PreOp Cardiac Evaluation

1
Pre-Op Cardiac Evaluation

• Renee Quillin
• Peter Law
• Sept 20, 2005

2
Introduction

• The ACC and AHA Task Force have provided a
  framework to assess cardiac risk for noncardiac
  surgery
• These guidelines were established to optimize
  treatment strategies and preoperative testing for
  the benefit of the cardiac patient

• Eagle KA, et al. Circulation. 20021051257-1267

3
Pre-Operative Clinical Evaluation

• History and Physical
• Electrocardiogram (EKG)
• Type of surgery (high/intermediate/low risk)
• Algorithm for every patient
• Cardiac Risk Index
• Functional Capacity (metabolic equivalents)

4
Cardiac Algorithm
5
Cardiac Algorithm
6
Cardiac Algorithm
7
Risk Indices

• Determine which patients are more likely to
  benefit from further cardiac evaluation
• Place patient into different algorithmic step
• Categories
• 1) Major
• 2) Intermediate
• 3) Minor

8
Functional Capacity

• Subjective method to assess a patients function
  at various levels of activity
• Expressed in metabolic equivalents (METs)
• Perioperative cardiac and long-term risks are
  increased in patients unable to meet a 4-MET
  demand
• 1 MET Eat, dress, or use the toilet?
• 4 METs Dusting, bowling, climb a flight of
  stairs?
• gt10 METs Strenuous sports (ie, football,
  swimming)?

9
Supplemental Pre-Op Evaluation

• Shortcut to the Decision to Test
• Any 2 factors present ? non-invasive testing
• Intermediate clinical predictors are present
  (Canadian Class I or II angina, prior MI, HF, DM)
• Poor functional capacity (lt4 METs)
• High surgical risk procedure

10
(No Transcript)
11
Types of Testing

• Resting Left Ventricular Function
• Exercise Stress Test
• Non-exercise Stress Test
• Myocardial Perfusion Imaging
• Dobutamine Stress Echocardiography
• Stress Testing in the Presence of Left
  Bundle-branch Block
• Ambulatory EKG monitoring

12
Cardiac Risk Complication Rate

• One point assigned per risk factor
• 1) Ischemic heart disease
• 2) Congestive heart failure
• 3) Cerebral vascular disease
• 4) High-risk surgery
• 5) Diabetic requiring insulin
• 6) Pre-op creatinine gt2.0 mg/dl

• Risk Class determines cardiac complication rate
• Class I zero 0.4
• Class II one 0.9
• Class III two 6.6
• Class IV three 11.0

Lee TH, et al. Circulation. 19991001043-49