Preoperative Cardiac Clearance

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Preoperative Cardiac Clearance

• Kelly D. Green, M3

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Revised Cardiac Risk Index

• High risk surgery (intra thoracic,
  intraperitoneal, suprainguinal vascular)
• Ischemic heart disease
• CHF History
• Cerebrovascular disease history (CVA or TIA)
• Preoperative Tx with insulin
• Creatinine gt 2.0

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Clinical predictors of increased perioperative
cardiovascular riskMajor

• Unstable coronary syndrome
• Decompensated heart failure
• Significant arrythmias
• Severe valvular disease

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Clinical predictors of increased perioperative
cardiovascular riskIntermediate

• Mild angina pectoris
• Previous MI by history or Q waves
• Compensated or prior heart failure
• DM (particularly insulin dependent)
• Renal insufficiency

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Clinical predictors of increased perioperative
cardiovascular riskMinor

• Advanced age
• Abnormal ECG (LBBB, LVH, ST-T abnormalities)
• Rhythm other than sinus
• Low functional capacity
• History of Stroke
• Uncontrolled systemic HTN

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Estimated energy requirements for various
activities

• 1 MET - Can you take care of yourself? (eat,
  dress, use toilet)
• Walk around the house
• Walk on level ground at 2-3 mph
• Do light house work

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Estimated energy requirements for various
activities

• 4 METs
• Climb a flight of stairs or walk up a hill
• Walk on level ground at 4-6 mph
• Run a short distance
• Heavy house work (lifting, moving furniture)
• Participate in recreational activities

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Estimated energy requirements for various
activities

• gt10 METs
• Strenuous activities like swimming, tennis,
  football, skiing.

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Cardiac Risk Stratification for Noncardiac Surgery

• High (risk gt5)
• Emergent procedures
• Aortic or other major vascular
• Peripheral vascular
• Prolonged surgery w large fluid shifts

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Cardiac Risk Stratification for Noncardiac Surgery

• Intermediate (risk lt5)
• CEA
• Head and neck surgery
• Intraperitoneal and intrathoracic
• Orthopedic surgery
• Prostate surgery

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Cardiac Risk Stratification for Noncardiac Surgery

• Low (risk lt1)
• Endoscopic procedure
• Superficial procedure
• Cataract surgery
• Breast surgery

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References

• Grayburn P, Hillis LD. Cardiac events in patients
  undergoing noncardiac surgery shifting the
  paradigm from noninvasive risk stratification to
  therapy. Ann of Intern Med. 2003138506-511
• ACC/AHA Guidelines Flow chart
• JACC. 2002 39545