perioperative cardiovascular evaluation for noncardiac surgery
DESCRIPTION
Perioperative Cardiovascular Evaluation for Noncardiac Surgery. By :Mahmoud M Othman MD, Prof of Anesthesia & SICU, Mansoura faculty of Medicine. General Approach. Team Work Patient Primary care physician Anesthesiologist Surgeon Medical consultant. Preoperative Clinical Evaluation. - PowerPoint PPT PresentationTRANSCRIPT
Perioperative Cardiovascular Evaluation for Noncardiac Surgery
By :Mahmoud M Othman MD,
Prof of Anesthesia & SICU,
Mansoura faculty of Medicine.
General Approach
Team Work– Patient – Primary care physician– Anesthesiologist– Surgeon– Medical consultant
Preoperative Clinical Evaluation Identification of serious cardiac disorder
– CAD, CHF, Arrhythmias(Initial history, Physical examination, ECG)
Define disease severity, stability, and prior treatment Functional capacity Age Comorbid conditions
(DM, peripheral vascular disease, renal dysfunction, chronic pulmonary disease)
Type of surgery– Consider higher risk
• vascular procedures• prolonged complicated thoracic, abdominal and head an
d neck procedures
Further Preoperative Testing to Assess Coronary Risk
CAD is the most frequent cause of perioperative cardiac mortality and morbidity after noncardiac surgery
Step-wise Bayesian strategyclinical markers
prior coronary evaluation and treatment
functional capacity
surgery-specific risk
Need for noncardiac surgery
O.R.emergencyPostoperative risk stratification and risk factor management
Urgent or elective
Coronary revascularization within 5 yrs
Recurrent symptoms or signs
Recent coronary evaluation
Recent coronary angiogram or stress test?
Intermediate
Clinical predictors
Major Minor or No
O.R.
yes
Unfavorable result and change in symptoms
favorable result and no change in symptoms
Stepwise Approach to Preoperative Cardiac Assessment
no
no
yes
yes
no
Major clinical predictors•Unstable coronary syndromes•Decompensated CHF•Significant arrhythmias•Severe valvular disease
Major clinical predictors
delay or cancel noncardiac surgery
Medical managementand risk factor modification
Coronaryangiography
Subsequent care dictated by findingsand treatment results
Stepwise Approach to Preoperative Cardiac Assessment
Intermediate clinical predictors•Mild angina pectoris•Prior MI•Compensated or prior CHF•DM
Intermediate clinical predictors
Poor(<4METs)
Moderate or excellent(>4METs)
High surgicalrisk precedure
Intermediate or lowsurgical precedure
Low surgicalrisk procedure
Noninvasivetesting
O.R. Postoperative risk stratificationand risk factor reduction
Consider coronaryangiography
Subsequent care dictated by findingsand treatment results
Low risk
High risk
Stepwise Approach to Preoperative Cardiac Assessment
Minor or no clinical predictors
Poor(<4METs) Moderate or excellent(>4METs)
High surgicalrisk procedure
Intermediatesurgical riskprocedure
Noninvasive testing O.R. Postoperative management
Subsequent care by findings and treatment results
Consider coronary angiographyMinor clinical predictors•Advanced age•Abnormal ECG•Rhythm other than sinus•Low functional capacity•History of stroke•Uncontrolled systemic hypertension
High risk
low risk
Stepwise Approach to Preoperative Cardiac Assessment
Clinical Predictors of Increased Perioperative Cardiovascular Risk(Myocardial Infarction, Congestive Heart Failure, Death)
MajorUnstable coronary syndromes– Recent myocardial infarction with evidence of important ischemic
risk by clinical symptoms or noninvasive study– Unstable or severe angina(Canadian Cardiovascular Society Class
III or IV)Decompensated CHFSignificant arrhythmias– High grade atrioventricular block– Symptomatic ventricular arrhythmias in the presence of underlying
heart disease– Supraventricular arrhythmias with uncontrolled ventricular rateSevere valvular disease
Clinical Predictors of Increased Perioperative Cardiovascular Risk(Myocardial Infarction, Congestive Heart Failure, Death)
IntermediateMild angina pectoris(Canadian Cardiovascular Society Class I or II)Prior myocardial infarction by history or pathological wavesCompensated or prior CHFDM
MinorAdvanced ageAbnormal EKG(LVH, LBBB, ST-T abnormalities)Rhythm other than sinus(eg, atrial fibrillation)Low functional capacity(eg, unstable to climb one flight or stairs with a bag of
groceries)History of strokeUncontrolled systemic hypertension
Estimated Energy Requirements for Various Activities
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 mphor 3.2-4.8 km/hrDo light work around the house dusting or washing dishes?
