Preoperative Assessment & Perioperative Care: Cardiac
 

PREOPERATIVE ASSESSMENT & PERIOPERATIVE CARE: Cardiac
Developed by UNMC Department of Anesthesia and Division of Geriatrics, Department of Internal Medicine
Tyler Hartley M4

Objectives:
Upon completion of this module, the learner will be able to;


Elderly patients are at highest risk

Postoperative adverse effects on Elderly


Incidence

surgery mortality


Over 80 Years

  • For the more than 20,000 patients aged 80 and older who had major surgery at VAMCs between 1991 and 1999, 30-day mortality was 8% overall
  • One in five patients suffered at least one postoperative complication, and 30-day mortality was more than 25% for patients who had complications.

Hamel M, et al, Surgical Outcomes for Patients Aged 80 and Older: Morbidity and Mortality from Noncardiac Surgery, J Am Geriatric Soc 53:424-429,2005

Post Operative Mortality >80yrs

Casue of Death % of total cuases of death
Cardiac 26.11%
Pulmonary 51.92
Sepsis 12.05%
Renal Failure 9.9%

Rate of Cardiac Death

Rate of cardiac death, nonfatal myocardial infraction, and nonfatal cardiac arrest according to the number of predictors.
No risk factors - 0.4 percent (95% CI: 0.1-0.8)
One risk factor - 1.0 percent (95% CI: 0.5-1.4)
Two risk factors 2.4 percent (95% 1.3-3.5)
Three or more risk factors  - 5.4 percent (95% CI: 2.8-7.9)

Lee TH, Marcantonio ER, Mangione CM, et al. Circulation 1999; 100:1043. Devereaux PJ, Goldman L, Cook DJ, et al. CMAJ 2005; 173:627.


MACE (Major Adverse Cardiac Event)

1. Acute myocardial infarction 
2. Ischemic stroke
3. Coronary arterial occlusion
4. Death


Cardiac Conditions that convet >5% risk of MACE

Lee A. Fleisher, 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines


Cardiac Conditions


Procedure Risk


Functional Capacity


Putting It All Together


RISK STRATIFYING ALGORITHM

 Patient scheduled for surgery with known or risk factors for CAD (STEP 1) 

   Emergency

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NO  
(proceed to STEP 2)

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YES  
Clinical Risk Stratification and proceed   with Surgery

ACS   (STEP 2)

NO  
(proceed to STEP 3)

YES    
Evaluate and treat according to guideline directed therapy

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Estimated perioperative risk of MACE   (major adverse cardiac event) based on combined clinical/surgical risk (STEP 3)

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Low Risk (<1%) (STEP 4)   No further testing (Class III)   Proceed with surgery

Elevated risk (>1% risk)   (STEP 5)

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Moderate or greater (> METs)

Functional Capacity

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Non or unknown

Moderate/good (>4-10 METs)   NO further testing (Class IIB)

Excellent (>10 METs)   NO further testing (Class IIA)

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Proceed   with surgery

Poor or unknown functional Capacity   (<4 METs): Will further testing impact decision making OR perioperative   care?   (STEP 6)

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NO    
Proceed to surgery according to guidline-directed therapy Or alternate strategies (non-invasive treatment palliation  
(STEP 7)

YES  
Pharmacologic stress testing (Class IIa)   If normal

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Coronary revascularization according to   existing clinical practice guidelines (Class I)   If Normal   proceed to  
(STEP 7)

 

Perioperative Medications used to minimize cardiac risk
Lee A. Fleisher, 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Summary
  • Elderly have an increased risk of adverse cardiac events.
  • Perioperative assessment and management can reduce cardiac risk.
  • Risk stratification includes LOW and ELEVATED classifications based on procedure, functional status, and clinical risk factors.
  • Low risk -> proceed to surgery (usually)
  • Elevated risk -> evaluate with more testing or medical management before surgery (usually)
  • Age is not an independent risk factor for adverse cardiac events.
  • Pharmacologic management may reduce cardiac risks in certain patient populations.