November, 1998 Council on Clinical Cardiology Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery* A Report of the American College.

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.


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


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.


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.


General Approach to the General Approach to the PatientPatient

History Physical Examination Comorbid Diseases

Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders

Ancillary Studies


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.


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.


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.



Intermediate surgical risk:• Carotid endarterectomy.• Head and neck surgery.• Intraperitoneal and intrathoracic,

orthopedic and prostate surgery.



Low surgical risk:• Endoscopic and superficial procedures.• Cataract surgery.• Breast surgery.


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.


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.




Specific Approaches: Exercise stress testing. Nonexercise stress testing:

Dobutamine stress echocardiography.

Dipyridamole/adenosine thallium testing.

Ambulatory electrocardiographic monitoring.




Recommendations: Test of choice is exercise ECG testing.

Provides estimate of functional capacity.

Detects myocardial ischemia.


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.


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.



Recommendation: Preoperative Coronary Angioplasty. No randomized clinical trials

documenting decreased incidence of perioperative cardiac events.

No prospective studies to determine optimal period of delay.



Recommendations: Medical Therapy. Few randomized trials. Preliminary studies suggest B-blockers

reduce perioperative ischemia and may reduce risk of MI and death.


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.


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.


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.


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.


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.


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.




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.




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.


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.


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.


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.


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


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.


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.


Perioperative Surveillance: Perioperative Surveillance: Arrhythmia/Conduction Arrhythmia/Conduction

Disease (1)Disease (1)

Often due to remedial noncardiac problems: Infection. Hypotension. Metabolic derangements. Hypoxia.


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.


Postoperative Postoperative Therapy/Future ManagementTherapy/Future Management

Assessment and management of risk factors for: CAD. Heart failure. Hypertension. Stroke. Other cardiovascular disease.


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.



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.



Use of both noninvasive and invasive preoperative testing should be limited to circumstances in which the results of the tests clearly affect patient management.



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.

November, 1998 Council on Clinical Cardiology Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery* A Report of the American College.

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