Cardiac morbidity: Pre-op factors

For more information on cardiac risk in non-cardiac surgery, see Cardiac Risk (Anesthesia Text). For more information on cardiac risk in cardiac surgery, see Risk Stratification in Cardiac Surgery.

Revised Cardiac Index

Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery [Lee et al.]

Goldman Risk Index (Historical Interest)

While RCI is the most commonly used index for non-cardiac surgery, the ABA test-taker should also be familiar with the Goldman Index, which includes third heart sound (or jugular venous distention, 11 points), MI in the preceding six months (10 points), > 5 PVCs per minute at any point before the operation or non-sinus rhythm or PACs (7 points), age > 70 (5 points), emergency (4 points) or high risk (3 points) operation, significant aortic stenosis (3 points), and “poor general medical condition” (3 points)

ACC/AHA Guidelines

ACC/AHA Guidelines suggest the following, in order:

1. Decide whether this is an emergency surgery. If yes, proceed to OR.
2. If there are active cardiac conditions, evaluate and treat prior to OR.

Active cardiac conditions:

• Unstable coronary syndroms:
• CCS III/IV (Angina/symptoms with everyday living, moderate limitation or worse)
• Decompensated heart failure
• Significant arrythmia:
• High grade AV block
• Mobitz II AV block
• 3rd degree block
• Symptomatic ventricular arrythmia
• SVR with HR>100 at rest
• Symptomatic bradycardia
• Newly recognized ventricular tachycardia
• Severe valvular disease:
• Severe AS (Mean gradient >40 mmHg, aortic valve area <1 cm2, or symptomatic)
• Symptomatic MS (DOE, exertional presyncope, or heart failure)

3. If surgery is low risk, proceed to OR.

• Low risk: endoscopic, superficial, cataracts, breast, ambulatory
• Intermediate risk: Intraperitoneal/Intrathoracic, carotid endarterectomy, head/neck, orthopedic, prostate
• High risk: aortic/other major vascular procedures, peripheral vascular surgery

4. If METS => 4 without symptoms, proceed to OR.

• METS<4: eat, dress, use toilet, walk around, walk a block or 2 on level ground slowly
• METS=4: light housework, climb a flight of stairs
• METS>4: walk@4 mph, run short distances, heavy housework, moderate recreational activities
• METS>10: participate in strenuous sports

5. Examine clinical risk factors (Revised Cardiac Risk Index). If the patient has no risk factors, proceed to OR. If the patient has 1-2, proceed to OR with HR control, or consider non-invasive testing if it will change management. If the patient has 3 or more and undergoing intermediate risk surgery proceed to OR with HR control, or consider non-invasive testing if it will change management. If the patient has 3 or more and undergoing vascular surgery, consider testing if it will change management.