1. Overview
•
Drafted out by American College of Cardiology (ACC) and American Heart
Association (AHA) initially in 1980 then revised again in 2002, 2007 and 2011.
•
Comprising almost 20 topics relating to cardiac issues for patients undergoing
non cardiac surgery.
•
Eg : preoperative noninvasive evaluation of LV function; preoperative resting
12-lead ECG; noninvasive stress testing before non-cardiac surgery;
reoperative coronary revascularization; betablocker therapy; statin therapy;
preoperative ICU monitoring; use of volatile anesthetic agents; prophylactic
Nitroglycerin, maintenance of normothermia; glucose control; use of
pulmonary artery catheters; intraoperative and postoperative ST-segment
monitoring; surveillance for perioperative myocardial infarction; and the
tissue of when patients with cardiac stents can safely undergo elective surgery

2. Purpose
•
Quick reference for decision making
•
lower the risk of surgery
•
evaluation of the patient’s current medical status
•
make recommendations concerning the evaluation,
management, and risk of cardiac problems over the entire
preoperative period
•
provide a clinical risk profile can be of use in making treatment
decisions that may influence short- and long-term cardiac
outcomes

3. GOALS
– IDENTIFICATION OF PATIENTS WITH UNSTABLE
CARDIOVASCULAR CONDITION
– IDENTIFICATION OF PATIENTS WITH KNOWN AND
SYMPTOMATIC Coronary Heart Disease (CHD)
– IDENTIFICATION OF PATIENTS AT RISK OF CHD
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PVD
HTN
DM
SMOKING
HYPERCHOLESTROLEMIA

4. CLASSIFICATION OF RECOMMENDATIONS

5. CLASS 1
CLASS II A
CLASS II B
CLASS III
SHOULD
REASONABLE
MAYBE
CONSIDERED
SHOULD NOT
Benefit >>>
Risk
LEVEL A
Multiple (3-5)
population risk
LEVEL B
Limited (2-3)
population risk
LEVEL C
Very limited
(1-2)
population risk
BENEFIT >>
RISK
BENEFIT >
RISK
RISK >
BENEFIT

6. PREOPERATIVE CARDIAC EVALUATION
•
Evaluation
History taking
•
to identify serious cardiac conditions such as unstable coronary syndromes,
prior angina, recent or past MI, decompensated HF, significant arrhythmias,
and severe valvular disease
•
history of a pacemaker or implantable cardioverter defibrillator
•
Accurate recording of current medications used, including herbal and other
nutritional supplements, and dosages
.

7. •
Determine ASA status , surgery classification and functional capacity.
Status
State
Class 1
No organic, physiologic, biochemical, or psychiatric
disturbance.
Class 2
Mild to moderate systemic disturbance that may or may
not be related to the reason for surgery
Eg : Essential HTN, DM, Morbid Obesity, Anemia
Class 3
Severe systemic disturbance that may or may not be
related to the reason for surgery, (does limit activity)
Eg ; Uncontrolled HTN, DM with vascular complications,
COPD with func. Limitation, angine pectoris, Hx of MI
Class 4
Severe systemic disturbance that is life-threatening with
or without surgery
Eg : CHF, advanced pulmonary, renal/hepatic dysfunction
Class 5
Moribund patient who has little chance of survival but is
submitted to surgery as a last resort (resuscitative effort)
Eg : Uncontrolled hemorrhage from ruptured abdominal
aneurysm, cerebal trauma, pulmonary embolism.
Emergency (E)
Any patient in whom an emergency operation is required

8. Risk Stratification
5 FACTORS FOR RISK STRATIFICATION
– Recency Of Coronary Revascularization
– Recency Of Last Favourable Cardiac Evaluation
– Presence Of Comorbidities-clinical Predictors
– Functional Status
– Risk Of Proposed Surgery

9. 1-CORONARY REVASCULARISATION
•
Complete coronary surgical revascularization -5 yrs
•
PCI-- > 6months-5 yrs
•
No recurrent Symptoms or signs of ischemia
•
Clinical status is stable
No further cardiac testing is necessary

10. 2-Coronary evaluation
• Past 2 years
• Invasive/non invasive tech
– Favorable
– No definite change or new symptom
No further cardiac testing is necessary

11. 3-Clinical predictors
• Major
– Unstable coronary syndromes
• recent MI with evidence for ischemia ( >7 days & < 30days)
• unstable or severe angina
– Decompensated CHF
– Significant arrhythmia
• high grade AV block
• symptomatic ventricular arrhythmia
• supraventricular arrhythmia with uncontrolled rate
– Severe valvular disease

12. • Intermediate
– Mild angina pectoris (Canadian class I or II)
– Prior MI by history or pathological Q waves
– Compensated or prior CHF
– Diabetes mellitus
– Renal impairment (creatinine > 2mg per dL)
– Anemia
– Pulmonary Disease (obstructive/restrictive)

13. • Minor
– Advanced age
– abnormal ECG (LVH, LBBB, ST-T change)
– Rhythm other than sinus
– Low functional capacity
– History of stroke
– Uncontrolled systemic hypertension

14. Functional Capacity
• Functional capacity can be expressed as
metabolic equivalents (METs); the resting
or basal oxygen consumption (Vo2) of a
70-kg, 40-year-old man in a resting state
is 3.5 mL per kg per min, or 1 MET.

