Perioperative Cardiovascular Evaluation for Noncardiac Surgery

Anestesiologi dan Reanimasi RSUD Tasikmalaya

General Approach
Team Work Patient Primary care physician Anesthesiologist Surgeon Medical consultant

Preoperative Clinical Evaluation

Identification of serious cardiac disorder CAD, CHF, Arrhythmias (Initial history, Physical examination, ECG) Define disease severity, stability, and prior treatment Functional capacity Age Comorbid conditions (DM, peripheral vascular disease, renal dysfunction, chronic pulmonary disease) Type of surgery Consider higher risk vascular procedures prolonged complicated thoracic, abdominal and head and neck procedures

Further Preoperative Testing to Assess Coronary Risk

CAD is the most frequent cause of perioperative cardiac mortality and morbidity after noncardiac surgery Step-wise Bayesian strategy
clinical markers prior coronary evaluation and treatment functional capacity surgery-specific risk

Stepwise Approach to Preoperative Cardiac Assessment

Need for noncardiac surgery emergency O.R. no
yes

Postoperative risk stratification and risk factor management

Urgent or elective Coronary revascularization within 5 yrs no

yes

Recurrent symptoms or signs

yes

Recent coronary evaluation no

Recent coronary angiogram or stress test?

favorable result and no change in symptoms

O.R.

Unfavorable result and change in symptoms

Clinical predictors Major Intermediate Minor or No

Stepwise Approach to Preoperative Cardiac Assessment

Major clinical predictors
Major clinical predictors Unstable coronary syndromes Decompensated CHF Significant arrhythmias Severe valvular disease

delay or cancel noncardiac surgery

Coronary angiography

Medical management and risk factor modification

Subsequent care dictated by findings and treatment results

Stepwise Approach to Preoperative Cardiac Assessment

Intermediate clinical predictors

Poor (<4METs)

Moderate or excellent (>4METs)

High surgical risk precedure

Intermediate or low surgical precedure

Low surgical risk procedure

Noninvasive Low risk testing High risk Consider coronary angiography Subsequent care dictated by findings and treatment results

O.R.

Postoperative risk stratification and risk factor reduction

Intermediate clinical predictors Mild angina pectoris Prior MI Compensated or prior CHF DM

Stepwise Approach to Preoperative Cardiac Assessment

Minor or no clinical predictors Poor(<4METs) Moderate or excellent(>4METs)

High surgical risk procedure

Intermediate surgical risk procedure low risk O.R. Postoperative management

Noninvasive testing High risk

Consider coronary angiography

Subsequent care by findings and treatment results

Minor clinical predictors Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension

Clinical Predictors of Increased Perioperative Cardiovascular Risk

(Myocardial Infarction, Congestive Heart Failure, Death)

Major
Unstable coronary syndromes Recent myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina(Canadian Cardiovascular Society Class III or IV) Decompensated CHF Significant arrhythmias High grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease

Clinical Predictors of Increased Perioperative Cardiovascular Risk

(Myocardial Infarction, Congestive Heart Failure, Death)

Intermediate
Mild angina pectoris(Canadian Cardiovascular Society Class I or II) Prior myocardial infarction by history or pathological waves Compensated or prior CHF DM

Minor
Advanced age Abnormal EKG(LVH, LBBB, ST-T abnormalities) Rhythm other than sinus(eg, atrial fibrillation) Low functional capacity(eg, unstable to climb one flight or stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension

Estimated Energy Requirements for Various Activities

1 MET
Can you take care of yourself? Eat. Dress, or use the toilet? Walk indoors around the house? Walk a block or two on level ground at 2-3 mphor 3.2-4.8 km/hr Do light work around the house dusting or washing dishes?

4 METs

4 METs

>10 METs

Climb a flight of stairs or walk up a hill Walk on level ground at 4 mph or 6.4 km/h? Run a short distance? Do heavy work around the house like scrubbing floors or moving heavy furniture? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? Participate in strenuous sports like swimming, singles tennis, football, basket ball, or skiing

Cardiac Event Risk Stratification for Noncardiac Surgical Procedures

High
(reported cardiac risk often >5%) Emergent major operations, particularly in the elderly Aortic and other major vascular Peripheral vascular Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

Intermediate
(Reported cardiac risk generally <5%) Carotid endarterectomy Head and neck Intraperitoneal and intrathoracic Orthopedic Prostatic

Low
(reported cardiac risk generally <1%) Endoscopic procedures Superficial procedures Cataract Breast

Combind incidence of cardiac death and nonfatal myocardial infarction Further preoperative cardiac testing is not generally required.

