STRATEGIES TO REDUCE
CARDIAC RISK IN A NON-Cardiac
Surgery
Professor Anil Ohri
DEPARTMENT OF ANAESTHESIA
IGMC ,SHIMAL
INDIRA GANDHI MEDICAL COLLEGE
SHIMLA
PREOPERATIVE CARDIAC ISSUES
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How healthy is the patient?
How active is the patient?
How risky in the planned surgery?
Is preoperative cardiac testing necessary?
What preventive measures can be taken to
reduce cardiac risk?
The past several years has seen a dramatic increase in the number and quality of randomized and prospective studies to define the optimal and most cost-effective
approach to preoperative cardiovascular evaluation and management for noncardiac surgery,
Strategies to Reduce Cardiac Risk of Noncardiac Surgery: What is the Evidence?
Lee A. Fleisher
RISK INVOLVED & MAGNITUDE OF
PROBLEM
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Low risk: heart disease-No evidence- low risk of MI (0.15%)
High risk: Past MI---Perioperative MI Motality- 40-70%
Cardiac Surgery-Evidence (In US)-25 million patients
Evidence Or Multiple Risk Factors –CAD-3 Million(Patients)
Patients Age>65 yrs -4 million
Surgical Patients At Risk(CVCOMPLICATIONS)-Nearly 1/3 of
surgical patients
• Common Cause For Peri-Operative Mortality&Morbidity Coronary heart disease -After Non-Cardiac Surgery
CARDIOVASCULAR morbidity and mortality after noncardiac surgery continues to be an area of active
investigative interest because of its clinical and economic impact.
Fleisher LA, Eagle KA: Clinical practice: Lowering cardiac risk in noncardiac surgery. N Engl J Med 2001; 345:1677–82
CAUSES OF INCREASED CARDIAC RISK
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Age
Functional capacity
Type of Surgery
Comorbid conditions: DM, Renal dysfn, CVA
Disease condition(severity and stability)-CAD,
CHF, Arrhythmias, Valvular diseases, Pulm
vascular disease
GOALS OF REDUCING RISK
1) To identify patients at risk through history,
physical examination & ECG.
2) To evaluate the severity of underlying
cardiac disease through cardiac tests.
3) Stratify the extent of risk
4) Determine the need for preoperative
interventions to minimize risk of peri
operative complications
Evaluation of cardiac risk
. Pillars of Preoperative Evaluation Includes :-
- Review Of History ,
- Physical Examination,
- Diagnostic Tests,
- Knowledge of Planned Surgical Procedure.
Developments in anaesthetic and surgical techniques—that is, loco‐regional anaesthesia and minimally invasive
surgery—have improved postoperative cardiac outcome considerably in recent years
Assessment of cardiac risk before non‐cardiac general surgery
Olaf Schouten, Jeroen J Bax, and Don Poldermans
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O Schouten, Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the
Netherlands
FOCUSING ON INITIAL ASSESSMENT
• Preoperative risk assessment(The initial history,
physical examination, and electrocardiogram
assessment should focus on identification of
potentially serious cardiac disorders.)
• In addition to identifying the presence of preexisting manifested heart disease, it is essential
to define disease severity, stability, and prior
treatment(Anticoagulation and antithrombotic
issues)
• Postoperative Management
• Endocarditis prophylaxis
PROBLEMS TO BE SORTED OUT
• Can these patient reasonably have noncardiac
surgery
• Is there a need for further testing
• Any drugs to be started
• Keep him in ICU before surgery
• How many ECGs in post op
• Role of intra-op NTG
• Would coronary revascularization improve the
long-term prognosis from a cardiac standpoint
and protect the patient from adverse events
during the necessary noncardiac surgery
PURPOSE OF EVALUATION
• Evaluate patient’s current medical status
• Provide clinical risk profile
• Decision on further testing
• Recommend management of cardiac risk over entire
perioperative period
• Treatment of modifiable risk factors
• NOT SIMPLY TO GIVE MEDICAL CLEARANCE
General Approach to the Patient
. History – angina, recent or past MI, CHF, symptomatic
arrhythmias, presence of pacemaker or ICD
. Physical Examination – general appearance, rales,
elevated JVP, carotid and other arterial pulses, S3 gallop,
murmurs
. Comorbid Diseases
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Pulmonary
Diabetes Mellitus
Renal Impairment
Hematologic Disorders
. Ancillary Studies - ECG, blood chemistries, chest Xray
IMPORTANCE OF ECG
 The ECG is frequently obtained as part of a
preoperative evaluation in all patients over a specific
age or undergoing a specific set of procedures.
 Metabolic & electrolyte disturbances, medications,
intracranial disease, pulmonary disease can alter ECG.
 Conduction disturbances (RBBB) or first-degree AV
block, may lead to concern but usually do not justify
further workup.
