Perioperative Cardiovascular Evaluation

and Management for Noncardiac Surgery

REFERENCES:
Circulation 2002;105:1257-68 OR
J Am Coll Cardiol 2002;39:542-53.
 http://www.acc.org/clinical/topic/topic.htm#guidelines
 Purpose of Preoperative Cardiac Evaluation
 Define patient’s current cardiac status.
 Assess and project perioperative CV risk.
 Determine if preoperative testing is needed to
define cardiovascular status - recommended only
if it will change surgical care or perioperative
medical therapy.
 Initiate management to minimize cardiac risk
over the entire perioperative period, and
subsequently.
 General Approach to the Patient - History

 “Have you ever had any problem with your heart or arteries?”
 “Do you exercise?” Typical responses …
 “I try to.” Translation: “No.”
 “Not as much as I should.” Translation: “No.”
 “I’m active.” Translation: “No.”
 “What exercise do you do? Tell me the most physically strenuous thing
you did in the last 2 weeks.”
 Is there real (exertional) angina, recent or past MI, HF, documented
arrhythmia, pacemaker or ICD?
 Any history or other indicators of atherosclerotic vascular disease?
 CAD risk factors and “doses of risk factors”
 unexplained, inordinate dyspnea
 Exercise capacity integrates the
physiologic effects of all the patient’s
combined cardiac abnormalities.

If history reveals
GOOD EXERCISE CAPACITY,
then the patient’s operative risk is low.
 General Approach to the Patient

 Physical Examination – general appearance,

bruits, rales, elevated JVP, heart rate & rhythm,
murmurs of severe AS or MS
 Comorbidity: renal impairment, diabetes,
pulmonary disease
 Basic Metabolic Panel, CBC, BNP, ECG, CXR
 BNP level (precise role in risk assessment and
post-op management remains to be defined)
Q: Which cardiac conditions worry me most?

A: Severe stenotic (flow-limiting) lesions:

 coronary - disease severity and extent
 AS > MS
 severe pulmonary hypertension

 Regurgitant valvular lesions are rarely a problem

perioperatively.
 I am less concerned about CHF or arrhythmia in the
absence of ischemia. Both are readily treated and usually
without permanent sequelae, unlike MI and death.
 AF is, however, a potentially costly (in money and
morbidity) nuisance. Avoid it.
 Patient-specific Clinical Predictors of Increased
Perioperative Cardiovascular Risk (ACC/AHA Guidelines)
 Major  Minor
 Acute coronary  Advanced age.
syndromes  Abnormal ECG.
 Decompensated CHF  Rhythm other than
 Significant (?) sinus.
arrhythmias  Low functional
capacity.
 Intermediate  History of stroke.
 Mild (?) angina pectoris  Uncontrolled HTN
 Prior MI
 Type of Surgery and Risk - I
 Urgency: emergent, urgent/soon, elective
 Influences not only risk, but also your pre-op testing
(if any) strategy.
 HIGH SURGICAL RISK:
 emergent major operations, esp. in elderly
 aortic and other major vascular surgery
 peripheral vascular surgery
 BIG SURGERY: anticipated prolonged surgical
procedures associated with large fluid shifts and/or
blood loss, and long recovery.
 Type of Surgery and Risk - II

 Intermediate risk:  Low risk:

carotid endoscopy
head and neck superficial procedures
intraperitoneal cataract surgery
intrathoracic breast surgery
orthopedic
prostate
 Preoperative non-invasive testing in
known or suspected CAD - Which patient?
 poor or unknown functional capacity: can’t exercise,
don’t exercise
 known or suspected CAD: angina, prior MI based on
history or pathological Q waves, CAD-equivalent
(peripheral vascular disease), risk factor profile
 known or suspected significant AS, MS, pulmonary HTN
 high surgical risk procedure: aortic or peripheral
vascular, BIG SURGERY
 Preoperative non-invasive testing
in known or suspected CAD - Which test?

 rest echocardiography: but little insight into CAD

 simple treadmill: exercise capacity
 stress or dobutamine echo
 but dobutamine in aortic aneurysm ???
 myocardial perfusion imaging - exercise or
dipyridamole

EXERCISE WHENEVER POSSIBLE.

 Recommendations for Coronary Angiography in
Perioperative Evaluation (ACC/AHA Guidelines)

Class I: Patients with suspected or known CAD

 Evidence for high risk of adverse outcome based on
noninvasive test results
 Angina unresponsive to adequate medical therapy
 Unstable angina, particularly when facing intermediate-
risk or high-risk noncardiac surgery
 Equivocal noninvasive test results in patients at high-
clinical risk undergoing high-risk surgery
 Q. When is revascularization (PCI, CABG)
recommended ? (ACC/AHA Guidelines)
A. Generally only when justified by the usual clinical
factors, apart from planned non-cardiac surgery.

 No randomized trials document decreased perioperative

cardiac events.
 No prospective studies have determined optimal period of
delay after PCI before noncardiac surgery.
 Delay of 2-4 weeks after PCI with stent placement is
supported by observational study.
 Preoperative Therapy with B-Blockers
(ACC/AHA Guidelines)

Class I indications
 When B-blockers have been required in recent past for
angina, symptomatic arrhythmia or hypertension.
Do not withdraw beta-blockade preoperatively.
 Patients undergoing vascular surgery with ischemia on
preoperative testing
Class IIa
 When preoperative assessment identifies untreated
hypertension, known CAD, or major CAD risk factors.
Class III: contraindication to B-blockade
 Preoperative Therapy with B-Blockers
(ACC/AHA Guidelines)

 Start pre-op, titrate to HR 50-60 bpm

 Short acting beta-blockers provide more flexible
dosing
 Give orally, if possible, with IV supplementation
when patient is NPO
 Anesthetic Considerations and
Intraoperative Management (ACC/AHA Guidelines)
No study clearly demonstrates improved outcome from :
 regional versus general anesthesia
 pulmonary artery catheter
 intraoperative nitroglycerin
 ST-segment monitoring
 TEE
 prophylactic intra-aortic balloon pump

Choice of anesthetic and intraoperative monitoring is best

left to discretion of anesthesia care team.
 Perioperative Surveillance (ACC/AHA Guidelines)
Post operative myocardial ischemia:
 Strongest predictor of perioperative cardiac morbidity.
 Often untreated until overt symptoms develop.
 Diagnosis of perioperative MI has short and long-term prognostic value.
 30% to 50% perioperative mortality and reduced long-term survival.

For patients with known or suspected CAD, undergoing high or

intermediate risk procedure:
 Check ECG at baseline, immediately after procedure, and daily x 2 days.
 Check cardiac troponin measurements 24 hours postoperatively and on
day 4, or hospital discharge (whichever comes first).
Consider troponion also days 2 & 3.
 Pacemakers & ICDs

 Electrocautery can cause oversensing, resulting

in failure to pace or an inappropriate shock from
an ICD.
 Contact Cardiology.
 Conclusions (ACC/AHA Guidelines)
 Insure good communication between surgeon, anesthesiologist,
primary care physician, and consultant.

 Further cardiac testing and treatments generally are the

same as in the non-operative setting, considering:
 the urgency of the noncardiac surgery
 patient-specific risk factors
 surgery-specific factors

 Preoperative testing:
 when surgical risk is high.
 when patient-specific and surgery-specific risks are intermediate.
 when results will affect patient management.
Questions you should always ask yourself

 Is there CAD?  Is there severe …

 If there is,  AS, MS
 how severe?  pulmonary hypertension
 how extensive?
 how “active”?
 How “big” is the
surgery?