Perioperative Cardiovascular Evaluation and Care …

1 Perioperative Cardiovascular Evaluation and care for noncardiac Goldman Criteria Surgery Age > 70 yrs (5). A Report of the American College of CAD: MI within 6 months (10). Cardiology/American Heart CHF: S3 or JVE (11). Association Task Force on Practice Rhythm: Guidelines (Writing Committee to other than NSR/PACs on most recent ECG (7);. > 5 PVCs/min any time preoperatively (7). Revise the 2002 Guidelines on Valvular Disease: important aortic stenosis (5). Perioperative Cardiovascular General Medical condition (5). Evaluation for noncardiac Surgery) PaO2 <60 or PaCO2 >50, K < , or HCO3 <20, BUN >50 or Cr > , abnormal AST, signs of chronic liver disease, bedridden from noncardic causes Tzong-Luen Wang, Surgery: intraperitoneal, thoracic, aortic surgery (3). MD, PhD, JM, FESC, FACC, FSPAC emergent surgery (4). Revised Goldman Goldman Criteria Criteria High risk type of surgery Class Total Score No or Minor Life Cardiac Complications Threatening Deaths History of ischemic heart disease History of heart failure I 0-5 99% History of CVA.

2 Preoperative treatment with insulin II 6-12 93% 5% 2% Preoperative serum creatinine > mg/dL. III 13-25 86% 11% 2% Rates: with no risk; with 1 risk; 7% with 2. risks; 11% with 3 or more risks IV >25 22% 22% 56%. Detsky Criteria Revised Detsky Criteria Age > 70 yrs (5). High risk type of surgery CAD: MI within 6 months (10) History of ischemic heart disease MI >6 months (5). History of heart failure CCS angina class III (10). CCS angina class IV (20) History of CVA. Unstable angina past 3 months (10). CHF: Preoperative treatment with insulin Pulmonary edema within 1 week (10) Preoperative serum creatinine > mg/dL. Pulmonary edema, ever (5). Rhythm: unstable angina within 3 months of surgery or other than NSR/PACs on last preop ECG (5); stable angina occurring with minimal exertion or > 5 PVCs/min any time preoperatively (5) recent pulmonary edema (HIGH RISK).

3 Valvular Disease: suspected critical aortic stenosis (5). General Medical condition (5). PaO2 <60 or PaCO2 >50, K < , or HCO3 <20, BUN >50 or Cr > , Rates: with no risk; with 1 risk; 7% with 2. abnormal AST, signs of chronic liver disease, bedridden from noncardic risks; 11% with 3 or more risks or HIGH RISK. causes Surgery: emergent surgery (10). Goldman and Detsky Eagle Criteria Criteria Access 5 significant clinical predictors May UNDERESTIMATE the Cardiac Risk in 1. Q waves on EKG. Vascular Patients . 2. History of angina 3. History of ventricular ectopy requiring treatment 4. Diabetes mellitus requiring therapy other than diet 5. Age > 70. Rate of postoperative ischemic events: if no predictors, 15% if 1-2 predictors and up to 50% if 3. or more predictors. Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence Class I Class IIa Class IIb Class III.

4 Level A Class I Class IIa Class IIb Class III. Benefit >>> Risk Benefit >> Risk Benefit Risk Risk Benefit Additional studies with Additional studies with No additional studies needed focused objectives needed broad objectives needed; Multiple (3-5) Recommen- Recommen- Recommen- Recommen- Additional registry data population risk dation that dation in favor dation's dation that would be helpful Procedure/Treatment should strata evaluated procedure or of treatment or usefulness/ procedure or IT IS REASONABLE to NOT be Procedure/ Treatment perform performed/administered treatment is procedure being efficacy less treatment not SHOULD be performed/ procedure/administer Procedure/Treatment SINCE IT IS NOT General useful/ effective useful/ effective well established useful/effective administered treatment MAY BE CONSIDERED HELPFUL AND MAY BE consistency of Sufficient Some Greater and may be HARMFUL direction and evidence from conflicting conflicting harmful magnitude of multiple evidence from evidence from Sufficient effect randomized multiple multiple evidence from trials

