Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

1
Guidelines for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery

• ACC/AHA Task Force
• JACC 1996 27910-945
• Circulation 1996 931278-1317

2
Objectives

• 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

3
Cardiac 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
4
Clinical 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
5
Clinical 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
6
Grading 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
7
Estimated 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?

8
Stepwise 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
9
Stepwise 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
10
Stepwise 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
11
Stepwise 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
12
Stepwise 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
13
Indications 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