Cardiac Patient For Non Cardiac Surgery-Preoperative Evaluation

Dr Pankaj N Surange MBBS,MD,FICMR

Graded Specialist Anesthesia

Artemis Health Institute

REFERENCES

• ACC/AHA Guidelines 2002-updated 2006(perioperative Beta Blockade Therapy)

• BJA 95(1): 3-19 2005- perioperative Myocardial Infarction

• BJA 93: 2004-Sympathomodulatory Therapies In Perioperative Medicine

GOALS

• PT CURRENT STATUS– IDENTIFICATION OF PTS UNSTABLE CV DS

– IDENTIFICATION OF PTS WITH KNOWN AND SYMPTOMATIC CAD

– IDENTIFICATION OF PTS AT RISK OF CAD» PVD» HTN» DM» SMOKING» HYPERCHOLESTROLEMIA

GOALS

• THERAPIES TO BRING PT IN OPTIMAL CONDITION

• ANESTHETIC PLAN

• PROCEDURE • PTS PHYSIOLOGY

approachapproach

• Preoperative• Evaluation, risk stratification, and preparation

• Intraoperativesmooth induction

smooth recovery

adequate monitoring

• Postoperativelycont. monitoring and vigilance

PREOPERATIVE CARDIAC EVALUATION

• ACC/AHA GUIDELINES-5 FACTORS FOR RISK STRATIFICATION

– Recency Of Coronary Revascularization

– Recency Of Last Favourable Cardiac Evaluation

– +Nce Of Comorbidities-clinical Predictors

– Functional Status

– Risk Of Proposed Surgery

1-CORONARY REVASCULARISATION

• Complete coronary surgical revascularization -5 yrs

• PCI-- 6months-5 yrs

• No recurrent S/S of ischemia

• Clinical status is stable

No further cardiac testing is necessary

2-Coronary evaluation

• Past 2 years

• Invasive/non invasive tech

– Favorable– No definite change or new symptom

No further cardiac testing is necessary

3-Clinical predictors

• Major– Unstable coronary syndromes

• recent MI with evidence for ischemia• unstable or severe angina (Canadian class III or IV)

– Decompensated CHF– Significant arrhythmia

• high grade AV block• symptomatic ventricular arrhythmia (with organic disease)• supraventricular arrhythmia with uncontrolled rate

– Severe valvular disease

• Intermediate– Mild angina pectoris (Canadian class I or II)– Prior MI by history or pathological Q waves– Compensated or prior CHF– Diabetes mellitus– Renal insufficiency (creatinine > 2)

• Minor– Advanced age– abnormal ECG (LVH, LBBB, ST-T change)– Rhythm other than sinus– Low functional capacity– History of stroke– Uncontrolled systemic hypertension

4-Functional Capacity

• 1 MET– Can you take care of

self? – Eat, dress, use toilet?– Walk indoors in house?– Walk a block or two on

level at 2-3 mph?– Do light housework like

dusting or dishes?

• 4 METs

• 4 METsClimb a flight of stairs,

walk up hill?Walk on level at 4 mph?Run a short distance?Heavy houseworkGolf, bowling, dancing,

doubles tennisSwimming, singles tennis

football, basketball, skiing

• >10 METs

1 MET = 3.5 ml/kg/mt VO2

>10 METs-Excellent7-10 good4-7 moderate≤ 4 poor

5-Surgical risk

High (reported cardiac risk > 5%)

•emergent major operations, esp. in elderly

•aortic and other major vascular procedures

•peripheral vascular procedures

•anticipated prolonged procedure with large fluid shift/blood loss

• Intermediate (reported cardiac risk < 5%)

– carotid endarterectomy

– head and neck

– intraperitoneal & intrathoracic

– orthopedic

– prostate

• Low (reported cardiac risk < 1%)

– endoscopic procedures

– superficial procedure

– cataract

– breast

9 step algorithm

9 step algorithm

9 step algorithm9 step algorithm

PREOP TESTING

• ECG

• DETECT LVH,BBB & CONDUCTION DEFECT

• PREVIOUS MI

• BASELINE FOR INTRA AND POST OP COMPARISON

• INCREASED PERIOP RISK• ST DEPRESSION MORE THAN .5 MM• LVH WITH STAIN PATTERN• LBBB

• EXERCISE STRESS TEST

• STRONGEST DETERMINANT OF RISK AND NEED FOR INVASIVE MONITORING

• LEAD SELECTION

• ECG CRITERIA– 1 M M OF J POINT DEPRESSION

– 2MM OF ST DEPRESSION AT 80 MS FROM J POINT

– ST ELEVATION

– NON ECG RESP• LOW ACHIEVED HR• SYSTOLIC HYPOTENSION• INABILITY TO EXERCISE FOR MORE THAN 3 MIN

PHARMACOLOGICAL STRESS TEST

• Two Categories– Dobutamine Stress Echo-incr. Mvo2

– New/Incr In Rwma– More Than 5/16 Lt Ventricular Segm Involvement

– Dipyridamole Thallium-mimics Coronary Art Dialatation Resp Associated With Exercise

– Infarcted Area-fixed Defect– Ischemic Area-reversible Defect

ECHOCARDIOGRAPHY

– LVEF– RWMA– Valvular Abn– Cong Cardiac Defects

CORONARY ANGIOGRAPHY

• Non Invasive Testing-high Risk Of Adverse Outcome

• Angina Unresponsive To adequate Medical Therapy

• Unstable Angina-intermediate And High Risk Sx

• High Clinical Predictor In High Risk Sx

PERIOP THERAPY

• BETA BLOCKERS– CVS EFFECTS

• ↓ HR-(diastolic Time)• ↓ Contractility• Plaque Stabilization- ↓ Shear Forces• Antiarrythmic Effect

– ELIGIBILITY CRITERIA• CLINICAL -ANY 2

– AGE>65– HTN– CHR SMOKER– SER CHOLESTROL>240 mg/dl– DM

• CARDIAC RISK INDEX CRITERIA– HIGH RISK SX PROCEDURE– IHD– CVA– DM– CRF

OTHER THERAPIES

• Alpha-2 Adrenergic Agonist

• Regional Anesthesia

– Epidural