball, or
skiing?
8Stepwise Approach to Preoperative Cardiac
Assessment
1. Need fornoncardiacsurgery
2. Coronaryrevascularizationwithin 5 years ?
3. Recentcoronaryevaluation
No
No
Urgent or Elective
Yes
4. Clinical predictors
Recurrentsymptomsor signs ?
Emergency
Yes
Yes
Recent coronaryangiogram or stress test ?
No
Operating Room
Unfavorable OR change in symptoms
Favorable AND no change in symptoms
Postoperative risk stratification and risk factor
management
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
9Stepwise Approach to Preoperative Cardiac
Assessment
4. Clinical predictors
6. Intermediate clinical predictor
7. Minor or no clinical predictor
5. Major clinical predictor
- Unstable coronary syndromes
- Decompensated congestive heart failure
- Significant arrhythmia
- Severe valvular disease
- Mild angina pectoris
- Prior myocardial infarction
- Compensated or prior CHF
- Diabetes mellitus
- Advanced age
- Abnormal ECG
- Rhythm other than sinus
- Low functional capacity
- History of stroke
- Uncontrolled systemic hypertension
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
10Stepwise Approach to Preoperative Cardiac
Assessment
5. Major clinical predictor
- Major Clinical Predictor
- Unstable coronary syndromes
- Decompensated congestive heart failure
- Significant arrhythmia
- Severe valvular disease
Consider delay or cancel noncardiac surgery
Consider coronary angiography
Medical management and risk factor modification
Subsequent care dictated by findings
and treatment results
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
11Stepwise Approach to Preoperative Cardiac
Assessment
Functionalcapacity
Surgicalrisk
Noninvasivetesting
Invasivetesting
Poor (lt4 METs)
8. Noninvasive testing
High risk
Low risk
6. Intermediate clinical predictor
Consider coronary angiography
High surgical risk procedure
Operating room
Moderate or excellent (gt4 METs)
Intermediate or low surgical risk procedure
Subsequent care dictated by findings
and treatment results
Postoperative risk stratification and risk
factor reduction
Low surgical risk procedure
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
12Stepwise Approach to Preoperative Cardiac
Assessment
Functionalcapacity
Surgicalrisk
Noninvasivetesting
Invasivetesting
Poor (lt4 METs)
High surgical risk procedure
8. Noninvasive testing
High risk
Low risk
7. Minor or no clinical predictor
Consider coronary angiography
Intermediate or low surgical risk procedure
Operating room
Moderate or excellent (gt4 METs)
Subsequent care dictated by findings
and treatment results
Postoperative risk stratification and risk
factor reduction
Low surgical risk procedure
ACC/AHA Task Force JACC 1996 27910-945
Circulation 1996 931278-1317
13Indications for Coronary Angiography in
Perioperative Evaluation Before (or After)
Noncardiac Surgery
- Class III
- Low-risk noncardiac surgery in a patient with
known CAD and low-risk results on invasive
testing - Screening for CAD without appropriate noninvasive
testing - Asymptomatic after coronary revascularization
with excellent exercise capacity (?7 METs) - Mild stable angina in patients with good LV
function, low-risk noninvasive test result - Patient is not a candidate for coronary
revascularization because of concomitant medical
illness - Prior technically adequate normal coronary
angiogram within previous 5 years - Severe LV dysfunction (EF lt20) and patient not
considered candidate for revasularization - Patient unwilling to consider coronary
revascularization procedure
- Class I (suspected or proven CAD)
- High-risk results during noninvasive testing
- Angina pectoris unresponsive to adequate medical
therapy - Most patients with unstable angina
- Nondiagnostic or equivocal noninvasive test in a
high-risk patient undergoing a high-risk
noncardiac surgical procedure - Class II
- Intermediate-risk results during noninvasive
testing - Nondiagnostic or equivocal noninvasive test in a
lower-risk patient undergoing a high-risk
noncardiac surgical procedure - Urgent noncardiac surgery in a patient
convlescing from acute MI - Perioperative MI
ACC/AHA Guidelines for Coronary Angiography JACC
1987 10935-950 Circ 1987 76963A-977A