Preoperative Cardiac Evaluation

Posted by e-Medical PPT
Perioperative Cardiac Outcomes
Ischemic Events
Congestive Heart Failure
Ventricular Tachycardia

Ischemic Events
Cardiac Death
Non-Fatal MI
Unstable Angina
 Chest pain >30 mins unresponsive to standard interventions
 Transient ST+T wave changes w/o Q waves
 No enzyme elevations
 Greater than or equal to 0.1mV ST depression during exercise

Major Clinical Predictors
If the patient has any of the major clinical predictors then the problem has to be addressed before surgery
Unstable coronary syndrome
decompensated CHF
significant arrhythmia
and severe valvular disease (aortic stenosis!)

Intermediate Predictors
Intermediate clinical predictors - Mild angina, prior MI, compensated or prior CHF, diabetes mellitus, and renal insufficiency
Assess functional status.  If <4 METs, consider non-invasive testing.  If >4METs and intermediate or low risk surgery, proceed to the OR

Minor Predictors
Advanced age, abnormal findings on echocardiography, rhythm other than sinus, history of stroke, low functional capacity, and uncontrolled hypertension
<4 METs and high-risk surgery, consider non-invasive testing

If <4 METs and intermediate or low-risk surgery proceed to OR
If >4 METs proceed to the OR

Interventions
Pharmacological vs. coronary revascularization
Recently, the Coronary Artery Revascularization Prophylaxis trial demonstrated that in the short term, there is no reduction in the number of postoperative myocardial infarctions, deaths, or duration of stay in the hospital, or in long-term outcomes in patients who underwent preoperative coronary revascularization compared with patients who received optimized medical therapy.

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