preoperative cardiac exam final - emarcus

7/28/2019 Preoperative Cardiac Exam Final - EMarcus

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Preoperative CardiacExam

Edward Marcus

Surgery Team IV 7/22/08


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Outline

DefinitionsPerioperative Cardiac Events

Risks of AnesthesiaRisks of Surgery Classifying heart disease and surgery Organizing into risk categories


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Definitions

Perioperative Cardiac OutcomesIschemic 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 PerioperativeIschemia Research Group. N Engl J Med. 1990 Dec 27;323(26):1781-8.


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Ischemic Events

Cardiac DeathNon-Fatal MIUnstable Angina

Chest pain > 30 mins unresponsive to standardinterventions

Transient ST+T wave changes w/o Q waves

No enzyme elevationsGreater than or equal to 0.1mV ST depressionduring exercise

Mangano et al. 1990


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Congestive Heart Failure

Left or Right ventricular faliureCardiomegaly

Jugular venous distensionPeripheral edemaS3

Mangano et al. 1990


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Ventricular Tachycardia

5 or more consecutive beats of ventricular origin at 100 or more beats

per minute

Mangano et al. 1990


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Events observed

15/474 (3.2%) had ischemic events30/474 (6.4%) had congestive heart failure

38/474 (8%) had ventricular tachycardia

half of all ischemic eventshalf of congestive heart failure30% of ventricular tachycardia

Events occurring after the 3 rd postoperative day

Mangano et al. 1990


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Unheralded MI

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

Mangano et al. 1990


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Why is there perioperative risk?

Major hemodynamic stressChanges in cholinergic activity

Changes in catecholamine activity Body temperature fluctuationsPulmonary function

Fluid shiftsPain

Mangano et al. 1990


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Risks of anesthesia

Decreased systemic vascular resistanceDecreased stroke volumeInduction of general anesthesia lowerssystemic arterial pressures by 20-30%,tracheal intubation increases the bloodpressure by 20-30 mm Hg, and agentssuch as nitric oxide lower cardiac outputby 15%.

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

Related to hemodynamicstress of the procedureHigh Risk

>5% risk of perioperativedeath or MIemergent major surgery,peripheral vascular or

aortic surgery, prolongedsurgery 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.
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Moderate Risk

Moderate Risk 1-5% risk of perioperativedeath or MI

Carotid endarectomy andurologic, orthopedic,uncomplicatedabdominal, head, neck,

and thoracic operations
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Low Risk

Low Risk


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Stratifying Patient Risk Clinical markers

Major clinical predictors - Unstable coronary syndrome, decompensated CHF,significant arrhythmia, and severe valvular diseaseIntermediate clinical predictors - Mild angina, prior MI, compensated or priorCHF, diabetes mellitus, and renal insufficiency Minor clinical predictors - Advanced age, abnormal findings on echocardiography,rhythm other than sinus, history of stroke, low functional capacity, anduncontrolled hypertension

Functional capacity Poor functional class (4 METS) - Energy expended during activities,

including walking up a flight of stairs, scrubbing floors, and swimming For reference, sleeping = 1 METOther risk factors

Smoking, Alcohol abuse

Fleisher, et al. 2007.


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METs

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

Mangano et al. 1990


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Algorithm

If surgery is an emergency then proceed to the OR. If not, thenIf the patient has undergone coronary revascularization

in the past 5 years without recurrent ischemicsymptoms, then proceed to the OR. If not, thenIf the patient has undergone coronary revascularizationin the past 2 years, and no change in symptoms thenproceed to the OR. If not, then


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Major Clinical Predictors

If the patient has any of the major clinicalpredictors then the problem has to be addressedbefore surgery

Unstable coronary syndromedecompensated CHFsignificant arrhythmiaand severe valvular disease (aortic stenosis!)


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Intermediate Predictors

Intermediate clinical predictors - Mild angina,prior MI, compensated or prior CHF, diabetesmellitus, and renal insufficiency

Assess functional status. If < 4 METs, considernon-invasive testing. If > 4 METs andintermediate or low risk surgery, proceed to theOR


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Minor Predictors

Advanced age, abnormal findings onechocardiography, rhythm other than sinus,history of stroke, low functional capacity, anduncontrolled hypertension

4 METs proceed to the OR


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InterventionsPharmacological vs. coronary revascularizationRecently, the Coronary Artery Revascularization Prophylaxis trialdemonstrated that in the short term, there isno reduction in the number of postoperativemyocardial infarctions, deaths, or duration of stay in the hospital, or in long-term outcomesin patients who underwent preoperativecoronary revascularization compared with

patients who received optimized medicaltherapy.

McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, HattlerB, 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; 351:2795 804
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Preoperative Stress Testing


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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 theNetherlands. Anesthesiology. 2007;107(4):537-44.


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Is it harming patients?

Legner VJ. Clinician agreement with perioperativecardiovascular evaluation guidelines and clinicaloutcomes. Am J Cardiol. 2006;97(1):118-22.

864 Patients, prospective study Found that clinicians ordered testing half of the times it wasrecommended, lower rate of complications when ACC/AHAguidelines were not followed

Frequency of complications not higher when guidelines notfollowed in general


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Thank You

preoperative cardiac exam final - emarcus

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