November, 1998 Council on Clinical Cardiology Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery* A Report of the American College.
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November, 1998 Council on Clinical Cardiology
Guidelines for Perioperative Guidelines for Perioperative Cardiovascular Evaluation Cardiovascular Evaluation for Noncardiac Surgery*for Noncardiac Surgery*
A Report of the American College of
Cardiology/American Heart AssociationTask Force on
Practice Guidelines
*Eagle KA, Brundage BH, Chaitman, BR et al: Circulation 1996;93:1278-1317 and
JACC 1996;27:910-948.© 1998 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.
November, 1998 Council on Clinical Cardiology
Committee on Post Graduate Committee on Post Graduate Education, Council on Clinical Education, Council on Clinical
Cardiology, Cardiology, American Heart AssociationAmerican Heart Association
Prepared by:Jamie Conti, MD
Forrester Lee, MD
November, 1998 Council on Clinical Cardiology
Purpose of Preoperative Purpose of Preoperative EvaluationEvaluation
Evaluate patient’s current medical status.
Provide clinical risk profile. Provide recommendations for
management of cardiac risk over entire perioperative period.
November, 1998 Council on Clinical Cardiology
Role of the ConsultantRole of the Consultant
Review available patient data, history and physical examination.
Communicate severity and stability of patient’s cardiovascular status.
Determine if patient in optimal medical condition, given context of surgical illness.
November, 1998 Council on Clinical Cardiology
General Approach to the General Approach to the PatientPatient
History Physical Examination Comorbid Diseases
Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders
Ancillary Studies
November, 1998 Council on Clinical Cardiology
Clinical Predictors of Clinical Predictors of Increased Perioperative Increased Perioperative
Cardiovascular RiskCardiovascular Risk Major
Unstable coronary syndromes.
Decompensated CHF. Significant Arrhythmias.
Intermediate Mild angina pectoris. Prior MI. Compensated or prior
CHF. Diabetes Mellitus.
Minor Advanced Age. Abnormal ECG. Rhythm other than
sinus. Low functional
capacity. History of stroke. Uncontrolled HTN.
November, 1998 Council on Clinical Cardiology
Disease Specific ApproachesDisease Specific Approaches
Coronary Artery Disease (CAD). Patients with known CAD. Patients with major risk factors for CAD.
Hypertension. Congestive Heart Failure. Valvular Heart Disease. Arrhythmias and Conduction Defects. Pulmonary Vascular Disease.
November, 1998 Council on Clinical Cardiology
Type of SurgeryType of Surgery
Urgency. High surgical risk:
Aortic and other major vascular. Peripheral vascular. Anticipated prolonged surgical
procedures associated with large fluid shifts
and/or blood loss.
November, 1998 Council on Clinical Cardiology
Type of SurgeryType of Surgery
Intermediate surgical risk:• Carotid endarterectomy.• Head and neck surgery.• Intraperitoneal and intrathoracic,
orthopedic and prostate surgery.
November, 1998 Council on Clinical Cardiology
Type of SurgeryType of Surgery
Low surgical risk:• Endoscopic and superficial procedures.• Cataract surgery.• Breast surgery.
November, 1998 Council on Clinical Cardiology
Supplemental Preoperative Supplemental Preoperative EvaluationEvaluation
Noninvasive resting left ventricular function: Risk of
complications greatest with EF<35%.
Recommendations Class I: Poorly
controlled CHF. Class II: Prior
CHF or dyspnea of unknown etiology.
Class III: Routine test without prior CHF.
November, 1998 Council on Clinical Cardiology
Assessment of Risk for Assessment of Risk for Coronary Artery Disease and Coronary Artery Disease and
Functional Capacity (1)Functional Capacity (1)
Goal: Provide objective measure of
functional capacity. Identify presence of preoperative
myocardial ischemia or cardiac arrhythmias.
Estimate perioperative cardiac risk and long-term prognosis.
November, 1998 Council on Clinical Cardiology
Assessment of Risk for Assessment of Risk for Coronary Artery Disease and Coronary Artery Disease and
Functional Capacity (2)Functional Capacity (2)
Specific Approaches: Exercise stress testing. Nonexercise stress testing:
Dobutamine stress echocardiography.
Dipyridamole/adenosine thallium testing.
Ambulatory electrocardiographic monitoring.
November, 1998 Council on Clinical Cardiology
Assessment of Risk for Assessment of Risk for Coronary Artery Disease and Coronary Artery Disease and
Functional Capacity (3)Functional Capacity (3)
Recommendations: Test of choice is exercise ECG testing.
Provides estimate of functional capacity.
Detects myocardial ischemia.
