Preoperative Assessment and
Royal United Hospital Bath
• The overriding theme of this document is
that intervention is rarely necessary
simply to lower the risk of surgery unless
such intervention is indicated irrespective
of the preoperative context.
• Indications for angiography and CABG
are independent of surgery.
• Intervention is not just to “get patients
• Evaluate current medical status
• Recommend treatment to improve
medical condition („optimisation‟)
• Provide clinical risk profile
– informed consent
– patient choice
• Plan management of risk over entire
• BP 140/85
• BP 179/109
• BP 180/110
Coronary Heart Disease
Class I: Ordinary physical activity does not cause angina. Angina
occurs on strenuous exercise only.
Class II: Slight limitation of ordinary activity. Angina occurs on walking
or climbing stairs rapidly, walking uphill, walking or stair climbing
after meals, or in cold, or in wind, or under emotional stress, or only
during the first few hours after wakening. Angina occurs on walking
more than 150 yards on the level and climbing more than one flight
of ordinary stairs at a normal pace and in normal conditions.
Class III: Marked limitation of ordinary activity. Angina occurs on
walking 75–150 yards on the level or climbing one flight of stairs in
normal conditions and at normal pace.
Class IV: Angina on slight exertion; possible at rest.
• Previous echocardiography
• Compensated heart failure
– No signs (elevated JVP, basal crackles)
– No symptoms (orthopnoea, PND)
• New York Heart Association Classification
New York Heart Association
Class I: No limitation of physical activity. Symptoms
(shortness of breath, fatigue or palpitations) on
strenuous exercise only.
Class II: Slight limitation of physical activity. Symptoms on
moderate exertion eg climbing 2 flights of stairs, long-
Class III: Marked limitation of activity. Symptoms on
minimal exertion eg climbing 1 flight of stairs, walking
short distances on the flat.
Class IV: Severe to complete limitation of activity.
Symptoms with any physical exertion and may appear
even at rest.
– Acute attacks less than once a month
– PEFR variability < 20%
– Moderate limitation of ordinary physical activity
– Able to climb one flight of stairs without stopping
– Able to walk 50–100 yards on the level without
– Only occasional episodes of acute chest infection
All patients for major surgery should have METs > 4
Duke Activity Index
1 MET Can you take care of yourself? 4 METs Climb a flight of stairs or walk up a hill?
Eat, dress, or use the toilet? Walk on level ground at 4 mph or 6.4 km/h?
Walk indoors around the house? Run a short distance?
Walk a block or two on level ground
at 2 to 3 mph or 3.2 to 4.8 km per h? Do heavy work around the house like scrubbing
floors or lifting or moving heavy furniture?
Do light work around the house like
4 METs dusting or washing dishes? Participate in moderate recreational activities
like golf, bowling, dancing, doubles tennis, or
throwing a baseball or football?
>10 METs Participate in strenuous sports like swimming,
singles tennis, football, basketball, or skiing?
Derivation and Prospective Validation of a Simple Index for
Prediction of Cardiac Risk of Major Noncardiac Surgery
Lee et al
Risk factor Criteria
High-risk surgery AAA repair, thoracic, abdominal surgery
IHD MI, Q on ECG, angina, nitrates, EST+
CCF History, examination, CXR
Cerebrovascular disease Stroke, TIA
Diabetes Insulin treatment
Renal impairment Creatinine >177 mol/L
Number of factors % population Major cardiac complications
0 36% 0.5%
1 39% 1%
2 18% 5%
3 7% 10%
Cardiac risk assessment indices
• Physiological & Operative Severity Score for the
enUmeration of Mortality & Morbidity
– CR / OG / Vascular – POSSUM
• 70 year old man
• Severe Parkinsons Disease on Rx
• Admitted for elective inguinal hernia repair
– also under investigation for change in bowel habit
• Two recent episodes of angina whilst walking to
keep up with his son
– stable class III angina
– start β-blocker (or rate-limiting calcium channel
blocker) prior to major surgery