Pre-op Clinic References for Cardiac Risk Assessment

American College of Cardiology and American Heart Association Guidelines

for Perioperative Cardiovascular Evaluation for Non-cardiac Surgery

(Circulation 1996;93:1278-1317)

Patient should be asked the following history and examined for signs of CHF and significant valvular disease (check JVP, S3, murmurs):

Clinical Predictors (cardiac history):

Major: Unstable coronary syndromes, de-compensated CHF, significant arrythmias, severe valvular disease

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 systemic hypertension

Þ Most patients with major clinical predictors should have their elective surgery cancelled and undergo further evaluation and treatment.

Patients must be queried about exercise capacity with the following guidelines:

Functional capacity (exercise capacity):

Poor (< 4 METS): eat, dress, bathe, walk slowly on 2 level blocks, light housework (dusting, mowing lawn, washing dishes), light recreational activities (billiards, canoeing, golfing with cart), moderate house work (vacuuming, sweeping carrying groceries)

Moderate (4-7 METS): climb a flight of stairs or walk up hill, walk briskly, heavy housework (mow lawn with push mower, wash car, move heavy furniture), sexual relations, moderate recreational activities (golf with carrying your own bag, dancing, bowling, skating, doubles tennis

Excellent (> 7 METS): climb stairs briskly or walk upstairs with 1-2 bags of groceries, heavy outdoor work (saw wood, gardening, lifting and spreading soil), strenuous sports (swimming, singles tennis, jog, skiing, basketball)

Þ Most patients with poor functional capacity have increased perioperative and long-term risk and should undergo further evaluation.

The risk of the surgical procedure must be estimated from the following:

Surgical Risk:

High (Cardiac risk > 5%): emergent major operations, aortic and other vascular, peripheral vascular, prolonged surgical procedure with associated with large fluid shifts or blood loss

Intermediate (Cardiac risk 1-5%): Carotid endarterectomy, intraperitoneal and intrathoracic surgery, head and neck, orthopedic and prostate

Low (Cardiac risk < 1%): endoscopic procedures, superficial procedures, cataract, breast

Þ Most patients undergoing high-risk surgery should be considered for further evaluation unless they have both minor clinical predictors and excellent functional capacity.

Please see the attached American College of Cardiology and American Heart Association algorithm to assess the patients risk by combining the clinical predictors, functional capacity and surgical risk.

Pre-op Clinic References for Cardiac Risk Assessment

Cardiac Risk Index for Non-cardiac Surgery

The Goldman’s Index was derived from 1001 patients greater than 40 years old who underwent major orthopedic, general, and urological procedures. Nine independent risk factors predicted cardiac morbidity and mortality.(NEJM 1977;297:845-850)

Goldman's Criteria (Risk)

Points

S3 gallop or JVD on exam

11

MI in previous 6 months

10

PVC's> than 5/min at any time before operation #

7

Rhythm other than sinus or PAC's on last ECG #

7

Age > than 70

5

Emergency operation

4

Poor general health (PaO2 < 60, PaCO2 > 50, K + <3, HCO3 < 20, BUN > 50, Cr > 3, elevated transaminases, signs of chronic liver disease or patient bedridden from non-cardiac causes)

3

Important valvular aortic stensois

3

Intraperitoneal, intrathoracic, or aortic surgery

(Reference#:  Only counted if underlying CV disease present)

3

 

Validation and cardiac risk stratification for Goldman’s original criteria:

 

Risk for Life Threatening Cardiac Complication Or Death

Class

Point Total

Combined Incidence

Range

I

0-5

1.6%

1-7%

II

6-12

5%

3-11%

III

12-25

16%

14-38%

IV

25-53

56%

30-100%

Goldman’s Criteria was derived from patients undergoing major non-cardiac surgery with a baseline risk of cardiac complications of approximately 4%. Altering the baseline risk will affect the predicted incidence of cardiac complications. The Goldman’s risk Index tends to underestimate the risk of certain high risk populations such as those undergoing abdominal aortic aneurysm repairs or those patients with complex medical problems. (Anesth Analg 1995;80:810-820)

.                                  

Type of Patient

Approx Baseline Risk of Major Cardiac Complications

Risk of Life Threatening Cardiac Complication of Death

 

Class I

Class II

Class III

Class IV

(0-5 pts)

(6-12 pts)

(13-25 pts)

(>26 pts)

Minor surgery

1%

0.3%

1%

3%

19%

Unselected consecutive patients >40 yo with major noncardiac surgery

3%

1%

3.5%

10%

45%

High risk patients, such as pts undergoing AAA repair or complicated medical problems

10%

3%

10%

30%

75%