1. Preoperative Evaluation of Cardiac Patient for Noncardiac surgery
Dr Balaji Asegaonkar
MD,DNB (Anaesthesia)
Consultant cardiac anaesthesiologist
Ozone Anaesthesia Group, Aurangabad.

2. CASE 1 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD
ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTS
ON DUAL ANTIPLATELATE AGENTS
TO BE POSTED FOR TURP

3. CASE 2 70 YR MALE ,HYPERTENSIVE, DIABETIC & SEVERE OSTEOARTHRITIS.
SMOKER FOR LAST 30 YRS.
TO BE POSTED FOR TKR

4. CASE 3 80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCE
TO BE POSTED FOR CATARACT

5. Let’s face it…
The surgical population is older, sicker, on more medications, and having more & more cardiac interventions.
There is a subset of your patients for whom the patient, the surgeon, or you may have questions about cardiovascular risk.

6. So what do you do?
Guess?…Argue?…Worry?…Refer everyone cardiological investigations
OR do a thorough, focused exam.
Followed by the individualized application of some authoritative guidelines…
…for evaluation, risk stratification, and management…
…and refer, delay, or cancel only when appropriate.

7. Authoritative guidelines…..?
Evidence based medicine.
Based on research findings, expert opinion, and consensus .
Cardiovascular authority, like American College of Cardiology/American Heart Association.
Anaesthesiology authority, like ASA.
I am not a cardiologist, nor do I play one on TV. The point is to learn as much as possible, act responsibly based on your own knowledge and the knowledge of experts, and get assistance when you need it.

8. Objectives: How to approach cardiac Patients. Risk stratification.
Modification of level of care.
Discuss standard recommendation.

9. focused approach………
We are not cardiologists, We simply need to recognize when a cardiac condition might affect the patient’s response to anaesthesia, and what to do about it. We need to be:
Thorough enough to find all significant problems (sensitivity).
Focused enough to consider only significant problems (specificity).

10. …and Stepwise Approach?
Thorough, focused cardiac evaluation
ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery (2007).
Indicated cardiac testing and consultation.
Optimization of cardiovascular function in relation to the demands of the surgery and the anaesthesia.

11. The courage is knowledge of how to fear what ought to be feared & how not to fear what ought not to be feared.

12. Applying Classification of Recommendations and Level of Evidence
Class I Benefit >>> Risk
Procedure/ Treatment SHOULD be performed/ administered
Class IIa Benefit >> Risk Additional studies with focused objectives needed
IT IS REASONABLE to perform procedure/administer treatment
Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III
Risk ≥ Benefit No additional studies needed
Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Level of Evidence:
Level A: Data derived from multiple randomized clinical trials or meta-analyses
Multiple populations evaluated
Level B: Data derived from a single randomized trial or nonrandomized studies
Limited populations evaluated
Level C: Only consensus of experts opinion, case studies, or standard of care
Very limited populations evaluated

13. So, let’s start with …
The Preop portion of the ACC/AHA Guidelines, which is based on your history and physical, plus indicated tests.

14. Guidelines : Stepwise approach
Need for surgery:Emergent vs Urgent/Elective.
Clinical Risk Predictors:
(Major, Intermediate, Minor).
Functional capacity (Exercise tolerance).

15. ACC/AHA Guidelines: Preop
Surgical Risk Predictors: (High, Intermediate, Low)
Recent coronary revascularization or Evaluation.

16. Major Clinical Risk Predictors
Unstable Coronary Syndromes:
Recent MI (> 7 and < 30 days).
Unstable angina (Canadian Class III-IV).
Decompensated CHF.
Significant Dysrhythmias.
High-grade AV block.
Symptomatic ventricular dysrhythmias.
Supraventricular dysrhythmias with uncontrolled ventricular rate.
Severe Valve Disease.

17. Intermediate Clinical Risk Predictors
Mild angina (Canadian Class I - II).
Prior MI by history or pathological Q waves.
Compensated or prior CHF.
Diabetes, especially IDDM.
Renal Insufficiency (creatinine > 2mg%).

18. Minor Clinical Risk Predictors
Advanced age.
Abnormal ECG (LVH, LBBB, ST-T abnl).
Rhythm other than sinus (e.g. a-fib).
Low functional capacity (< 4 METs).
Hx CVA.
Uncontrolled HTN (>180 / >110).
So, at some point someone is going to ask, “What’s Canadian Class Angina?”

19. Cardiac Functional Classification: Canadian Cardiovascular Society
No angina with ordinary physical activity . Angina with strenuous exertion.
II. Slight limitation of ordinary activity.
III. Marked limitation of ordinary activity.
IV. Inability to carry on any physical activity without discomfort. Angina may be present at rest.