IMPOTANCE OF ECG
• Preoperative resting electrocardiogram is readily
available, inexpensive, easy to perform and able
to interpret and detect previous myocardial
infarction, acute ischemia, or arrhythmias.
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The presence of abnormalities such as Q
waves and non sinus rhythms has been shown
to correlate with adverse postoperative cardiac
events.
INDICATIONS FOR PREOPERATIVE
CARDIAC TESTING
1. Patients with intermediate clinical
predictors.
2. Prognostic assessment of patients undergoing
initial evaluation for suspected or proven CAD.
3. Evaluation of patients with change in clinical
status.
4. Evaluation of adequacy of medical treatment
5. Prognostic assessment after an acute
coronary syndrome.
NONINVASIVE TESTS
 Resting tests – Resting ECHO.
 Exercise tests and pharmacologic tests .
1. Exercise stress test.
2. DSE.
3. DTS.
4. Adenosine stress test.
 Ambulatory ECG monitoring
 Further Investigate If Really Required and
Affect Management.
PREOPERATIVE CORONARY
ANGIOGRAM/CORONARY INTERVENTION
CLASS I:1. patients with stable angina who have significant LMCA
stenosis.
2.patients with stable angina who have 3-vessel disease.
(Survival benefit is greater when LVEF is less than 0.50.)
3. patients with stable angina who have 2-vessel disease with significant
proximal LAD stenosis and either EF less than 0.50 or demonstrable
ischemia on noninvasive testing.
4. for patients with high-risk unstable angina or non– ST segment
elevation MI.
5. Coronary revascularization before noncardiac surgery is recommended
in patients with acute ST-elevation MI.
( All have level of evidence A).
There is increasing evidence that coronary revascularization before noncardiac surgery does not reduce the incidence of perioperative
cardiac morbidity. Strategies to Reduce Cardiac Risk of Noncardiac Surgery: What is the Evidence?
Lee A. Fleisher
Cardiac risk stratification for noncardiac surgery:2007 Guide lines of American College of Cardiology
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Lee A. Fleisher
Table 3: Laboratory Tests to Risk-Stratify
(BNP-b-type Natriuretic Peptide,N-Terminal,Hb A1c,IGT(Glucose
Intolerance) Patients UndergoingNon Cardiac Surgery
Noncardiac Surgery(BNP-b-type Natriuretic Peptide,N-Terminal,Hb
A1c,IGT(Glucose Intolerance)
• Dernellis et al BNP≥189 pg/mL
• Feringa et al NT proBNP≥270 ng/L
• Feringa et al HbA1c≥7%
• Feringa et al GT5.6-7.0 mmol/L
• Feringa et al DM≥7 mmol/L HR
• *Odds ratio for each 1 ng/L rise in the natural logarithm of baseline
NT proBNP. †Hazard ratio for all-cause mortality ‡Hazard ratio
for major adverse cardiac events.
§Fasting glucose values.
• Glucose and Hemoglobin A1c Measurement
Cardiac Risk Stratification for Noncardiac Surgery
Adam W. GrassoWael A. Jaber
Figure 1. Suggested initial clinical assessment of patients undergoing
noncardiac surgery
Auerbach A , and Goldman L Circulation. 2006;113:1361-1376
ROLE OF CARDIOLOGIST SURGEON
AND ANAESTHESIOLOGIST
• Cardiologist:
• Review available patient data, history and physical
examination
• Determine if further testing is needed to define
cardiovascular status
• Recommend treatment to improve medical condition
• Participate in postoperative medical management
• Anaesthesiologist:
• Surgeon:
PRE-OPERATIVE CLINICAL INDEX
Functional capacity
Expressed in metabolic equivalent (MET)levels
Oxygen consumption (VO2) of 70Kg, 40-yr-old man in
resting state is
3.5 ml/kg/mt or 1 MET
>10 METS - Excellent
4-7
- Moderate
7-10 METS - Good
<4
- Poor
Patients with a low functional capacity (less than 4 Mets) have
a worse prognosis than patients with a good functional
capacity
FUNCTIONAL CAPACITY(ASSESSMENT)
Expressed in metabolic equivalent (MET)levels
• Can you take care
1 MET
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?
• Do light work around
4 MET
the house like dusting
or washing dishes?
FUNCTIONAl CAPACITY(ASSESSMENT)
Expressed in metabolic equivalent (MET)levels
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Climb a flight of stairs or walk
4 MET
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 furniture?
Participate in moderate
recreational activities like
golf, bowling, dancing, doubles
Tennis, or throwing a baseball
or football?
Participate in strenuous sports 10 MET
like swimming, singles tennis,
football, basketball, or skiing?
