Professional Documents
Culture Documents
↑ Oxygen demand
1. ASA/Dripps
2. Goldman Multifactorial Index
Quantitative
3. Detsky Modified Index
4. Revised Risk Index
5. ACC/AHA Task Force Strategic
Recommendations
Dripps/ASA Classification
Class Systemic Disturbance Mortality*
1 Healthy patient with no disease outside of the surgical <0.03%
process
2 Mild-to-moderate systemic disease caused by the 0.2%
surgical condition or by other pathologic processes
No
No
No
No Manage based on
clinical risk factors
Active Cardiac Conditions
High Risk:
•Acute or recent MI (7-30 d)
•Unstable coronary syndrome
•Decompensated CHF
•Significant Arrhythmias
•Severe Valvular Disease
Surgery
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergency Yes Vigilant perioperative
noncardiac Operating room and postoperative
surgery management
No
No
No
No Manage based on
clinical risk factors
Low Risk Surgery Risk < 1%
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
Low Risk Situations
Low Risk:
1 MET Can you take care of yourself? 4 METs Climb a flight of stairs or walk up a
Eat, dress, or use the toilet? hill?
Walk indoors around the house? Walk on level ground at 4 mph or
6.4 km/h?
Walk a block or two on level
ground at 2-3 mph or 3.2-4.8 Run a short distance?
km/h? Do heavy work around the house
4 METs Do light work around the house like scrubbing floors or lifting or
like dusting or washing clothes? 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
MET = metabolic equivalent swimming, singles tennis, football,
baseball, or skiing?
No
No
No
No Manage based on
clinical risk factors
Clinical Risk Factors
Proceed Cautiously
Asymptomatic but
poor/unknown functional Manage based on
capacity clinical risk factors
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease
Intermediate Risk Surgery Risk < 5%
Carotid endarterectomy
Orthopedic
Prostate
High Risk Surgery Risk > 5%
Abnormal resting
Exercise
ECG (dig, LVH) echo or sestamibi
LBBB DSE
Unable to exercise Adenosine sestamibi
dipyridamole sestamibi
Preoperative Testing
Negative Predictive Value
Freedom from MI or Death
99.4
100 98.6
96.3
95
% 90
85
80
Stress ECG Dipyramadole Tl Dobutamine Echo
25
20
15
10
5
0
Preop Induction Incision Emerg. PostOp
Not low
< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days
25
21 Mortality • 200 pts undergoing
20 non-cardiac surgery
6 Months • Random assignment
15 14
1 Year to:
2 Years 10 – IV followed by oral
10 8 atenolol or
5 – Placebo
3
0
• Double-blind follow-
0 up over 2 years
Placebo Atenolol
25 •173 patients
Cardiac Death
undergoing vascular
20 Non-fatal MI
17 17 surgery with positive
15 DSE
%
10 •Randomized to BB
1 week pre-op or
5 3.4 placebo
0 0
Placebo Bisoprolol
•Followed for 30
days
Placebo n=53 Bisoprolol n=59
Poldermans et al. NEJM 1999;341:1789.
Perioperative Beta Blockers
AHA/ACC Recommendations: 2006 Update
•Beta blockers required in recent past to control symptoms of angina or
patients with symptomatic arrhythmias or hypertension
•Patients at high cardiac risk owing to the finding of ischemia on
preoperative testing who are undergoing vascular surgery
•Patients undergoing vascular surgery and with identified CAD
•Vascular surgery and multiple cardiac risk factors
•Moderate or high risk surgery and multiple cardiac risk factors
» Wallace et al (PDBT)
Perioperative Management
• Revascularization
• Beta blockers
• Statins
• Alpha-2 agonists
• Calcium channel blockers
Preoperative Hgb and Mortality
Study of Untreated Anemia
14
Relative Risk Mortality
12 No CAD
10 CAD
8
6
4
2
0
6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 >12
Preop Hemoglobin
7.9
8 • 300 pts undergoing
7 6.3 general surgery
Cardiac Morbidity
6
• Randomized,
(percent)
5
4 double blinded
3 2.4
assignment to
2 1.4 routine care or
1 supplemental
0 warming
Morbidity VT
↑ Oxygen demand