5 Or meta- randomized randomized multiple analyses trials or meta- trials or meta- randomized analyses analyses trials or meta- should is reasonable may/might be considered is not recommended analyses is recommended can be useful/effective/ may/might be reasonable is not indicated is indicated beneficial usefulness/effectiveness is should not is useful/effective/ beneficial is probably recommended or unknown /unclear/uncertain or is not useful/effective/beneficial indicated not well established may be harmful Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence Level B Class I Class IIa Class IIb Class III Level C Class I Class IIa Class IIb Class III. Limited (2-3) Recommen- Recommen- Recommen- Recommen- Very limited (1-2) Recommen- Recommen- Recommen- Recommend- population risk dation that dation in favor of dation's dation that population risk dation that dation in favor of dation's ation that strata evaluated procedure or treatment or usefulness/ procedure or strata evaluated procedure or treatment or usefulness/ procedure or treatment is procedure being efficacy less well treatment not treatment is procedure being efficacy less well treatment not useful/effective useful/ effective established useful/effective useful/ effective useful/effective established useful/effective Limited Some conflicting Greater and may be Only expert Only diverging Only diverging and may be evidence from evidence from conflicting harmful opinion, case expert opinion, expert opinion, harmful single single evidence from Limited evidence studies, or case studies.

6 Or case studies, or Only expert randomized trial randomized trial single from single standard-of- care standard-of- care standard-of- care opinion, case or non- or non- randomized trial randomized trial studies, or randomized randomized or non- or non- standard-of- care studies studies randomized randomized studies studies Active Cardiac Conditions for Which the Estimated Energy Requirements Patient Should Undergo Evaluation and Treatment Before noncardiac Surgery for Various Activities Condition Examples Can You Can You . Unstable coronary Unstable or severe angina* (CCS class III or IV) . syndromes Recent MI . 1 Met Take care of yourself? 4 Mets Climb a flight of stairs or walk up a hill? Decompensated HF NYHA functional class IV;. Worsening or new-onset HF Eat, dress, or use the toilet? Walk on level ground at 4 mph ( kph)? Significant arrhythmias High-grade atrioventricular block Mobitz II atrioventricular block Walk indoors around the Do heavy work around the Third-degree atrioventricular heart block house?

7 House like scrubbing floors or Symptomatic ventricular arrhythmias lifting or moving heavy Supraventricular arrhythmias (including atrial fibrillation) furniture? with uncontrolled ventricular rate (HR > 100 bpm at rest) Walk a block or 2 on level Participate in moderate Symptomatic bradycardia ground at 2 to 3 mph ( to recreational activities like golf, Newly recognized ventricular tachycardia kph)? bowling, dancing, doubles Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 tennis, or throwing a baseball mm Hg, aortic valve area less than cm2, or symptomatic). or football? Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF) 4 Mets Do light work around the 10 Participate in strenuous sports house like dusting or Mets like swimming, singles tennis, CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, washing dishes?

8 Football, basketball, or skiing? New York Heart Association. *According to May include stable angina in patients who are unusually sedentary. The ACC National Database Library defines recent MI as more than 7 days but within 30 days) MET indicates metabolic equivalent; mph, miles per hour; kph, kilometers per hour. *Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et Cardiac Risk Stratification for Recommendations for Preoperative noncardiac Surgical Procedures Noninvasive Evaluation of LV Function Risk Stratification Procedure Examples Class I (none). Vascular (reported cardiac Aortic and other major vascular surgery Class IIa It is reasonable for patients with dyspnea of unknown origin to risk often > 5%) Peripheral vascular surgery undergo preoperative Evaluation of LV function.

9 (C). It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical status to Intermediate (reported Intraperitoneal and intrathoracic surgery undergo preoperative Evaluation of LV function if not performed within 12 months. (C). cardiac risk generally 1%-5%) Carotid endarterectomy Class IIb Head and neck surgery Orthopedic Reassessment of LV function in clinically stable patients with surgery Prostate surgery previously documented cardiomyopathy is not well established. (C). Low (reported cardiac Endoscopic procedures Class III. Routine Perioperative Evaluation of LV function in patients is risk generally <1% Superficial procedure not recommended. (B). Cataract surgery Breast surgery Ambulatory surgery Evaluation Recommendations for Preoperative Resting 12-Lead ECG High Risk 12-Lead ECG.)

10 Class I: Preoperative resting 12-lead ECG is recommended for pts with: At least 1 clinical risk factor* who are undergoing vascular surgical procedures. (B). Known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (C). Class IIa: Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (B). Class IIb: Preoperative resting 12-lead ECG may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (B). Class III: Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (B). *Clinical risk factors include history of ischemic heart disease, history of compensated or prior HF, history of cerebrovascular disease, DM, and renal insufficiency.