Cardiac risk assessment prior to non-cardiac surgery resident survival guide

Does the patient have either active OR unstable cardiac disease?

❑ MI within 30 days or current unstable or severe angina

❑ Decompensated HF

❑ Significant arrhythmia

❑ Mobitz II AV block

❑ 3rd degree AV block

❑ New VT

❑ Symptomatic VT

❑ SVT with Heart rate > 100 bpm

❑ Symptomatic bradycardia

❑ Severe aortic stenosis

❑ Symptomatic mitral stenosis

Evaluate for patient or surgical specific factors that would dictate approach for pre-operative assessment

❑ Peri-operative medical management

❑ Peri-operative ECG surveillance for cardiac events

❑ Continue chronic CV medical therapy

❑ Evaluate the approach for peri-operative care based on surgical urgency and extent of cardiac condition
❑ Plan the approach for peri-operative care with multidisciplinary team, involving the anesthesiologist and surgeon

Determine the risk of the surgical procedure

Intermediate or high risk

❑ Intermediate risk (risk 1% to 5%)

❑ Intraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy

❑ Carotid symptomatic (CEA or CAS)

❑ Peripheral arterial angioplasty

❑ Endovascular aneurysm repair

❑ Head and neck surgery

❑ Neurological surgery or orthopedic surgery: major (hip surgery or spine surgery)

❑ Urological surgery or gynecological surgery: major

❑ Renal transplant

❑ Intra-thoracic surgery: non-major

❑ High risk (risk > 5%)

❑ Aortic surgery or major vascular surgery

❑ Open limb revascularization or amputation or thromboembolectomy

❑ Duodeno-pancreatic surgery

❑ Liver resection or bile duct surgery

❑ Esophagectomy

❑ Repair of perforated bowel

❑ Adrenal resection

❑ Total cystectomy

❑ Pneumonectomy

❑ Low risk (risk < 1%)

❑ Superficial surgery

❑ Breast surgery

❑ Dental surgery

❑ Thyroid surgery

❑ Eye surgery

❑ Reconstructive surgery

❑ Carotid asymptomatic (CEA or CAS)

❑ Gynecology surgery: minor

❑ Orthopedic surgery: minor (meniscectomy)

❑ Urological surgery: minor (transurethral resection of the prostate)

❑ Identify patient risk factors for CV diseases
❑ Recommend lifestyle interventions
❑ Recommend medical therapy according to guidelines based on patient risk factors

❑ Obtain preoperative baseline ECG

Consider the patient's functional capacity
❑ Ask about activities that require minimal amounts (up to 4) of metabolic equivalents (METs)

❑ Can you take care of yourself (eat, dress or use the toilet)?

❑ Can you walk indoors around the house?

❑ Can you walk 100 meters on level ground at 3 to 5 km per hour?

❑ Ask about activities that require moderate amounts (between 4 and 10) of metabolic equivalents (METs)

❑ Can you climb two flight of stairs or walk up a hill?

❑ Can you do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?

❑ Ask about activities that require high amounts (> 10) of metabolic equivalents (METs)

❑ Can you participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

Evaluate need for additional therapy for the following conditions:

❑ Known ischemic heart disease (IHD) or myocardial ischemia

❑ Consider titration of low-dose beta blocker therapy (starting ideally more than 1 day (preferably more than 1 week and up to 30 days) prior to planned surgery)

❑ Administer ANY of the following beta-blocker agents if the patient has no contraindications to beta-blocker therapyBeta blockers are contraindicated in bradycardia, heart block, decompensated heart failure, hypotension, asthma, severe chronic obstructive pulmonary disease

❑ Atenolol 50 mg PO once daily^[2], OR

❑ Metoprolol succinate 100 mg PO controlled and extended release once daily^[3], OR

❑ Bisoprolol 5 mg PO once daily^[4]

❑ Increase beta-blocker dose as needed to achieve target resting HR and SBP

❑ Target resting HR = 60 to 70 bpm

❑ Target SBP > 100 mm Hg

❑ Avoid hypotension or bradycardia

❑ Continue beta-blocker therapy for several months following surgery/intervention (unknown optimal duration)

❑ Known HF and systolic dysfunction

❑ Consider pre-op ACEI or ARB at least 1 week prior to surgery/intervention

❑ Transiently discontinue ACEI or ARB 1 day before surgery/intervention in patients known to be hypertensive

❑ Resume ACEI or ARB once blood volume and pressure are stable post-operatively

❑ Patient undergoing vascular surgery

❑ Consider initiation of statin therapy for at least 2 weeks before surgery/intervention using statins with long half-life

❑ Atorvastatin 20 mg PO once daily

❑ Lovastatin 20 mg PO once daily

❑ Continue statin therapy for at least 1 month following surgery

❑ Monitor for any of hepatotoxicity, myositis, or rhabdomyolysis

❑ Intermediate risk (risk 1% to 5%)

❑ Intraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy

❑ Carotid symptomatic (CEA or CAS)

❑ Peripheral arterial angioplasty

❑ Endovascular aneurysm repair

❑ Head and neck surgery

❑ Neurological surgery or orthopedic surgery: major (hip surgery or spine surgery)

❑ Urological surgery or gynecological surgery: major

❑ Renal transplant

❑ Intra-thoracic non-major

❑ Consider non-invasive stress testing if patient has at least one clinical risk factor according to cardiac risk index

❑ Ischemic heart disease (suggested by angina pectoris and/or previous MI)

❑ HF

❑ History of stroke of transient ischemic attack

❑ Renal dysfunction (defined as either serum creatinine > 2 mg/dL OR creatinine clearance < 60 mL/min/1.73m²

❑ Diabetes mellitus requiring insulin therapy

❑ High risk (risk > 5%)

❑ Aortic surgery or major vascular surgery

❑ Open limb revascularization or amputation or thromboembolectomy

❑ Duodeno-pancreatic surgery

❑ Liver resection or bile duct surgery

❑ Esophagectomy

❑ Repair of perforated bowel

❑ Adrenal resection

❑ Total cystectomy

❑ Pneumonectomy

❑ Evaluate clinical risk factors

❑ Ischemic heart disease (suggested by angina pectoris and/or previous MI)

❑ HF

❑ History of stroke of transient ischemic attack

❑ Renal dysfunction (defined as either serum creatinine > 2 mg/dL OR creatinine clearance < 60 mL/min/1.73m²

❑ Diabetes mellitus requiring insulin therapy

❑ Consider rest echocardiogram
❑ Consider pre-op cardiac troponins in high risk patients before major surgeries AND 48 to 72 hours after majory surgery
❑ Consider NT-proBNP and BNP (prognostic information of per-operative risk and risk of late cardiac events)

❑ Consider non-invasive stress testing

❑ Perform individual peri-operative assessment (with consideration to potential benefit of surgical procedure, predicted adverse outcomes, and effect of medical therapy or coronary revascularization

❑ Plan surgery > 2 weeks following intervention
❑ Continue aspirin treatment

❑ Plan surgery >4 weeks following intervention
❑ Continue DAPT for at least 4 weeks

❑ Plan surgery within 12 months following intervention

New generation DES
❑ Plan surgery within 6 months following intervention

❑ Consider the need to discontinue aspirin therapy based on patient bleeding risk vs. thrombotic complications