General Approach

History Physical Exam Investigations

Important Features in History

Risk factors for IHD:

smoking, DM m, HTN, chol.
previous MI m family history of heart disease

Important Features in History

Acute Coronary Syndrome M unstable angina new onset angina acute MI
Congestive Heart Failure (CHF) M orthopnea, ankle swelling, PND, diuretics

Important Features in History

Presence of Valvular Disease M ask the patient about valves History of Arrhythmias M palpitations, dizziness, syncope

Important Features in History

Medications for CHF (diuretics, AT blocker, ACE I) for angina (beta blocker, NTG) for arrhythmia (sotalol, amiodarone)

The medication profile often provides good in formation about the patients condition

Physical Exam
Perform a thorough physical exam with a focu s on airway, respiratory and cardiac systems Look for MAJOR patient risk factors: CHF: (crackles, S3, JVP, edema) M Valve disease (murmurs) M

Investigations

Labs K from diuretic m Na from CHF m Cr from CRF m glucose (DM) m troponin M Hb to rule out as cause of ischemia

Investigations
Chest X-Ray (CXR)
Signs of CHF: M hilar fullness vascular redistribution Kerley B lines alveolar infiltrates (pulmonary edema) pleural effusions

Investigations
ECG
Acute MI M

Old MI m
Dysrhythmias M ventricular, 2nd or 3rd degree blocks, SVT

Echocardiography
Look for:
Valvular disease M

Decreased EF (<35% is high risk)

Method of Assessing Cardiac Risk

Resting Left Ventricular Function
Exercise Stress Testing

Pharmacological Stress Testing

Ambulatory EKG monitoring Coronary Angiography

Method of Assessing Cardiac Risk

Resting Left Ventricular Function Increased risk:
Ejection fraction < 35% severe diastolic dysfunction

CHF prior CHF or dyspnea of unknown etiology

Method of Assessing Cardiac Risk

Exercise Stress Testing treadmill or bicycle stress and ECG analysis, echocardiography degree of functional incapacity, symptoms of ischemia, severity of ischemia(depth, time of onset, duration of ST depression), evidence of hemodynamic or electrical instability correlated with increasing ischemic risk

Method of Assessing Cardiac Risk

Pharmacological Stress Testing for patients who are unable to exercise Dipyridamole or adenosine with thallium myocardial perfusion imaging Dobutamine echocardiography
Ambulatory ECG Monitoring

Coronary Angiography

Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class I:Patients with suspected or proven CAD High-risk results during noninvasive testing Angina pectoris unresponsive to adequate medical therapy Most patient with unstable angina pectoris Nondiagnostic or equivocal noninvasive test in a highrisk noncardiac surgical procedure
Class I: conditions for which there is evidence for and/or general agreement that a procedure or a treatment is of benefit

Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class II: Intermediate-risk results during noninvasive testing Nondiagnostic or equivocal noninvasive test in a lower-risk patients undergoing a high-risk noncardiac surgical procedure Urgent noncardiac surgery in a patient convalescing from acute MI Perioperative MI
Class II: conditions for which there is a divergence of evidence and/or opinion about the treatment

Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class III:

Low-risk noncardiac surgery in a patient with known CAD and low-risk results on noninvasive testing Screening for CAD without appropriate noninvasive testing Asymptomatic after coronary revascularization, with excellent exercise capacity(>7METs) Mild stable angina in patients with good LV function, low-risk noninvasive test results Patient is not a candidate for coronary revascularization because of concomitant medical illness Prior technically adequate normal coronary angiogram within previous 5years Severe LV dysfunction(e.g., EF<20%) and patient not considered candidate for revascularization procedure Patient unwilling to consider coronary revascularization procedure

Class III: conditions for which there is evidence and/or general agreement that the procedure is not necessary

Management of Preoperative Cardiovascular Conditions

Hypertension
Valvular Heart Disease Myocardial Heart Disease

Arrhythmias and Conduction Abnormalities

Cardiovascular
Routine ECG men over 40 and women ov

er 55. Full eval if symptomatic Med levels(digitalis) preop Take hypertensive and cardiac meds preop. No MAO or guanethidine 2 weeks prior to s urgery

Management of Preoperative Cardiovascular Conditions

Hypertension Severe HBP(DBP >110) should be controlled before surgery when possible Continuation of preoperative antihypertensive treatment is critical to avoid severe postoperative hypertension. Consider the urgency of surgery and the potential benefit of more intensive medical therapy.

