Pocket Medicine

CARDIOLOGY

CARDIAC RISK ASSESSMENT FOR NONCARDIAC SURGERY

Preoperative evaluation

Figure 1-7 ACC/AHA approach to preoperative cardiovascular evaluation for noncardiac surgery

Preoperative testing and assessment

•  ECG if ≥1 risk factor and planned vascular surgery or if known vascular disease and intermediate risk surgery. ? prior to any vascular surgery.

•  TTE if dyspnea of unknown origin or if HF w/ ↑ dyspnea and no TTE in past 12 mo

•  Stress test if active cardiac issues (see above) or vascular surgery w/ ≥3 risk factors & it will Δ mgmt. Overall low PPV to predict periop CV events.

•  ? consider CXR and ECG in preop evaluation of severely obese Pts (Circ 2009;120:86)

•  Comorbidity indices (eg, Charlson index) may predict mortality (Am J Med Qual 2011;26:461)

Pre- & perioperative management

•  Coronary revascularization should be based on standard indications (eg, ACS, refractory sx, lg territory at risk). Has not been shown to Δ risk of death or postop MI when done prior to elective vasc. surgery based on perceived cardiac risk (NEJM 2004;351:2795) or documented extensive ischemia (AJC 2009;103:897), but systematic angio ↓ 2–5 y mortality in a vascular surgery trial ( JACC 2009;54:989).

•  Continue ASA: ↓ MACE in Pts w/ cardiac risk factors (Br J Anaesth 2010;104:305)

•  Given need for dual antiplatelet Rx after stenting, wait 4–6 wk after BMS and ideally >12 mo after DES before discontinuing ADP receptor blockade

•  If possible, wait >4–6 wk after MI (even if  ETT or  ETT & revascularized). If no

revasc, wait 6 mo before elective surgery.

•  Preop statins: ↓ ischemia & CV events in Pts undergoing vascular surg (NEJM 2009;361:980); may reduce AF, MI, LOS in statin-naïve Pts (Arch Surg 2012;147:181)

Perioperative β-blocker (Circ 2009;120:2123; JAMA 2010;303:551; Am J Med 2012;125:953)

•  Conflicting evidence: some studies show ↓ death & MI (NEJM 1996;335:1713 & 1999;341:1789), another showed ↓ MI, but ↑ death & stroke and ↑ bradycardia/HoTN (Lancet 2008;371;1839)

•  ? consider if CAD,  stress test, or ≥2 cardiac risk factor, esp. if vascular surgery

•  Ideally initiate weeks prior to surgery and titrate slowly and carefully to achieve desired individual HR and BP goal (? HR ~55–65). Avoid bradycardia and hypotension. Do not discontinue bB abruptly postop, as may cause sympathetic activation from withdrawal.

Postoperative monitoring

•  ✓ Postop ECG if known CAD or high-risk surgery. Consider if >1 risk factor for CAD.

•  ✓ Postop troponin only if new ECG Δs or chest pain suggestive of ACS