20. Functional Capacity = Exercise Tolerance
Major clinical risk predictors are sufficient alone to trigger further testing or intervention before pt posted for Sx.
Intermediate and minor clinical risk predictors are subject to a second step:
Evaluation of cardiovascular functional capacity, i.e., exercise tolerance.

21. Exercise Tolerance
Angina or anginal equivalents (DOE, palpitations, fatigue)= Ischemic threshold.
Point where metabolic demand > supply
Metabolic equivalent (MET): MET = resting O2 consumption(VO2)
= 3.5mL/kg/min
Functional capacity in METs:
Poor: < 4
Mod: 4-7: > 4 is the “tipping point”.
Good:
Excellent: > 10.

22. Exercise Tolerance in METs
1 MET: Eat, dress, use the toilet.
2 METs: Household ambulation.
3 METs: Light housework Walk level ground 2-3 MPH.
4 METs: Walk up one flight stairs. Walk level ground 4 MPH.
4-10 METs: Run short distance. Scrub floors, move furniture. Moderate sports.
>10 METs: Strenuous sports.

23. Surgical Risk Predictors
High (> 5% Cardiac Death/MI). Emergent major operation, espec. in elderly, Aortic and other major vascular Sx Peripheral vascular,Prolonged procedure.
Intermediate (< 5%) Carotid endarterectomy, Head & neck Intraperitoneal, Intrathoracic, Prostate, Ortho
Low (< 1%) Endoscopic, Superficial, Cataract, Breast

25. Procedure Details : Angioplasty
Time since procedure.
Which artery.
Present medication.
Symptoms benefits.
Baseline ECG.
Which stents.

26. DRUG ELUTING STENT ANTICACER DRUGS COATED.
SLOW RELEASE TILL 6 TO 8 MONTH.
NO ENDOTHELIAZATION.
LEAST CHANCE OF INSTENT THROMBOSIS
ANTIPLATELETS

27. Post plasty :Noncardiac surgery

28. Treatment for patients requiring PCI who need subsequent surgery

29. Procedure Details : CABG
Time since procedure.
Which arteries grafted & Type of conduit.
Present medication.
Symptoms benefits.
Baseline ECG

30. Recommended stepwise approach
How urgent noncardiac surgery is ?
p/o risk stratification & assessment done.
All these are Gr V cases.

31. Step 2 Has Pt undergone coronary revascularisation in past 5 yrs ?
If yes & Pt has no s/s of cardiac problem – further detail cardiac testing not required.

32. Step 3
If Pt has any coronary evaluation in past yrs – revealing no significant CAD ,if there is no aggravations of s/s –no further testing is needed.

33. Step 4 Does Pt have any major clinical predictors ?
Delay noncardiac surgery until problem has identified & treated.

34. Step 5 If Pt have intermediate clinical predictors.
Consider functional capacity & surgery specific risks.
Decide accordingly weather further testing needed or not.

35. Step 6
Pt with intermediate predictor & mod to excellent functional capacity can undergo intermediate Sx.
Pt with 2 or more intermediate predictor & poor functional capacity OR mod functional capacity but high risk Sx – further testing & evaluation needed.

36. Step 7
Noncardiac Sx safe in Pt with minor clinical predictor & mod to excellent functional capacity.
Additional testing must for Pt with no clinical predictors but poor functional capacity & who are facing high risk Sx.

37. CASE 1 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD
ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTS
TO BE POSTED FOR TURP

38. CASE 2 70 YR FEMALE ,HYPERTENSIVE & SEVERE OSTEOARTHRITIS.
CABG DONE 2 YRS BACK ON ANTIPLATE, ANTI HT & STATINS
TO BE POSTED FOR TKR

39. CASE 3 80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCE
TO BE POSTED FOR CATARACT

40. Thanks....!

43. Step 8
In documented CAD , if risk of coronary interventions or CABG exceeds proposed noncardiac Sx & if such Sx improves long term prognosis of Pt – noncardiac Sx should be done.

48. Summary from ACC / AHA
Perioperative evaluation and mgmt of high-risk cardiac patients for noncardiac surgery requires careful teamwork and communication between patient, surgeon, anesthesiologist, physian or cardiologist.
Indications for cardiac testing and treatments are the same as in the non-operative setting, and should clearly affect patient management.
Factors include the urgency of surgery, patient-specific risk factors, and surgery-specific considerations.

49. Summary
For many patients, noncardiac surgery represents their first opportunity for assessment of short- and long-term cardiac risk. The consultant best serves the patient by making recommendations aimed at lowering the immediate perioperative cardiac risk, as well as assessing the need for postoperative risk stratification and interventions directed to modify cardic risk factors.
Future research should be directed at determining the value of routine prophylactic medical therapy vs. more extensive diagnostic testing and interventions.