Hypertension
Anesthetic agents vasodilate
Hypervolemia, hypoventilation,pain, meds,

distended bladder/stomach, pre-existing hyp ertension. Correct underlying d/o Nitroprusside

Management of Preoperative Cardiovascular Conditions

Valvular Heart Disease Symptomatic stenotic lesions(MS or AS): associated with risk of perioperative severe CHF or shock and often require percutaneous valvotomy or replacement to lower cardiac risk. Symptomatic regurgitant lesions(AR or MR): usually better tolerated perioperatively and may be stabilized before surgery with intensive medical therapy and monitoring

Management of Preoperative Cardiovascular Conditions

Myocardial Heart Disease Dilated and hypertrophic cardiomyopathy are associated with an increased incidence of perioperative CHF. Maximizing preoperative hemodynamic status and providing intensive postoperative medical therapy and surveillance.

Management of Preoperative Cardiovascular Conditions

Arrhythmias and Conduction Abnormalities careful evaluation for underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality. Therapy: reverse any underlying cause and treat the arrhythmia

Arrythmias
Cardiac dz,hypoxia, hypotension, acid/base/

electrolyte Supraventricular tachy adenosine, verapa mil, propanolol, diltiazem Afib/flutter Digoxin Ventricular tach- lidocaine Cardiology consult

Preoperative Coronary Revascularization

Coronary Artery Bypass Graft Surgery
Coronary Angioplasty

Medical Therapy for Coronary Artery Disease

If patients require beta-blockers, calcium channel

blockers, or nitrates before surgery, continue them into the operative and post-op period. The same is true for therapies used to control CHF Beta-blockers reduce postoperative ischemia,
Protection against ischemia may also reduce risk of MI

Anesthetic Considerations
Anesthetic agent No one best myocardial protective anesthetic technique. Opioid:cardiovascular stability, but need postoperative ventilation Inhalational agent: myocardial depression Neuraxial block: sympathetic blockade
low level:minimal hemodynamic change abdominal operation: profound effects(hypotension, reflex tachycardia)

Anesthetic Considerations
Perioperative pain management PCA(iv or epidural) leads to a reduction in postoperative catecholamine surges and hypercoagulability, both of which can theoretically impact myocardial ischemia.

Anesthetic Considerations
Intraoperative nitroglycerine Helpful or harmful
vasodilating properties of NTG with anesthetics can cause significant hypotension and even myocardial ischemia.

Transesophageal echocardiography Guidelines for the use of TEE to diagnosis or guide therapy are being developed by ASA

Perioperative Surveillance
Pulmonary artery catheters
recent MI complicated by CHF significant CAD with procedures assoc. with significant hemodynamic stress. Systolic or diastolic LV dysfunction cardiomyopathy

valvular disease with high risk operation

Perioperative Surveillance
Intraoperative and postoperative ST

monitoring
Intraoperative and postoperative ST changes are strong predictors of perioperative MI in patients at high risk who undergo noncardiac surgery proper use of computerized ST-segment analysis may improve sensitivity for detection of myocardial ischemia

Perioperative Surveillance
Surveillance for perioperative MI Clinical symptoms Postoperative ECG changes CK-MB, troponin-I, troponin-T, CK-MB isoforms
In patients with known or suspected CAD undergoing high risk procedures, obtaining ECG at baseline, immediately after the procedure, and for the first 2 postoperative days appears to be cost effective Use of cardiac enzymes is best reserved for patients with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction.

Postoperative Therapy and LongTerm Management

Postoperative management should include

assessment and management of modifiable risk factors for CAD, heart failure, HBP, stroke, and other cardiovascular diseases. Assessment for hypercholesterolemia, smoking, hypertension, DM, physical inactivity, peripheral vascular disease, cardiac murmur(s), arrhythmias, perioperativeischemia, and MI may lead to evaluation and treatments that reduce future cardiovascular risk