Climb a flight of stairs or walk up a hillWalk 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 moving heavy furniture?Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?Participate in strenuous sports like swimming, singles tennis, football, basket ball, or skiing
1 MET
4 METs
4 METs
>10 METs
Cardiac Event Risk† Stratification for Noncardiac Surgical Procedures
High(reported cardiac risk often >5%)
•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(Reported cardiac risk generally <5%)•Carotid endarterectomy•Head and neck•Intraperitoneal and intrathoracic•Orthopedic•Prostatic
Low‡
(reported cardiac risk generally <1%)•Endoscopic procedures•Superficial procedures•Cataract•Breast
† Combind incidence of cardiac death and nonfatal myocardial infarction
‡ Further preoperative cardiac testing is not generally required.
Method of Assessing Cardiac Risk
Resting Left Ventricular Function
Exercise Stress Testing
Pharmacological Stress Testing
Ambulatory ECG monitoring
Coronary Angiography
Method of Assessing Cardiac Risk
Resting Left Ventricular Function– Increased risk:
• Ejection fraction < 35%• severe diastolic dysfunction
– CHF– prior CHF or dyspnea of unknown etiology
Method of Assessing Cardiac Risk
Exercise Stress Testing – treadmill or bicycle stress and ECG analysis,
echocardiography– degree of functional incapacity, symptoms of
ischemia, severity of ischemia(depth, time of onset, duration of ST depression), evidence of hemodynamic or electrical instability correlated with increasing ischemic risk
Method of Assessing Cardiac Risk
Pharmacological Stress Testing– for patients who are unable to exercise– Dipyridamole or adenosine with thallium
myocardial perfusion imaging– Dobutamine echocardiography
Ambulatory ECG Monitoring Coronary Angiography
Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery
Class I:Patients with suspected or proven CAD
–High-risk results during noninvasive testing
–Angina pectoris unresponsive to adequate medical therapy
–Most patient with unstable angina pectoris
–Nondiagnostic or equivocal noninvasive test in a high-risk noncardiac surgical procedure
Class I: conditions for which there is evidence for and/or general agreement that a procedure or a treatment is of benefit
Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery
Class II:
– Intermediate-risk results during noninvasive testing
–Nondiagnostic or equivocal noninvasive test in a lower-risk patients undergoing a high-risk noncardiac surgical procedure
–Urgent noncardiac surgery in a patient convalescing from acute MI
–Perioperative MIClass II: conditions for which there is a divergence of evidence and/or opinion about the treatment
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 noninvasive testing– Screening for CAD without appropriate noninvasive testing– Asymptomatic after coronary revascularization, with excellent
exercise capacity(>7METs)– Mild stable angina in patients with good LV function, low-risk
noninvasive test results– Patient is not a candidate for coronary revascularization because
of concomitant medical illness– Prior technically adequate normal coronary angiogram within
previous 5years– Severe LV dysfunction(e.g., EF<20%) and patient not considered
candidate for revascularization procedure– Patient unwilling to consider coronary revascularization
procedure
Class III: conditions for which there is evidence and/or general agreement that the procedure is not necessary
Management of Preoperative Cardiovascular Conditions
Hypertension Valvular Heart Disease Myocardial Heart Disease Arrhythmias and Conduction Abnormalities
Management of Preoperative Cardiovascular Conditions
Hypertension– Severe HBP(DBP >110) should be controlled
before surgery when possible– Continuation of preoperative antihypertensive
treatment is critical to avoid severe postoperative hypertension.