50. Proposed Approach to the Management of Patients with Previous PCI Who Require Noncardiac Surgery
Balloon
Bare-metal
Drug-eluting
angioplasty
stent
stent
<365 days
> days
< days
>365 days
Time since PCI
<14 days
>14 days
Delay for elective or
Proceed to the
Delay for elective or
Proceed to the
nonurgent
surgery
operation room
nonurgent
surgery
operating room
with aspirin
with aspirin
PCI, percutaneous coronary intervention

51. Proposed Treatment for Patients Requiring PCI Who Need Subsequent Surgery
Acute MI, H risk ACS, or
H risk cardiac anatomy
Stent & continue dual antiplatelet therapy
Bleeding risk of surgery
low
Not low
Timing of surgery
14-29 days
days
>365 days
Bare-metal
stent
Balloon
angioplasty
Drug-eluting
stent

52. Recommendations for Perioperative Beta-Blocker Therapy
Surgery
No Clinical Risk Factors
CAD or High Risk (1 or more clinical risk factors)
Patients Currently Taking Beta Blockers
Vascular
Class llb, Level of Evidence: B
Class lla, Level of Evidence: B
Class 1, Level of Evidence: C
Intermediate risk …
Low risk

53. Recommendations for Statin Therapy
For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued.
For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable.
For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures,
statins may be considered. I
IIa
IIb
III B

54. Happy Anaesthesia Day

58. Aims on evaluation Delay case for treatment of unstable symptoms.
Modification of intraoperative or postoperative (e.g. ICU) monitoring.

59. Aims on evaluation Modification of perioperative medical therapy.
Coronary or valve procedure before noncardiac surgery.
Modification of location of care

60. Rest ECG: Indications
Class I:Recent angina with intermed-high risk clinical predictors for intermed-high risk procedure.
Class IIa: Asymptomatic diabetics.
Class IIb: Prior coronary revascularization or cardiac hospital admission. Asymptomatic males > 45 or females > 55 with 2 CAD risk factors.
Class III: Asymptomatic pts. For low-risk procedures

61. Rest ECG: Significant Findings
Path.Q waves (> 0.4s wide, or > 25% of R, in 2 contiguous leads): Size and extent predict LVEF, long term mortality.
Horizontal or downsloping ST depression > 0.5mm, LVH with strain pattern (ST depression + TWI in I, II, III, AVL or AVF, V5, V6), LBBB with CAD predict increased perioperative risk and long term mortality.
Significant dysrhythmias: High-grade AV block, symptomatic ventricular dysrhythmias, supraventricular dysrhythmias with uncontrolled rate.

62. Echocardiogram: Indications
Asymptomatic murmurs :
Class I: Diastolic, continuous, holosystolic, mid & late systolic, III/VI murmurs.
Class IIa: Murmur assoc with abnl cardiac palpation or auscultation, abnl ECG or CXR.
Class III: II/VI midsystolic innocent murmur. Dx of “silent” AR or MR without murmur, to recommend endocarditis prophylaxis.

63. Echocardiogram: Indications
Symptomatic murmur:
Class I: S/S of CHF, MI, syncope, infective endocarditis, thromboembolism
Class IIA: S/S possibly non-cardiac.
Class III: S/S non-cardiac dz with midsystolic “innocent” murmur

64. Stress Testing: ECG or Echo
Normal rest ECG → ECG stress, Abnl ECG → Echo
Class I: Dx of intermediate probability CAD, Prognosis of CAD or s/p ACS, Eval of med tx. Proof of ischemia before revascularization.
Class IIa: Evaluate exercise tolerance in unreliable historian.
Class IIb: Dx of high or low probability CAD, Resting ST depression < 1mm, On digoxin, LVH by ECG, Dx of restenosis in high-risk asymptomatic .
Class III: Resting pre-excitation or ST depression > 1mm, Routine screening. 28

65. Recommendations for CAG in Preop Evaluation
Class I: Patients With Suspected or Known CAD
Evidence for high risk of adverse outcome based on noninvasive test results.
Angina unresponsive to adequate medical therapy.
Unstable angina, particularly when facing intermediate-risk* or high-risk* noncardiac surgery.
Equivocal noninvasive test results in patients at high clinical risk undergoing high-risk* surgery.
Class IIa
Multiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first).
Moderate to large ischemia on noninvasive testing but without high-risk features and lower left ventricular ejection fraction.
Nondiagnostic noninvasive test results in patients at intermediate clinical risk undergoing high-risk* noncardiac surgery.
Urgent noncardiac surgery while convalescing from acute MI.

66. Recommendations for CAG in Preop Evaluation
Class IIb
Perioperative MI.
Medically stabilized class III or IV angina and planned low-risk or minor* surgery.
Class III
Low-risk* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).
Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., left ventricular ejection fraction less than 0.20), or refusal to consider revascularization.
Candidate for liver, lung, or renal transplant less than 40 years old, as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.