Preoperative Evaluation
Primary Assessment on Three Categories
 Patient Specific Clinical Variables
o Major predictors – when present, require intensive management which may delay or
cancel surgery unless emergent
 Recent MI - < 6 weeks
 Unstable or Severe Angina
 Decomensated heart failure NYHA class 4 or worsening or new-onset CHF
 Arrhythmias
 High grade AV block
 Symptomatic ventricular arrhythmias
 SVT with vent rate >100 bmp at rest
 Symptomatic bradycardia
 Newly recognized ventricular tachycardia
 Heart Valve Disease
 Severe aortic stenosis
 Symptomatic mitral stenosis
o Other Clinical Predictors That Warrant Careful Assessment
 Hx ischemic heart disease

 Hx Stroke
 Hx of prior CHF
 Diabetes Mellitus
 Chronic Renal Insuffiency (CKD)
o Special Issues
 Recent PCI – risk of MI and death elevated in patients who stop anti-platelet
therapy for surgery
 Bare metal stent – wait at least 6 weeks to stop anti-platelet therapy
 Drug eluting stent – wait at least 6 months to stop anti-platelet therapy
 Exercise Capacity
o Usually expressed in METs (metabolic equivalent)
 1 MET = resting oxygen uptake in a sitting position
 Increased risk if MET capacity <= 4
 1 MET = take care of self, eat, dress, use toilet
 4 MET = walk up a flight of steps or a hill
 4-10 MET = heavy housework including scrubbing floors, lifting, or moving
heavy furniture
 >10 MET = strenuous sports such as swimming, tennis, football, basketball, and
skiing.
 Surgery-Specific Risk
o High Risk
 Aortic and other major vascular surgery
 Peripheral artery surgery
o Intermediate Risk
 Carotid Endarterectomy
 Head and Neck surgery
 Intraperitoneal and intrathoracic surgery
 Orthopedic surgery
 Prostate surgery
o Low Risk
 Ambulatory surgery
 Endoscopic procedures
 Superficial procedures
 Cataract surgery
 Breast surgery
Evaluation
 History
o Prior CAD
o Angina Symptoms
o Hx CHF
o Hx Aortic Stenosis
o Severe HTN
o Peripheral Artery Disease
 Physical Exam
o BP in both arms
o Carotid eval for bruit
o JVP for signs of overload
o Auscultation lungs
o Pulses and pit edema check in extremities
o Cardiac Auscultation
 Resting EKG
o Recommended for patients with at least one clinical risk factor
o Q waves
o ST depression or elevation (duh)
Revised Goldman cardiac risk index (RCRI)
 Six independent predictors of major cardiac complications
o High Risk Surgery
 any intraperitoneal, intrathoracic, or suprainguinal vascular procedure
o Hx ischemic heart disease
 Hx MI
 Positive stress text
 Use of nitrates
 Chest pain considered to be secondary to myocardial ischemia
 EKG with pathologic Q waves
 DO NOT count prior coronary revascularization unless one of above is present
o Hx of heart failure
o Hx of cerebrovascular disease
o Diabetes requiring treatment with insulin
o Preoperative serum creatinine >2.0 mg/dL
 Rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest according to # of predictors with
and without use of beta blockers
o No beta blockers
 0 : 0.4% - 1.0%
 1-2 : 2.2% – 6.6%
 3+ : >9%
o Beta blockers
 0 : <1%
 1-2 : 0.8% – 1.6%
 3+ : >3%
Figure: Auerbach and Goldman. Circulation 2006;113:136-1376.