Assessment of Peri-operative Risk (not pre-op clearance)
Quick non-cardiac eval:
Long-standing rheumatoid arthritis – assess C-spine stability with flexion/extension films
Gathering Background Information
History
Past cardiac history
Recent changes in cardiac symptoms
Pacer/AICD
Current medications
Risk factors (HTN, HLD, DM, PVD, tobacco, illicit drug use)
Estimate of functional capacity
Physical Exam
Vitals
JVP
Cardiac/Chest exam
Bruits (carotid, abdominal, femoral)
Labs
HCT (hct <28% is associated with increased incidence of perioperative ischemia and
postoperative complications in patients undergoing vascular and prostate surgery)
Risk stratifying the patient – Revised Cardiac Risk Index
Each risk factor is assigned one point.
1. High-risk surgical procedures
 Intraperitoneal
 Intrathoracic
 Suprainguinal vascular
2. History of ischemic heart disease
 History of myocardial infarction
 History of positive exercise test
 Current complain of chest pain considered secondary to myocardial ischemia
 Use of nitrate therapy
 ECG with pathological Q waves
3. History of congestive heart failure
 History of congestive heart failure
 Pulmonary edema
 Paroxysmal nocturnal dyspnea
 Bilateral rales or S3 gallop
 Chest radiograph showing pulmonary vascular redistribution
4. History of cerebrovascular disease
 History of transient ischemic attack or stroke
5. Preoperative treatment with insulin
6. Preoperative serum creatinine > 2.0 mg/dL
Risk of Major Cardiac Event
Points Class/Risk
0
Class I – 0.4%
1
Class II – 0.9%
2
Class III – 6.6%
3+
Class IV – 11%
"Major cardiac event" includes myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest,
and complete heart block
Risk Stratify the Surgery
Evaluation of Specific Testing and Interventions
ECHO Indications
Dyspnea of unknown origin
Known HF with worsening dyspnea or other change in clinical status
ECG Indications
Vascular Surgery
Indicated if at least one clinical risk factor and undergoing vascular surgery
Reasonable for any vascular surgery
Intermediate Risk Surgery
Indicated for known CAD, PAD, CVD
Reasonable if one risk factor
Low-risk Surgery – Not indicated
Noninvasive Stress Testing
Treat per ACC guidelines if active cardiac condition and noncardiac surgery
3+ risk factors & poor functional capacity who require vascular surgery may be
evaluated if it will change management
1-2 risk factors & poor functional capacity & intermediate-risk noncardiac surgery
1-2 risk factors and good functional capacity who are undergoing vascular surgery
Not useful for low-risk noncardiac surgery
Not useful for intermediate-risk surgery in patients with no risk factors
CABG/PCI
Useful in patients with stable angina and significant left main stenosis
Useful in stable angina and 3VD
Useful in stable angina & 2VD with stenosis of proximal LAD and EF < 50%, or
demonstable ischemia on noninvasive testing
Recommended for unstable angina or NSTEMI
Recommended for STEMI
Beta-blocker therapy
Continue in all patients who were receiving them prior to surgery
Give to patients undergoing vascular surgery or who are at high cardiac risk
Probably recommended in patients with 1+ risk factor or CAD found in perioperative
assessment who are undergoing vascular surgery
Uncertain for single risk factor and intermediate or vascular surgery
Uncertain in patients with no clinical risk factors who are not currently using them
Should not be given to those with contraindications
Care should be taken applying these recommendations to patients with decompensated
heart failure, NICM, or severe valvular disease
Statin Therapy
Continue statins for those taking them
Reasonable for those undergoing vascular surgery
Consider for those with 1+ risk factor who are undergoing intermediate risk
procedures
Alpha-2 Agonist
May be considered for perioperative control of hypertension in patients with CAD or
1+ risk factor
Should not be given if there is a contraindication to this medication