1 / 37

Cardiac Risk Assessment

Cardiac Risk Assessment. Moderator : Dr S. Aneja. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Goals. Identify pts at risk history , physical examination, ECG Evaluate the severity of underlying cardiac disease

rory
Download Presentation

Cardiac Risk Assessment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cardiac Risk Assessment Moderator : Dr S. Aneja www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  2. Goals • Identify pts at risk history , physical examination, ECG • Evaluate the severity of underlying cardiac disease • Stratify extent of risk & determine the need for pre op interventions to minimize risk of peri op cardiac complications

  3. Evaluation of Cardiac Risk • Review of History • Physical Examination • Diagnostic tests • Knowledge of planned surgical procedure

  4. HISTORY : • Risk factors : Age, HTN, DM, Dyslipidemias, Smoking. • Angina : Stable/ unstable, present medications. • Previous MI : How was it? • MI : NYHA grading, functional capacity • Dysrhythmias : Palpitations. • Associated CVS disease : Carotid, cerebral, aortic, PVD. 7) Presence of pacemaker/ ICD.

  5. Valvular Heart disease : • Dyspnea, Orthopnea, PND. • Embolic events. • Hemoptysis. • Heart failure, palpitations. Prior cardiac evaluation : • Non invasive tests. • Angiography/ Stenting. Medications : • Details. • Effectiveness.

  6. Physical examination : • General examination : Cyanosis, pallor, dyspnea during conversation or with minimal activity, poor nutritional status, obesity, skeletal deformities, tremor & anxiety are just a few of the clues of underlying disease or CAD. 2) Vitals : Pulse, BP , Pulse pressure, Respiration.

  7. 3) Cardiac examination : JVP, edema feet, Displaced apical impulse (cardiomegaly), S3 gallop ( increased LVEDP ), S4 ( decreased compliance), Apical systolic murmur ( Papillary muscle dysfunction ), Presence of murmurs, Pulmonary edema.

  8. Functional Capacity • Functional status has shown to be a reliable periop and long-term predictor of cardiac events • Functional status determined based on ability to do ADL’s • MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest wch is 3.5 ml/kg/min

  9. Functional Capacity : Excellent : > 10 METS Good : 7 -10 METS Moderate : 4 – 7 METS Poor : < 4 METS

  10. Moderate recreational golf, dancing, baseball Strenuous sports swimming, basketball DO light house work i.e. Washing dishes Climb a flight of stairs Run a short distances Eat, dress 10 MET 1 MET 4 MET

  11. Cardiac Risk Indices

  12. Goldman Risk Index Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

  13. Goldman Risk Index Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

  14. Revised Cardiac Risk Index (RCRI) by Lee • High Risk Surgical Procedure – defined as thoracic, abdominal, or pelvic vascular(eg aorta, renal , mesenteric) • Ischemic heart ds – defined as - h/o MI - h/o or current angina - use of s/l nitroglycerine - positive exercise test - Q waves on ECG - h/o PTCA or CABG done

  15. 3. Heart failure - defined as - LV failure by physical examination - h/o PND - h/o Pulmonary Edema - S3 or b/lrales on physical exam - pulmonary edema on CXR 4 . Cerebro vascular ds – defined as - h/o transient ischemic attack - h/o CVA

  16. Insulin dependent DM • Chronic Renal Insufficiency – defined as baseline creatinine > = 2.0 mg/dl The rates of major cardiac complications were found to be 0.5 %,1.3% , 4 % & 9 % in pts with 0 , 1 , 2 or 3 or more of these risk factors, respectively.

  17. Detsky modified multifactorial index

  18. ACC/ AHA 2007 GUIDELINES Overriding theme is that Intervention is RARELY necessary to simply lower the risk of sx, unless such intervention is indicated irrespective of the pre op context. No test should be performed unless it is likely to influence pt treatment.

  19. ACC/AHA Classification of Pts

  20. Clinical Assessment ACC/AHA 2007 have done away with segregation into major, intermediate & minor risk factors Now : ACTIVE CARDIAC CONDITIONS that wn present indicate major clinical risk Presence of 1 or more of these cond mandates intensive mx & may result in delay or cancellation of sx unless the sx is emergent

  21. 1. Unstable Coronary Syndromes - Recent MI - Unstable or severe angina 2. Decompensated congestive cardiac failure 3. Significant arrhythmias 4. Severe Valvulards

  22. Intermediate risk category is replaced with CLINICAL RISK FACTORS from Lee’s Index • h/o ischemic heart ds • Compensated or prior cong heart failure • h/o cerebro vascular ds • DM • Renal insufficiency

  23. Minor risk predictors like advanced age, abnormal ECG – LVH, LBBB, ST T abnormalities, uncontrolled systemic htn have been done away with. Not proven to increase peri op risk independently

  24. Surgery Risk Stratification

  25. 2007 ACC/AHA Perioperative Guidelines

  26. PRE OPERATIVE EVALUATION

  27. Noninvasive tests can be divided into : • Resting tests – Resting ECHO. • Exercise stress tests • pharmacologic tests • Dobutamine stress echo • Dipyridamole thallium scanning • Ambulatory ECG monitoring.

  28. Preoperative TestingNegative Predictive Value Freedom from MI or Death Eagle et al. JACC 1996;27:910.

  29. Preoperative TestingPositive Predictive Value MI or Death

  30. Recommendations for Noninvasive Stress Testing According to the ACC/AHA Guidelines (2007) Poldermans, D. et al. J Am CollCardiol 2008;51:1913-1924

  31. Pre op coronary revascularization with CABG or PCI The indication for CABG or PCI before non cardiac surgery remains the same as in non operative setting. The philosophy of performing pre op coronary re vascularization merely “ to get the pt thro sx” is contrary to available evidence.

  32. Timing of Surgery After PCI Balloon angioplasty Bare-metalstent Drug-elutingstent < 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days Delay Sx with aspirin Delay Sx with aspirin Delay Sx with aspirin

  33. PCI before anticipated surgery Acute MIHigh Risk ACSHigh risk anatomy Bleeding risk of anticipated surgery Stent and continued Dual-antiplatelet rx Low Not low 14 to 29 Days 30 – 365 Days > 365 Days Balloon angioplasty Bare-metalstent Drug-elutingstent

  34. Preoperative Therapy with B-Blockers • Start pre-op, titrate to HR<60 bpm • Short acting beta-blockers provide more flexible dosing • Give orally, if possible, with IV supplementation when patient NPO

  35. Postoperative Cardiac Events In High Risk Patients • 173 patients undergoing vascular surgery with positive DSE • Randomized to BB 1 week pre-op or placebo • Followed for 30 days Placebo n=53 Bisoprolol n=59 Poldermans et al. NEJM 1999;341:1789.

  36. THANK YOU www.anaesthesia.co.in anaesthesia.co.in@gmail.com

More Related