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Non cardiac surgery clearance

Non cardiac surgery clearance. ACC/AHA guidelines Reena Kuriacose MD, FACP March 28, 2013. Need for emergency non cardiac surgery - Yes : operating room Peri -operative surveillance and post risk stratification and risk factor management. No  step 2:

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Non cardiac surgery clearance

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  1. Non cardiac surgery clearance ACC/AHA guidelines ReenaKuriacose MD, FACP March 28, 2013

  2. Need for emergency non cardiac surgery - Yes : operating room Peri-operative surveillance and post risk stratification and risk factor management.

  3. No  step 2: Active cardiac conditions: 1. Unstable coronary syndromes: * unstable/ severe angina * recent MI 2. Decompensated heart failure 3. Significant arrhythmias 4. Severe valvular disease Yes- evaluate and treat prior to surgery

  4. No  Step 3: Low risk surgery (cardiac risk <1%): 1. Endoscopic procedures 2. Superficial procedures 3. Cataract surgery 4. Breast surgery 5. Ambulatory surgery Yes- Proceed with surgery

  5. No  Step 4: Good functional capacity (MET ≥4) 1. Dusting/ washing dishes 2. Climb a flight of stairs/ walk up a hill 3. Walk on level ground at 4mph Yes- Proceed with surgery

  6. No  Step 5: Clinical risk factors: 1. History of heart disease 2. History of compensated/ prior HF 3. History of CVA 4. DM 5. Renal insufficiency

  7. A. ≥ 3 clinical risk factors: a) Vascular surgery (reported cardiac risk >5%): • Aortic and other major vascular surgery • Peripheral vascular surgery Consider testing if it will change management

  8. Intermediate surgery (cardiac risk:1-5%): • Intraperitoneal & intrathoracic • Carotid endartectomy • Head and neck surgery • Orthopedic • Prostate

  9. Proceed with planned surgery with HR control OR Consider non invasive testing if it will change management

  10. B. 1 or 2 clinical risk factors: • Vascular surgery • Intermediate risk surgery Proceed with planned surgery with HR control OR Consider non invasive testing if it will change management

  11. C. No clinical risk factors  proceed with surgery

  12. Questions: Case 1 75 year old male with history of CAD s/p stent placement on 3/25/10 in OM1 comes in for pre-op clearance for cataract surgery. He has been asymptomatic since then. What would you do?

  13. Need for emergent surgery  No 2. Active cardiac condition  No 3. Low risk surgery  Yes Proceed with surgery.

  14. The same patient comes again now for pre-op clearance of cataract of the other eye. However he has been having some discomfort in his chest on and off specially at night 1 hour after going to bed. What would you do?

  15. Need for emergent surgery  No 2. Active cardiac condition  ? Chest pain in patient with known heart problem. Rule out ischemia

  16. Case 2 A 55 year old male with history of DM for the last 10 years comes in for pre-op clearance for surgery for prostatectomy. He exercises on the tread mill daily and climbs 2 flights of stair at work. What is your w/u?

  17. Need for emergent surgery  No 2. Active cardiac condition  No 3. Low risk surgery  No 4. Good functional capacity  Yes Proceed with surgery

  18. The same patient in case 2 comes in 1 year later. He has had an MI in the interim and had a MVA with compound fracture which needs surgery. What all tests would you do for pre-op clearance?

  19. Need for emergent surgery  Yes Peri-operative surveillance and post risk stratification and risk factor management.

  20. Case 3 A 65 year old male with history of DM for 20 years, creatinine of 2.2 baseline, and a history of CAD s/p stent placement 5 years back has come for pre- op clearance for knee replacement surgery. What is you evaluation?

  21. Need for emergent surgery  No 2. Active cardiac condition  ?  No 3. Low risk surgery  No 4. Good functional capacity  Yes  Proceed with surgery No  Clinical risk factors = 3

  22. 5. Intermediate surgery (Orthopedic) Consider non invasive testing.

  23. The same patient comes back after 1 year (no w/u was done initially for the knee surgery, as METs then was good) for carotid endarterectomy. What is your w/u?

  24. Need for emergent surgery  No 2. Active cardiac condition  ?  No 3. Low risk surgery  No 4. Good functional capacity  Yes  Proceed with surgery No  Clinical risk factors = 3

  25. 5. Intermediate surgery (Carotid) Consider non invasive testing.

  26. The same patient comes after 6 months for fem-pop. What are your recommendations now?

  27. Need for emergent surgery  No 2. Active cardiac condition  ?  No 3. Low risk surgery  No 4. Good functional capacity  Yes -> Proceed with surgery No -> Clinical risk factors = 3

  28. High risk surgery (Vascular) Consider testing

  29. Case 4 A 65 year old physically active male with history of DM, creatinine 2.3, CAD s/p stent placement in 2003 is here for pre- op clearance for colonoscopy. What are your recommendations?

  30. Need for emergent surgery  No 2. Active cardiac condition  ?  No 3. Low risk surgery  Yes Proceed with surgery

  31. Case 5 A 65 year old female with history of DM, CAD, CVA, Breast cancer right side- comes for pre-op clearance for mastectomy. What would you do?

  32. Need for emergent surgery  No 2. Active cardiac condition  ?  No 3. Low risk surgery  Yes Proceed with surgery

  33. Case 6 A 65 year old male with history of COPD on 2 liters of oxygen comes for elective AAA repair. EKG shows RBBB. How will you w/u?

  34. Need for emergent surgery  No 2. Active cardiac condition  No 3. Low risk surgery  No 4. Good functional capacity  Yes  Proceed with surgery No  Clinical risk factors = 0

  35. However he has history tobacco abuse, FH of premature CAD- Are you sure whether he has had a silent MI or not?

  36. The above patient also has an echo which shows aortic valve area of 1cm X 1cm. Is the w/u the same?

  37. Need for emergent surgery  No 2. Active cardiac condition  Yes Severe valve disease  address prior to surgery.

  38. Questions?

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