3/99medslides.com1 Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery ACC/AHA Task Force JACC 1996; 27:910-945 Circulation 1996;

3/99 medslides.com 1

Guidelines for Perioperative Cardiovascular Evaluation for

Noncardiac Surgery

ACC/AHA Task ForceJACC 1996; 27:910-945

Circulation 1996; 93:1278-1317


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


Cardiac Risk Stratification (nonfatal MI and Death) 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 (risk generally <5% )• Carotid endarterectomy• Head and neck• Intraperitoneal and intrathoracic• Orthopedic• Prostate

Low * (cardiac risk generally <1% )• Endoscopic procedures• Superficial procedures• Cataract• Breast

* Further preoperative cardiac testing is generally unnecessary.

ACC/AHA Task ForceJACC 1996; 27:910-945; Circulation 1996; 93:1278-1317


Clinical Predictors of Increased Perioperative Cardiovascular Risk (MI, CHF, Death)

Major• Unstable coronary syndromes

– Recent MI ( >7 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



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



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; 54:522-523


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?


Stepwise Approach to Preoperative Cardiac Assessment

1. Need fornoncardiac

surgery

2. Coronaryrevascularizationwithin 5 years ?

Recurrentsymptomsor signs ?

3. Recentcoronary

evaluation

Recent coronaryangiogram orstress test ?

Postoperative riskstratification and riskfactor management

OperatingRoom

4. Clinicalpredictors

Urgent orElective

Emergency

Yes

Yes Yes

No

No No

Unfavorable OR change insymptoms

Favorable AND nochange in symptoms




4. Clinicalpredictors

6. Intermediateclinical

predictor

7. Minor or noclinical

predictor

5. Majorclinical

predictor

• Unstable coronary syndromes


• 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




5. Majorclinical

predictor Major Clinical Predictor

• Unstable coronary syndromes


• Significant arrhythmia• Severe valvular disease


Consider delayor cancel

noncardiac surgery

Considercoronary

angiography

Medicalmanagement and

risk factormodification

Subsequent caredictated by

findings andtreatment results




Poor(<4 METs)

6. Intermediateclinical

predictor

Moderate orexcellent(>4 METs)

Intermediateor low surgicalrisk procedure

High surgicalrisk procedure

Low surgicalrisk procedure

8. Noninvasivetesting

Considercoronary

angiography

Subsequentcare dictated

by findings andtreatment results

Operating room

Postoperativerisk stratification

and risk factorreduction

Low risk

High risk

Functionalcapacity

Surgicalrisk

Noninvasivetesting

Invasivetesting




Poor(<4 METs)

Moderate orexcellent(>4 METs)

Intermediateor low surgicalrisk procedure

High surgicalrisk procedure

Low surgicalrisk procedure

8. Noninvasivetesting

Considercoronary

angiography

Subsequentcare dictated

by findings andtreatment results

Operating room

Postoperativerisk stratification

and risk factorreduction

Low risk

High risk

Functionalcapacity

Surgicalrisk

Noninvasivetesting

Invasivetesting

7. Minor or noclinical

predictor


Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery

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 AngiographyJACC 1987; 10:935-950; Circ 1987; 76:963A-977A

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 <20%) and patient not considered candidate for revasularization

• Patient unwilling to consider coronary revascularization procedure

Documents

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