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:
- Procedural Site
- Functional status (independent, partially dependent, totally dependent)
- Creatinine ≥ 1.5
- American Society of Anesthesiologists’ class
- 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:
- High-risk surgery (according to RCRI: intraperitoneal, intrathoracic, suprainguinal vascular)
- 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)
- History of congestive heart failure
- History of cerebrovascular disease (CVA/TIA)
- Diabetes requiring insulin
- 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.