Medical Terms Learned today

Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery
British Journal of Anaesthesia, 2002, Vol. 89, No. 5 747-759
Abstract

The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.
Eagle's Cardiac Risk Assessment
# See Also

1. Preoperative Cardiovascular Evaluation

# Major Cardiovascular Risks: Unstable Coronary Syndromes

1. Recent Myocardial Infarction (Within 30 days)
2. Unstable Angina or severe Angina (Angina Class 3-4)
3. Decompensated Congestive Heart Failure
4. Severe valvular disease
5. Significant arrhythmia
1. High grade Atrioventricular Block
2. Symptomatic ventricular arrhythmia
3. Uncontrolled rate in supraventricular arrhythmia

# Intermediate Cardiovascular Risks

1. Mild Angina Pectoris (Angina Class 1-2)
2. Prior Myocardial Infarction (by history or EKG)
3. Compensated or prior Congestive Heart Failure
4. Renal Insufficiency (Serum Creatinine >2 mg/dl)
5. Diabetes Mellitus

# Minor Cardiovascular Risks

1. Advanced age
2. Abnormal Electrocardiogram
1. Left Ventricular Hypertrophy
2. Left Bundle Branch Block
3. ST segment abnormalities
4. T Wave abnormalities
3. Heart rhythm other than sinus rhythm (e.g. Atrial Fib)
4. Low functional capacity (<4 METS)
5. History of Cerebrovascular Accident
6. Uncontrolled Hypertension (diastolic BP >110 mmHg)

Performance of three preoperative risk indices; CABDEAL, EuroSCORE and Cleveland models in a prospective coronary bypass database
Conclusions: The CABDEAL model was initially developed for the prediction of major morbidity. Thus, it is not surprising that this model evinced the highest predictive value for increased morbidity in this database. Both the Cleveland and the EuroSCORE models were better predictive of mortality. These results have implications for the selection of risk indices for different purposes. The simple additive CABDEAL model can be used as a hand-held model for preoperative estimation of patients' risk of postoperative morbidity, while the EuroSCORE and Cleveland models are to be preferred for the prediction of mortality in a large patient sample.

PREOPERATIVE ASSESSMENT Chapter 22
High risk: cardiac risk often > 5%

Aortic repair (aneurysmal, dissection)

Noncarotid major vascular (infrainguinal and intraabdominal)

Peripheral vascular surgery

Anticipated prolonged surgical procedures with large fluid shifts and/or blood loss

Major emergency procedures, particularly in the elderly

Intermediate risk: cardiac risk generally < 5%

Major intraabdominal (nonvascular)

Intrathoracic (nonendoscopic)

Major orthopedic

Carotid endarterectomy

Major head and neck

Radical prostatectomy

Low risk: cardiac risk generally < 1%

Opthalmologic (excluding prolonged retinal)

Minor head and neck

Minor prostate (such as cystoscopy or TURP)

Biopsies and superficial procedures

ACC-AHA Preoperative Cardiac Risk Assessment

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery


Class I: Patients With Suspected or Known CAD
1. Evidence for high risk of adverse outcome based on noninvasive test results.
2. Angina unresponsive to adequate medical therapy.
3. Unstable angina, particularly when facing intermediate-risk* or high-risk* noncardiac surgery.
4. Equivocal noninvasive test results in patients at high-clinical risk† undergoing high-risk* surgery.

Class IIa
1. Multiple markers of intermediate clinical risk † and planned vascular surgery (noninvasive testing should be considered first).
2. Moderate to large ischemia on noninvasive testing but without high-risk features and lower LVEF.
3. Nondiagnostic noninvasive test results in patients of intermediate clinical risk† undergoing high-risk* noncardiac surgery.
4. Urgent noncardiac surgery while convalescing from acute MI.

Class IIb
1. Perioperative MI.
2. Medically stabilized class III or IV angina and planned low-risk or minor* surgery.

Class III
1. Low-risk* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
2. Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).
3. Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
4. Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., LVEF less than 0.20), or refusal to consider revascularization.
5. Candidate for liver, lung, or renal transplant more than 40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.