Preoperative Cardiac Exam

Edward Marcus Surgery Team IV 7/22/08

Outline

Definitions Perioperative Cardiac Events Risks of Anesthesia Risks of Surgery Classifying heart disease and surgery Organizing into risk categories

Definitions
Perioperative
Ischemic

Cardiac Outcomes

Events Congestive Heart Failure Ventricular Tachycardia

Mangano, DT. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med. 1990 Dec 27;323(26):1781-8.

Ischemic Events

Cardiac Death Non-Fatal MI Unstable Angina

Chest pain > 30 mins unresponsive to standard interventions Transient ST+T wave changes w/o Q waves No enzyme elevations Greater than or equal to 0.1mV ST depression during exercise

Mangano et al. 1990

Congestive Heart Failure

Left or Right ventricular faliure Cardiomegaly Jugular venous distension Peripheral edema S3

Mangano et al. 1990

Ventricular Tachycardia
5

or more consecutive beats of ventricular origin at 100 or more beats per minute

Mangano et al. 1990

Events observed

15/474 (3.2%) had ischemic events 30/474 (6.4%) had congestive heart failure 38/474 (8%) had ventricular tachycardia
Events occurring after the 3rd postoperative day

half of all ischemic events half of congestive heart failure 30% of ventricular tachycardia
Mangano et al. 1990

Unheralded MI

50-70% of MIs perioperatively are painless Compare with only 20-40% in non-surgical patients

Mangano et al. 1990

Why is there perioperative risk?

Major hemodynamic stress Changes in cholinergic activity Changes in catecholamine activity Body temperature fluctuations Pulmonary function Fluid shifts Pain
Mangano et al. 1990

Risks of anesthesia

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 agents such as nitric oxide lower cardiac output by 15%.

Jassal, D. Perioperative Cardiac Management. eMedicine. January, 2008.

Surgical Risk

Related to hemodynamic stress of the procedure High Risk

>5% risk of perioperative death or MI emergent major surgery, peripheral vascular or aortic surgery, prolonged surgery involving excessive blood loss

Fleisher, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. Circulation. 2007;116:1971-1996.

Moderate Risk

Moderate Risk

1-5% risk of perioperative death or MI Carotid endarectomy and urologic, orthopedic, uncomplicated abdominal, head, neck, and thoracic operations

Low Risk

Low Risk

<1% risk Cataract removal, endoscopy, superficial procedure, cosmetic procedures, and breast surgery

Stratifying Patient Risk

Clinical markers

Major clinical predictors - Unstable coronary syndrome, decompensated CHF, significant arrhythmia, and severe valvular disease Intermediate clinical predictors - Mild angina, prior MI, compensated or prior CHF, diabetes mellitus, and renal insufficiency Minor clinical predictors - Advanced age, abnormal findings on echocardiography, rhythm other than sinus, history of stroke, low functional capacity, and uncontrolled hypertension Poor functional class (<4 METS) - Energy expended during activities, including dressing, eating, and walking around the house Adequate functional class (>4 METS) - Energy expended during activities, including walking up a flight of stairs, scrubbing floors, and swimming For reference, sleeping = 1 MET Smoking, Alcohol abuse
Fleisher, et al. 2007.

Functional capacity

Other risk factors

METs

Metabolic Equivalent 3.5 mL O2/kg/min, or sitting and reading

Mangano et al. 1990

Algorithm

If surgery is an emergency then proceed to the OR. If not, then If the patient has undergone coronary revascularization in the past 5 years without recurrent ischemic symptoms, then proceed to the OR. If not, then If the patient has undergone coronary revascularization in the past 2 years, and no change in symptoms then proceed to the OR. If not, then

Major Clinical Predictors

If the patient has any of the major clinical predictors then the problem has to be addressed before surgery
Unstable coronary syndrome decompensated CHF significant arrhythmia and severe valvular disease (aortic stenosis!)

Intermediate Predictors

Intermediate clinical predictors - Mild angina, prior MI, compensated or prior CHF, diabetes mellitus, and renal insufficiency Assess functional status. If < 4 METs, consider non-invasive testing. If > 4 METs and intermediate or low risk surgery, proceed to the OR

Minor Predictors

Advanced age, abnormal findings on echocardiography, rhythm other than sinus, history of stroke, low functional capacity, and uncontrolled hypertension
<4 METs and high-risk surgery, consider noninvasive testing If < 4 METs and intermediate or low-risk surgery proceed to OR If > 4 METs proceed to the OR

Interventions

Pharmacological vs. coronary revascularization Recently, the Coronary Artery Revascularization Prophylaxis trial demonstrated that in the short term, there is no reduction in the number of postoperative myocardial infarctions, deaths, or duration of stay in the hospital, or in long-term outcomes in patients who underwent preoperative coronary revascularization compared with patients who received optimized medical therapy.
McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG: Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004; 351:2795804

Preoperative Stress Testing

Are the guidelines used?

Poor adherence, especially when testing is indicated

Hoeks SE. Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands. Anesthesiology. 2007;107(4):537-44.

Is it harming patients?

Legner VJ. Clinician agreement with perioperative cardiovascular evaluation guidelines and clinical outcomes. Am J Cardiol. 2006;97(1):118-22.

864 Patients, prospective study Found that clinicians ordered testing half of the times it was recommended, lower rate of complications when ACC/AHA guidelines were not followed Frequency of complications not higher when guidelines not followed in general

References

Fleisher, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. Circulation. 2007;116:1971-1996 Hoeks SE. Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands. Anesthesiology. 2007;107(4):537-44. Jassal, D. Perioperative Cardiac Management. eMedicine. 1/16/2008 Legner VJ. Clinician agreement with perioperative cardiovascular evaluation guidelines and clinical outcomes. Am J Cardiol. 2006;97(1):118-22. Mangano, DT. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med. 1990 Dec 27;323(26):1781-8.

Thank You