1. 3/99medslides.com1 Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery ACC/AHA Task Force JACC 1996; 27:910-945 Circulation 1996; 93:1278-1317

2. 3/99medslides.com2 Objectives Understand ACC/AHA guidelines Evaluate and accurately manage cardiac patients undergoing noncardiac surgery Identify preoperative techniques for assessing cardiac risk in patients being considered for noncardiac surgery

3. 3/99medslides.com3 Cardiac Risk Stratification (nonfatal MI and Death) 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 (risk generally <5% ) Carotid endarterectomy Head and neck Intraperitoneal and intrathoracic Orthopedic Prostate Low * (cardiac risk generally <1% ) Endoscopic procedures Superficial procedures Cataract Breast * Further preoperative cardiac testing is generally unnecessary. ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

4. 3/99medslides.com4 Clinical Predictors of Increased Perioperative Cardiovascular Risk (MI, CHF, Death) Major Unstable coronary syndromes –Recent MI ( >7 days but  30 days) with evidence of important ischemic risk by clinical symptoms or noninvasive study –Unstable or severe angina (Canadian Cardiovascular Society Class III or IV). May include “stable” angina in patients who are unusually sedentary. Decompensated congestive heart failure Significant arrhythmia –High-grade atrioventricular block –Symptomatic ventricular arrhythmias in the presence of underlying heart disease –Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

5. 3/99medslides.com5 Clinical Predictors of Increased Perioperative Cardiovascular Risk (MI, CHF, Death) Intermediate Mild angina pectoris (Canadian Cardiovascular Society Class I or II) Prior myocardial infarction by history or pathological waves Compensated or prior congestive heart failure Diabetes mellitus Minor Advanced age Abnormal electrocardiogram (LVH, LBBB, ST-T abnormalities) Rhythm other than sinus(eg. atrial fibrillation) Low functional capacity (eg. Unable to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

6. 3/99medslides.com6 Grading of Angina of Effort by the Canadian Cardiovascular Society I.“Ordinary physical activity does not cause … angina,” such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation. II.“Slight limitation of ordinary activity.” Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. III.“Marked limitation of ordinary physical activity.” Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace. IV.“inability to carry on any physical activity without discomfort -- anginal syndrome may be present at rest.” Circulation 1976; 54:522-523

7. 3/99medslides.com7 Estimated Energy Requirements for Various Activities 1 METCan 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 mph or 3.2-4.8 km/h? 4 METsDo light work around the house like dusting or washing clothes? MET = metabolic equivalent 4 METsClimb 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 lifting or moving heavy objects? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? 10 METsParticipate in strenuous sports like swimming, singles tennis, football, baseball, or skiing?

8. 3/99medslides.com8 Stepwise Approach to Preoperative Cardiac Assessment 1. Need for noncardiac surgery 2. Coronary revascularization within 5 years ? Recurrent symptoms or signs ? 3. Recent coronary evaluation Recent coronary angiogram or stress test ? Postoperative risk stratification and risk factor management Operating Room 4. Clinical predictors Urgent or Elective Emergency Yes No Unfavorable OR change in symptoms Favorable AND no change in symptoms ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

9. 3/99medslides.com9 Stepwise Approach to Preoperative Cardiac Assessment 4. Clinical predictors 6. Intermediate clinical predictor 7. Minor or no clinical predictor 5. Major clinical predictor Unstable coronary syndromes Decompensated congestive heart failure Significant arrhythmia Severe valvular disease Mild angina pectoris Prior myocardial infarction Compensated or prior CHF Diabetes mellitus Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

10. 3/99medslides.com10 Stepwise Approach to Preoperative Cardiac Assessment 5. Major clinical predictor Major Clinical Predictor Unstable coronary syndromes Decompensated congestive heart failure Significant arrhythmia Severe valvular disease ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317 Consider delay or cancel noncardiac surgery Consider coronary angiography Medical management and risk factor modification Subsequent care dictated by findings and treatment results

11. 3/99medslides.com11 Stepwise Approach to Preoperative Cardiac Assessment ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317 Poor (<4 METs) 6. Intermediate clinical predictor Moderate or excellent (>4 METs) Intermediate or low surgical risk procedure High surgical risk procedure Low surgical risk procedure 8. Noninvasive testing Consider coronary angiography Subsequent care dictated by findings and treatment results Operating room Postoperative risk stratification and risk factor reduction Low risk High risk Functional capacity Surgical risk Noninvasive testing Invasive testing

12. 3/99medslides.com12 Stepwise Approach to Preoperative Cardiac Assessment ACC/AHA Task Force JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317 Poor (<4 METs) Moderate or excellent (>4 METs) Intermediate or low surgical risk procedure High surgical risk procedure Low surgical risk procedure 8. Noninvasive testing Consider coronary angiography Subsequent care dictated by findings and treatment results Operating room Postoperative risk stratification and risk factor reduction Low risk High risk Functional capacity Surgical risk Noninvasive testing Invasive testing 7. Minor or no clinical predictor

13. 3/99medslides.com13 Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class I: (suspected or proven CAD) High-risk results during noninvasive testing Angina pectoris unresponsive to adequate medical therapy Most patients with unstable angina Nondiagnostic or equivocal noninvasive test in a high-risk patient undergoing a high-risk noncardiac surgical procedure Class II: Intermediate-risk results during noninvasive testing Nondiagnostic or equivocal noninvasive test in a lower-risk patient undergoing a high-risk noncardiac surgical procedure Urgent noncardiac surgery in a patient convlescing from acute MI Perioperative MI ACC/AHA Guidelines for Coronary Angiography JACC 1987; 10:935-950; Circ 1987; 76:963A-977A Class III: Low-risk noncardiac surgery in a patient with known CAD and low-risk results on invasive testing Screening for CAD without appropriate noninvasive testing Asymptomatic after coronary revascularization with excellent exercise capacity (  7 METs) Mild stable angina in patients with good LV function, low-risk noninvasive test result Patient is not a candidate for coronary revascularization because of concomitant medical illness Prior technically adequate normal coronary angiogram within previous 5 years Severe LV dysfunction (EF <20%) and patient not considered candidate for revasularization Patient unwilling to consider coronary revascularization procedure