Cardiac morbidity: Pre-op factors
Last updated: 03/04/2015
Revised Cardiac Index
Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery [Lee et al.]
|0||0.4% risk of cardiac complications|
|1||0.9% risk of cardiac complications|
|2||7% risk of cardiac complications|
|3||11% risk of cardiac complications|
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 suggest the following, in order:
- Decide whether this is an emergency surgery. If yes, proceed to OR.
- 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.
- T H Lee, E R Marcantonio, C M Mangione, E J Thomas, C A Polanczyk, E F Cook, D J Sugarbaker, M C Donaldson, R Poss, K K Ho, L E Ludwig, A Pedan, L Goldman Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation: 1999, 100(10);1043-9 PubMed Link
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