November, 1998 Council on Clinical Cardiology
Implications of Risk Implications of Risk Assessment Strategies on Assessment Strategies on
CostsCosts
Proposed benefit: Identifying unsuspected CAD. Decreasing morbidity/mortality.
Risk: Morbidity/mortality from test. Cost of screening. Cost of treatment.
November, 1998 Council on Clinical Cardiology
Preoperative Therapy (1)Preoperative Therapy (1)
Recommendation: Preoperative CABG Patients with prognostic high risk
coronary anatomy in whom long-term outcome would likely be improved.
Noncardiac elective surgical procedure of high or intermediate risk.
November, 1998 Council on Clinical Cardiology
Preoperative Therapy (2)Preoperative Therapy (2)
Recommendation: Preoperative Coronary Angioplasty. No randomized clinical trials
documenting decreased incidence of perioperative cardiac events.
No prospective studies to determine optimal period of delay.
November, 1998 Council on Clinical Cardiology
Preoperative Therapy (3)Preoperative Therapy (3)
Recommendations: Medical Therapy. Few randomized trials. Preliminary studies suggest B-blockers
reduce perioperative ischemia and may reduce risk of MI and death.
November, 1998 Council on Clinical Cardiology
Preoperative Therapy with B-Preoperative Therapy with B-BlockersBlockers
Class I. B-blockers required in recent past to control symptoms of angina; patients with symptomatic arrhythmias or hypertension.
Class II. Preoperative assessment identifies untreated hypertension, known coronary disease, or major risk factors for coronary disease.
Class III. Contraindications to B-blockade.
November, 1998 Council on Clinical Cardiology
Preoperative Valve SurgeryPreoperative Valve Surgery
Valvular heart disease severe enough to warrant surgical treatment should have valve surgery before elective noncardiac surgery.
Patients with severe mitral or aortic stenosis who require urgent noncardiac surgery may benefit from catheter balloon valvuloplasty.
November, 1998 Council on Clinical Cardiology
Preoperative Intensive Care Preoperative Intensive Care (1)(1)
Goal Optimize and augment oxygen delivery
in patients at high risk. Hypothesis
Indices derived from pulmonary artery catheter and invasive blood pressure monitoring can be used to maximize oxygen delivery, which leads to reduction in organ dysfunction.
November, 1998 Council on Clinical Cardiology
Preoperative Intensive Care Preoperative Intensive Care (2)(2)
Recommendations:
Based on scant evidence, preoperative preparation in intensive care unit may benefit certain high risk patients, particularly those with decompensated CHF.
November, 1998 Council on Clinical Cardiology
General Guidelines for General Guidelines for PerioperativePerioperative
Prophylaxis for Venous Prophylaxis for Venous Thromboembolism*Thromboembolism*Type of Patient/Surgery
Minor surgery in a pt <40 yo w/ no correlates of venous thromboembolism risk
Moderate-risk surgery in a pt >40 yo w/ correlates of thromboembolism risk †
Major surgery in pt >40 yo w/ clinical conditions associated w/ venous thromboembolism risk †
Recommendation
Early ambulation
ES; LDH (2 h preop & q 12 h after), or IPC (intraop & postop)
LDH (q 8 h) or LMWH. IPC is prone to wound bleeding
*Developed from Clagett et al. Prevention of venous thromboembolism. Chest. 1992;102(suppl 4):391S-407S.
November, 1998 Council on Clinical Cardiology
Perioperative Prophylaxis for Perioperative Prophylaxis for Venous Thromboembolism (2)Venous Thromboembolism (2)
Type of Patient/Surgery
Very high-risk surgery in a pt w/multiple clinical conditions associated with thromboembolism risk
Total hip replacement
Recommendation
LDH, LMWH, or dextran combined w/ IPC. In selected pts, periop warfarin (INR2.0-3.0) may be used.
LMWH (postop, subq twice daily, fixed dose unmonitored) or warfarin (INR 2.0-3.0, started preop) or immed after surgery) or adjusted dose unfractionated heparin (started preop). ES or IPC may provide addn’l efficacy.
November, 1998 Council on Clinical Cardiology
Perioperative Prophylaxis for Perioperative Prophylaxis for Venous Thromboembolism (3)Venous Thromboembolism (3)
Type of Patient/Surgery
Total knee replacement
Hip fracture surgery
Intracranial neurosurgery
Recommendation
LMWH (posto, subq, twice daily, fixed dose unmonitored) or IPC.
LMWH (preop, subq., fixed dose unmonitored) or warfarin (INR 2.0-3.0). IPC may provide addn’l benefit.
IPC w/ or w/o ES. Consider add’n of LDH in high-risk pts.
