02. Preoperative Cardiac Evaluation for Noncardiac Surgery

General Considerations

  • Cardiac risk assessment should take place in all pre-operative medicine consults and is primarily achieved from a quality history and physical exam. Additional prognostic testing only adds value in limited circumstances.
  • Goal: To estimate cardiac risk and optimize cardiac health prior to surgery in order to allow surgeons and patients to make an educated decision whether or not to proceed with surgery.
  • Misnomer: Patients are NOT “cleared” for surgery, but instead are optimized medically.
  • Common Complications: myocardial infarction (NSTEMI > STEMI) often occurs 0-3 days post-op, arrhythmia (Afib, SVT, VT), pulmonary edema, stroke, and death.

Procedural Classification

PROCEDURAL CLASSIFICATION

DEFINITION

Emergent

Life or limb threatened if surgery is not performed in <6 hours

Urgent

Life or limb threatened if surgery is not performed in 6-24 hours

Semi-Urgent

Delay of 1-6 weeks would negatively affect outcome

Elective

Surgery can be delayed up to 1 year without clinical impact

 

The ACC/AHA Guidelines for Pre-Operative Evaluation (2014)

 

Risk Calculators:

NSQIP universal surgical risk calculator: (https://riskcalculator.facs.org/RiskCalculator/)

  • Universal surgical risk calculator derived from a retrospective cohort of 1,414,006 patients which uses 20 patient risk factors and specifics of the surgical procedure to provide comprehensive risk estimates.
  • Superior performance for mortality.

Limitations: More involved and time consuming to use.

Gupta perioperative risk MICA: (http://www.surgicalriskcalculator.com/miorcardiacarrest)

Database of 200,000 patients who underwent surgery in 2007 utilized to derive risk factors associated with MI or cardiac arrest.

Limitations: Does not provide comprehensive risk assessment beyond MI and cardiac death.

Risk Factors:

  1. Procedural Site
  2. Functional status (independent, partially dependent, totally dependent)
  3. Creatinine ≥ 1.5
  4. American Society of Anesthesiologists’ class
  5. Age

Revised Goldman Cardiac Risk Index (RCRI):

  • Retrospectively derived risk factors from cohort of 2893 patients undergoing elective major noncardiac procedures evaluating for perioperative cardiac complications validated in patients >50 years old.

Limitations: Substantially underestimates risk in patients undergoing major vascular surgery. Underestimates arrhythmogenic complications and heart failure.

Risk Factors:

  1. High-risk surgery (according to RCRI: intraperitoneal, intrathoracic, suprainguinal vascular)
  2. Ischemic heart disease (history of MI or current angina, use of SL NTG, positive stress test, Q waves on ECG, or history of PTCA/CABG with ongoing chest pain)
  3. History of congestive heart failure
  4. History of cerebrovascular disease (CVA/TIA)
  5. Diabetes requiring insulin
  6. Creatinine > 2.0 mg/dl

Risk Predictors

RCRI Class*

Complications**

0

I

0.5%

1

II

1%

2

III

5%

3 or more

IV

10%

* Beware of confusing RCRI terminology: 0 Predictors = “Class I,” 1 Predictor = “Class II,” 2 Predictors = “Class III,” 3+ Predictors = “Class IV.”

** Complications include MI, pulmonary edema, cardiac arrest, and complete heart block.

Other Perioperative Testing Considerations

TEST

WHEN TO CONSIDER

NOT INDICATED

EKG

History of CAD or structural heart disease (established preoperative baseline)

(Class 2A)

 

Asymptomatic patients undergoing low risk surgery (Class 3)

Moderate or high-risk surgical candidate (Class 2B)

 

TTE

New or worsening dyspnea of unclear etiology (Class 2A)

 

Routine Screening (Class 3)

 

Heart failure with worsening dyspnea or clinical change (Class 2A)

 

EXERCISE STRESS TEST

Elevated surgical risk with normal (Class 2A), good (Class 2B), or unknown functional capacity (Class 2B) if it will change management

 

Routine Screening (Class 3)

 

EXERCISE STRESS TEST W/ CARDIAC IMAGING

Elevated surgical risk with poor functional capacity if it will change management (Class 2B)

 

Routine Screening (Class 3)

 

NON-INVASIVE PHARM STRESS IMAGING

Elevated surgical risk with poor functional capacity if it will change management (Class 2B)

 

Routine Screening (Class 3)

 

CORONARY ANGIOGRAPHY

ROUTINE TESTING IS NOT RECOMMENDED

Routine Screening (Class 3)

 

 

 

Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann.Intern.Med. 2010 Jan 5;152(1):26-35.

Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J.Am.Coll.Cardiol. 2014 12/9;64(22):e77-e137.

Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation 2011 Jul 26;124(4):381-387.