Preoperative Evaluation

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					                                  Preoperative Evaluation
Primary Assessment on Three Categories
    Patient Specific Clinical Variables
         o Major predictors – when present, require intensive management which may delay or
             cancel surgery unless emergent
                 Recent MI - < 6 weeks
                 Unstable or Severe Angina
                 Decomensated heart failure NYHA class 4 or worsening or new-onset CHF
                 Arrhythmias
                          High grade AV block
                          Symptomatic ventricular arrhythmias
                          SVT with vent rate >100 bmp at rest
                          Symptomatic bradycardia
                          Newly recognized ventricular tachycardia
                 Heart Valve Disease
                          Severe aortic stenosis
                          Symptomatic mitral stenosis
         o Other Clinical Predictors That Warrant Careful Assessment
                 Hx ischemic heart disease
                 Hx Stroke
                 Hx of prior CHF
                 Diabetes Mellitus
                 Chronic Renal Insuffiency (CKD)
         o Special Issues
                 Recent PCI – risk of MI and death elevated in patients who stop anti-platelet
                     therapy for surgery
                          Bare metal stent – wait at least 6 weeks to stop anti-platelet therapy
                          Drug eluting stent – wait at least 6 months to stop anti-platelet therapy
    Exercise Capacity
         o Usually expressed in METs (metabolic equivalent)
                 1 MET = resting oxygen uptake in a sitting position
                 Increased risk if MET capacity <= 4
                 1 MET = take care of self, eat, dress, use toilet
                 4 MET = walk up a flight of steps or a hill
                 4-10 MET = heavy housework including scrubbing floors, lifting, or moving
                     heavy furniture
                 >10 MET = strenuous sports such as swimming, tennis, football, basketball, and
    Surgery-Specific Risk
         o High Risk
                 Aortic and other major vascular surgery
                 Peripheral artery surgery
         o Intermediate Risk
                 Carotid Endarterectomy
                 Head and Neck surgery
                 Intraperitoneal and intrathoracic surgery
                 Orthopedic surgery
                 Prostate surgery
           o Low Risk
                 Ambulatory surgery
                 Endoscopic procedures
                 Superficial procedures
                 Cataract surgery
                 Breast surgery

    History
          o Prior CAD
          o Angina Symptoms
          o Hx CHF
          o Hx Aortic Stenosis
          o Severe HTN
          o Peripheral Artery Disease
    Physical Exam
          o BP in both arms
          o Carotid eval for bruit
          o JVP for signs of overload
          o Auscultation lungs
          o Pulses and pit edema check in extremities
          o Cardiac Auscultation
    Resting EKG
          o Recommended for patients with at least one clinical risk factor
          o Q waves
          o ST depression or elevation (duh)

Revised Goldman cardiac risk index (RCRI)
    Six independent predictors of major cardiac complications
          o High Risk Surgery
                  any intraperitoneal, intrathoracic, or suprainguinal vascular procedure
          o Hx ischemic heart disease
                  Hx MI
                  Positive stress text
                  Use of nitrates
                  Chest pain considered to be secondary to myocardial ischemia
                  EKG with pathologic Q waves
                  DO NOT count prior coronary revascularization unless one of above is present
          o Hx of heart failure
          o Hx of cerebrovascular disease
          o Diabetes requiring treatment with insulin
          o Preoperative serum creatinine >2.0 mg/dL
    Rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest according to # of predictors with
       and without use of beta blockers
          o No beta blockers
                0 : 0.4% - 1.0%
                1-2 : 2.2% – 6.6%
                3+ : >9%
          o Beta blockers
                0 : <1%
                1-2 : 0.8% – 1.6%
                3+ : >3%

Figure: Auerbach and Goldman. Circulation 2006;113:136-1376.

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