November, 1998 Council on Clinical Cardiology
Perioperative Prophylaxis for Perioperative Prophylaxis for Venous Thromboembolism (4)Venous Thromboembolism (4)
Type of Patient/Surgery
Acute spinal cord injury with lower- extremity paralysis
Patients with multiple trauma
Recommendation
Adjusted dose heparin or LMWH for prophylaxis. Warfarin may also be effective. LDH, ES, and IPC may have benefit when used together.
IPC, warfarin, or LMWH when feasible, serial surveillance with duplex ultrasonography may be useful. In selected very high-risk pts, consider prophylactic caval filter.
November, 1998 Council on Clinical Cardiology
Anesthetic Considerations Anesthetic Considerations and Intraoperative and Intraoperative Management (1)Management (1)
No study clearly demonstrated improved outcome from use of: Pulmonary artery catheter. ST-segment monitoring. Transesophageal echocardiography. Intravenous nitroglycerin. Prophylactic placement of intra-aortic
balloon counterpulsation device.
November, 1998 Council on Clinical Cardiology
Anesthetic Considerations Anesthetic Considerations and Intraoperative and Intraoperative Management (2)Management (2)
Choice of anesthetic and intraoperative monitoring best left to discretion of anesthesia care team.
November, 1998 Council on Clinical Cardiology
Perioperative SurveillancePerioperative Surveillance
Post operative myocardial ischemia: Strongest predictor of perioperative
cardiac morbidity. May go untreated until overt
symptoms of cardiac failure develop. Diagnosis of perioperative MI has short
and long-term prognostic value. 30% to 50% perioperative mortality
and reduced long-term survival.
November, 1998 Council on Clinical Cardiology
Perioperative Surveillance: Perioperative Surveillance: Intraoperative and Postoperative Use Intraoperative and Postoperative Use
of Pulmonary Artery Cathetersof Pulmonary Artery Catheters
Class I: Patients at risk for major hemodynamic disturbances most easily detected by a pulmonary artery catheter undergoing procedure likely to cause these hemodynamic changes in setting with experience in interpreting results.
Class II: Either patients' condition or surgical procedure (but not both) places patient at risk for hemodynamic disturbances.
Class III: No risk of hemodynamic disturbances
November, 1998 Council on Clinical Cardiology
Perioperative Surveillance: Perioperative Surveillance: Potential Myocardial Potential Myocardial
Infarction (1)Infarction (1)
Patients without evidence of CAD: Surveillance restricted to those who
develop perioperative signs of cardiovascular dysfunction.
November, 1998 Council on Clinical Cardiology
Perioperative Surveillance: Perioperative Surveillance: Potential Myocardial Potential Myocardial
Infarction (2)Infarction (2)
Patients with known or suspected CAD: ECGs at baseline, immediately after
procedure, and daily x 2 days. Measurements of cardiac enzymes best
reserved for patients at high risk or who demonstrate ECG or hemodynamic evidence of cardiovascular dysfunction.
November, 1998 Council on Clinical Cardiology
Perioperative Surveillance: Perioperative Surveillance: Arrhythmia/Conduction Arrhythmia/Conduction
Disease (1)Disease (1)
Often due to remedial noncardiac problems: Infection. Hypotension. Metabolic derangements. Hypoxia.
November, 1998 Council on Clinical Cardiology
Perioperative Surveillance: Perioperative Surveillance: Arrhythmia/Conduction Arrhythmia/Conduction
Disease (2)Disease (2)
Cardioversion not recommended until precipitating causes corrected or modified.
Electrical cardioversion for supraventricular or ventricular arrhythmias causing hemodynamic compromise.
November, 1998 Council on Clinical Cardiology
Postoperative Postoperative Therapy/Future ManagementTherapy/Future Management
Assessment and management of risk factors for: CAD. Heart failure. Hypertension. Stroke. Other cardiovascular disease.
November, 1998 Council on Clinical Cardiology
Conclusions (1)Conclusions (1)
Successful perioperative evaluation and management of high-risk cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between surgeon, anesthesiologist, primary care physician, and consultant.
November, 1998 Council on Clinical Cardiology
Conclusions (2)Conclusions (2)
Indications for further cardiac testing and treatments are the same as in the nonoperative setting, but timing is dependent on several factors, including: The urgency of the noncardiac surgery. Patient-specific risk factors. Surgery-specific considerations.
November, 1998 Council on Clinical Cardiology
Conclusions (3)Conclusions (3)
Use of both noninvasive and invasive preoperative testing should be limited to circumstances in which the results of the tests clearly affect patient management.
November, 1998 Council on Clinical Cardiology
Conclusions (4)Conclusions (4)
The consultant best serves the patient by making recommendations aimed at: Lowering immediate perioperative
cardiac risk. Assessing need for subsequent
postoperative risk stratification and interventions directed to modify coronary risk factors.
© 1998 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.
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