CLINICAL PREDICTORS FOR
INCREASED PERIOPERATIVE
CARDIOVASCULAR RISK
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Major(cardiac risk
> 5%)
– Unstable coronary syndromes
– Decompensated CHF
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Significant ArrhythmiasMinor (cardiac risk < 1%)
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Advanced Age.
Abnormal ECG.
Rhythm other than sinus.
Low functional capacity.
History of stroke.
Uncontrolled systemic
hypertension
Severe valvular disease
. Intermediate (cardiac risk< 5%)
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Mild angina pectoris
Prior MI
Compensated or prior HF
Diabetes Mellitus (particularly taking insulin)
Renal insufficiency
Surgical risk(HIGH & URGENCY)
. Urgency (cardiac compl 2 to 5 times more)
. 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.
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Assessing and Reducing the Cardiac Risk of Noncardiac Surgery. Circulation March 2006 vol. 113 no. 10
1361-1376
MAJOR CLINICAL PREDICTORS
• Acute (<7 days) or Recent MI (7 days-1 month)
- Unstable or severe angina
(Canadian class III or IV)
. Significant Arrythmias
- High grade atrioventricular block
- Symptomatic ventricular arrhythmias in the presence
of underlying heart disease
- Supraventricular arrhythmias with uncontrolled
ventricular rate
Sugical risk (INTERMEDIATE)
. Carotid endarterectomy
. Head and neck surgery
. Intraperitoneal and intrathoracic
. Orthopedic surgery
. Prostate surgery
Low surgical risk:
. Endoscopic procedures
. Superficial procedures
. Cataract surgery
. Breast surgery
Figure 2. Additional risk stratification and treatment before noncardiac
surgery.
Auerbach A , and Goldman L Circulation. 2006;113:1361-1376
VARIOUS CARDIAC RISK INDEX
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
ASA.
NYHA/CCS.
Goldman ( 1977).
Detsky (1997 ).
ACC / AHA ( Updated in 2007 ).
ACP.
Lee ( 1999 ).
Cooperman ( 1978 ).
Larsen( 1987 ).
Pedersen ( 1990 ).
Vanzetto ( 1996 ).
CARDIAC RISK INDEX AND THEIR
VALUE
• ASA – used for assessment of the patient’s
overall physical status and to predict morbidity &
mortality.
• NYHA/CCS - used for risk stratification of medical
patients with angina, but they have been adapted
for use in surgical patients.
• Cardiac Risk Index (CRI) by Goldman et al
identified 9 independent variables that correlated
with adverse perioperative events.
CARDIAC RISK INDEX AND THEIR
VALUE
 Modified Cardiac Risk Index ,is modified by
Detsky et al identified risk factors for cardiac
morbidity but were very cumbersome to apply.
Revised Cardiac Risk Index (RCRI) by Lee
identified 6 independent predictors of adverse cardiac
outcome in patients undergoing noncardiac surgery.
. Eagle’s Cardiac Risk Index-Q-wave,Thallium
Scan,Age
ACC/AHA guidelines :
The ACC/AHA guidelines
provide a framework for screening and identifying
patients who are at high risk for perioperative cardiac
ACCURACY OF RISK INDEX
• The accuracy of any of the above risk indices is controversial.
• A cardiac risk index to be useful, has to be applicable to all and be
consistently accurate.
• They couldn’t be applied to all surgeries.
• They were at times cumbersome to apply.
• Non prospective.
Cardiac risk stratification for noncardiac surgery:2007 Guide lines of American
College of Cardiology Lee A. Fleisher
• Cardiac Risk Stratification for Noncardiac SurgeryAdam W. Grasso
Wael A. Jaber(Laboratory Tesing,Obesity,AHA Classification)
PREOPERATIVE CARE IN SOME HIGH
RISK PATIENTS
. Recommendation:
- Based on scanty evidence, preoperative preparation
in intensive care unit may benefit certain high risk
patients, particularly those with decompensated HF
.Goal
- Optimize and augment oxygen delivery in
patients at high risk
.Hypothesis
- Indices derived from pulmonary artery catheter and invasive
blood pressure monitoring can be used to maximize oxygen
delivery, which leads to reduction in organ dysfunction
REASONS OF RISKS IN THESE
PATIENTS
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Major hemodynamic stress,
Changes in cholinergic activity,
Changes in catecholamine activity,
Body temperature fluctuations,
Pulmonary function is altered,
Fluid shifts,
Pain.
ANAESTHESIA--(RISK)
• Decreased systemic vascular resistance,
• Decreased stroke volume,
• Induction of general anesthesia lowers
systemic arterial pressures by 20-30%,
tracheal intubation increases the blood
pressure by 20-30 mm Hg, and many
anesthetic agents lower cardiac output by
15%.