15. Duke’s Activity Status Index
• 1 MET
– Can you take care of
self?
– Eat, dress, use toilet?
– Walk indoors in house?
– Walk a block or two on
level at 2-3 mph?
– Do light housework like
dusting or dishes?
• 4 METs
1 MET = 3.5 ml/kg/mt VO2
• 4 METs
Climb a flight of stairs,
walk up hill?
Walk on level at 4 mph?
Run a short distance?
Heavy housework
Golf, bowling, dancing,
doubles tennis
Swimming, singles tennis
football, basketball, skiing
• >10 METs
>10 METs-Excellent
7-10
good
4-7
moderate
≤4
poor

16. Classification of surgeries according to Risk.
• High
(reported cardiac risk > 5%)
• emergent major operations, esp. in elderly
• aortic and other major vascular procedures
• peripheral vascular procedures
• anticipated prolonged procedure with large fluid
shift/blood loss

17. • Intermediate
(reported cardiac risk < 5%)
– carotid endarterectomy
– head and neck
– intraperitoneal & intrathoracic
– orthopedic
– prostate

18. • Low
(reported cardiac risk < 1%)
– endoscopic procedures
– superficial procedure
– cataract
– breast

19. 9 step algorithm

20. 9 step algorithm

21. 9 step algorithm
9 step algorithm

22. Cardiac Conditions that Need Evaluation and Treatment Before
Surgery
Condition
Unstable coronary
syndromes
Examples
Unstable or severe angina (CCS class III, IV) , Recent
MI
Decompensated HF
Significant Arrhythmias
High Grade AV Block, Mobitz II AV Block, 3rd Degree
AV block, Symptomatic Ventricular Arrhythmias,
Supraventricular Arrhytmias with HR > 100 bpm at
rest, Symptomatic Bradycardia, Newly Recognized
VT
Severe Valvular Disease
Severe aortic stenosis, Symptomatic Mitral Stenosis
(dyspnea on exertion, exertional presyncope or HF)

24. •
Class IIA
•
It is probably recommended that patients with functional capacity greater than or
equal to 4 METs without symptoms‡ proceed to planned surgery.
•
It is probably recommended that patients with poor (less than 4 METs) or unknown
functional capacity and 3 or more clinical risk factors who are scheduled for vascular
surgery consider testing if it will change management.
•
It is probably recommended that patients with poor (less than 4 METs) or unknown
functional capacity and 3 or more clinical risk factors who are scheduled for
intermediate risk surgery proceed with planned surgery with heart rate control.
•
It is probably recommended that patients with poor (less than 4 METs) or unknown
functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or
intermediate risk surgery proceed with planned surgery with heart rate control.

25. •
Class IIB
•
Noninvasive testing might be considered if it will change management for patients
with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical
risk factors∥ who are scheduled for intermediate risk surgery.
•
Noninvasive testing might be considered if it will change management for patients
with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk
factors∥ who are scheduled for vascular or intermediate risk surgery.

26. PREOP TESTING
• ECG
• DETECT LVH,BBB & CONDUCTION DEFECT
• PREVIOUS MI
• BASELINE FOR INTRA AND POST OP COMPARISON
• INCREASED PERIOP RISK
• ST DEPRESSION MORE THAN .5 MM
• LVH WITH STAIN PATTERN
• LBBB

27. • EXERCISE STRESS TEST
•
STRONGEST DETERMINANT OF RISK AND NEED FOR
INVASIVE MONITORING
•
LEAD SELECTION
•
ECG CRITERIA
–
–
–
–
1 M M OF J POINT DEPRESSION
2MM OF ST DEPRESSION AT 80 MS FROM J POINT
ST ELEVATION
NON ECG RESP
• LOW ACHIEVED HR
• SYSTOLIC HYPOTENSION
• INABILITY TO EXERCISE FOR MORE THAN 3 MIN

28. PHARMACOLOGICAL STRESS TEST
• Two Categories
– Dobutamine Stress Echo-incr. Mvo2
– New/Incr In Rwma
– More Than 5/16 Lt Ventricular Segm Involvement
– Dipyridamole Thallium-mimics Coronary Art
Dialatation Resp Associated With Exercise
– Infarcted Area-fixed Defect
– Ischemic Area-reversible Defect

29. ECHOCARDIOGRAPHY
– LVEF
– RWMA
– Valvular Abn
– Cong Cardiac Defects

30. CORONARY ANGIOGRAPHY
• Non Invasive Testing-high Risk Of Adverse
Outcome
• Angina Unresponsive To adequate Medical
Therapy
• Unstable Angina-intermediate And High Risk Sx
• High Clinical Predictor In High Risk Sx

31. PERIOP THERAPY
•
BETA BLOCKERS
– CVS EFFECTS
•
•
•
•
↓ HR-(diastolic Time)
↓ Contractility
Plaque Stabilization- ↓ Shear Forces
Antiarrythmic Effect
– ELIGIBILITY CRITERIA
• CLINICAL -ANY 2
–
–
–
–
–
AGE>65
HTN
CHR SMOKER
SER CHOLESTROL>240 mg/dl
DM
• CARDIAC RISK INDEX CRITERIA
–
–
–
–
–
HIGH RISK SX PROCEDURE
IHD
CVA
DM
CRF

32. OTHER THERAPIES
•
Alpha-2 Adrenergic Agonist
•
Regional Anesthesia
– Epidural