– Consider the urgency of surgery and the potential benefit of more intensive medical therapy.
Management of Preoperative Cardiovascular Conditions
Valvular Heart Disease– Symptomatic stenotic lesions(MS or AS):
associated with risk of perioperative severe CHF or shock and often require percutaneous valvotomy or replacement to lower cardiac risk.
– Symptomatic regurgitant lesions(AR or MR): usually better tolerated perioperatively and may be stabilized before surgery with intensive medical therapy and monitoring
Management of Preoperative Cardiovascular Conditions
Myocardial Heart Disease– Dilated and hypertrophic cardiomyopathy are
associated with an increased incidence of perioperative CHF.
– Maximizing preoperative hemodynamic status and providing intensive postoperative medical therapy and surveillance.
Management of Preoperative Cardiovascular Conditions Arrhythmias and Conduction Abnormalities
– careful evaluation for underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality.
– Therapy: reverse any underlying cause and treat the arrhythmia
Preoperative Coronary Revascularization
Coronary Artery Bypass Graft Surgery Coronary Angioplasty
Medical Therapy for Coronary Artery Disease
If patients require beta-blockers, calcium channel blockers, or nitrates before surgery, continue them into the operative and post-op period.
The same is true for therapies used to control CHF
Beta-blockers reduce postoperative ischemia,– Protection against ischemia may also reduce risk of MI
Anesthetic Considerations
Anesthetic agent– No one best myocardial protective anesthetic techniq
ue.– Opioid:cardiovascular stability, but need postoperativ
e ventilation– Inhalational agent: myocardial depression– Neuraxial block: sympathetic blockade
low level:minimal hemodynamic change
abdominal operation: profound effects(hypotension, reflex tachycardia)
Anesthetic Considerations
Perioperative pain management– PCA(iv or epidural) leads to a reduction in post
operative catecholamine surges and hypercoagulability, both of which can theoretically impact myocardial ischemia.
Anesthetic Considerations
Intraoperative nitroglycerine– Helpful or harmful
vasodilating properties of NTG with anesthetics can cause significant hypotension and even myocardial ischemia.
Transesophageal echocardiography– Guidelines for the use of TEE to diagnosis or
guide therapy are being developed by ASA
Perioperative Surveillance
Pulmonary artery catheters– recent MI complicated by CHF
– significant CAD with procedures assoc. with significant hemodynamic stress.
– Systolic or diastolic LV dysfunction
– cardiomyopathy
– valvular disease with high risk operation
Perioperative Surveillance
Intraoperative and postoperative ST monitoring– Intraoperative and postoperative ST changes ar
e strong predictors of perioperative MI in patients at high risk who undergo noncardiac surgery
– proper use of computerized ST-segment analysis may improve sensitivity for detection of myocardial ischemia
Perioperative Surveillance
Surveillance for perioperative MI– Clinical symptoms– Postoperative ECG changes– CK-MB, troponin-I, troponin-T, CK-MB isoforms– In patients with known or suspected CAD undergoing high
risk procedures, obtaining ECG at baseline, immediately after the procedure, and for the first 2 postoperative days appears to be cost effective
– Use of cardiac enzymes is best reserved for patients with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction.
Postoperative Therapy and Long-Term Management
Postoperative management should include assessment and management of modifiable risk factors for CAD, heart failure, HBP, stroke, and other cardiovascular diseases.
Assessment for hypercholesterolemia, smoking, hypertension, DM, physical inactivity, peripheral vascular disease, cardiac murmur(s), arrhythmias, perioperativeischemia, and MI may lead to evaluation and treatments that reduce future cardiovascular risk