ANAESTHESIA
• Any anesthetic technique that does not
effectively eliminate pain will be associated with
markedly increased cardiac demands
• Choice should be left to the discretion of the
anesthesia care team
• Opiod-based anesthetics popular because of
cardiovascular stability, but high doses result in
postoperative ventilation
• ROLE OF INTRAOPERATIVE
NITROGLYCERINE:High-risk patients previously
taking nitroglycerin who have active signs of
myocardial ischemia without hypotension
MONITORING IN PERIOPERATIVE
PERIOD
. Patients
without evidence of CAD:
– Monitoring restricted to those who develop perioperative signs of
cardiovascular dysfunction
. Patients with known or suspected CAD, and
high or intermediate risk procedure:
undergoing
– ECGs at baseline, immediately after procedure, and daily x 2 days
• Cardiac troponin measurements 24 hours postoperatively and on
day 4 or hospital discharge-<1.5ng/l (whichever comes first)
Strategies to Reduce Cardiac Risk in Noncardiac Surgery: Where Are We in 2005?
Fleisher, Lee A. M.D.-in Journal of Anaesthesiology-American
Risk reduction strategies
1. Perioperative management :a. Anesthetic techniques.
i. General versus regional anesthesia ,
ii. Temperature regulation ,
iii. Invasive monitoring – PAC, TEE.
b. Surgical approach
i. Laparoscopic, endovascular procedures. .
2.Management
a. Beta blockers.
b)alpha-2 agonists in the perioperative setting Clonidine- reduces incidence of perioperative ischemia and
mortality.(Only Vascular surgery)
b. Other anti-ischemic medications(NTG).
c. Statins.
3. Preoperative coronary revascularization /
valvuloplasty.(Rare And Extreme Cases)
Mangano DT, Layug EL, Wallace A, Tateo I: Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of
Perioperative Ischemia Research Group. N Engl J Med 1996; 335:1713–20
Despite several randomized trials suggesting that perioperative β-blockade significantly reduces PMI,
two recent investigations suggest that β-blocker therapy is not as effective as originally suggested.1
Strategies to Reduce Cardiac Risk in Noncardiac Surgery: Where Are
We in 2005?
Fleisher, Lee A. M.D.
• CARDIOVASCULAR morbidity and mortality after
noncardiac surgery continues to be an area of
active investigative interest because of its
clinical and economic impact. With the aging of
the population, increasing numbers of patients
present to surgery with complex comorbidities.
Preoperative cardiovascular evaluation has been
an area of intense interest and has led to the
development of several sets of guidelines.
(cardiac troponin I (cTnI) release after surgery)
Peri-Operative Cardiac Evaluation
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Perioperative Cardiac Evaluation: Assessment, Risk Reduction, and Complication
ManagementKaren F. Mauck, MD, MSc Efren C. Manjarrez, , Steven L. Cohn, MDEvidence based Risk
Reduction Should be thereGuideline ACC 2007
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Clinical Investigation and Reports Derivation
and Prospective Validation of
a Simple Index for Prediction of Cardiac Risk of Major Noncardiac
Surgery
Thomas H. Lee, ; Edward R. Marcantonio, Carol M. Mangione et al,2014
The purpose of this prospective cohort study was to develop and validate an index for risk of
cardiac complications.
RCRI Six independent -high-risk type of surgery, history of ischemic heart disease,
history of congestive heart failure, history of cerebrovascular disease, preoperative
treatment with insulin, and preoperative serum creatinine >2.0 mg/dL.
• This index identifies risk stratification with noninvasive technologies or
other management strategies, as well as low-risk patients in whom
additional evaluation is unlikely to be helpful.
MOST COMMON REQUEST FOR THE
ANAESTHETIST
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Cardiac Risk Stratification for Noncardiac SurgeryAdam W. GrassoWael A. Jaber
• Laboratory Tests to Risk-Stratify (BNP-b-type Natriuretic Peptide,NTerminal,Hb A1c,IGT(Glucose Intolerance) Patients UndergoingNon
Cardiac Surgery
One of the most common requests made to physicians is to assess the
perioperative cardiac risks of noncardiac surgery.
Moribund Obesity Since the 1980s, the prevalence of obesity in the United States and the rest of
the world has increased dramatically. In 2005, 31% of all Americans older than 20 years had a body mass index greater than
30. The use of bariatric surgery as a therapeutic option for weight reduction has increased 10 times from the 1990s to 2004
(140,000 bariatric surgeries done in 2004). Anticoagulants,
Perioperative Medical therapy Beta Blockers,A2- Agonists,Lipid lowering
agents
CONCLUSION :
.Thorough history,
• Detailed physical examination,
• Judicious use of tests.
• Categorize patients into low, intermediate &
high risk category .
• Combine pre-operative assessment with perioperative risk reduction strategies & optimize
medical treatment to improve outcome.