Preanesth eval: Cardiac
Last updated: 06/07/2018
Pre-operative cardiac risk stratification is a common and important topic for anesthesiologists. There are several risk calculators in use; both patient factors and surgery factors play into overall risk of a major adverse cardiac event (MACE).
The two most commonly used and data-driven approaches to estimating risk of a major cardiovascular event in the perioperative period are the RCRI (Revised Cardiac Risk Index) and the NSQIP database calculator. RCRI will determine risk of a major cardiovascular event (ventricular fibrillation, primary cardiac arrest, pulmonary edema, myocardial infarction, complete heart block) based upon:
- Procedure (high risk or vascular procedures)
- Patient history of ischemic heart disease, congestive heart failure, or CVA, respectively;
- Insulin-dependent diabetes mellitus
- Pre-operative creatinine greater than or equal to 2.0.
It will then assign a risk percentage based on the number of positive risk factors:
- 0: 0.4%
- 1: 0.9%
- 2: 6.6%
- 3 or more: 11%
Taking this risk stratification into consideration, we can then use the AHA/ACC algorithm for determining overall risk and consideration of further testing.
For a patient scheduled for surgery with known or suspected risk factors for CAD:
- Determine if the case represents an emergency. If yes, proceed to surgery; if no, continue to step 2.
- Determine if the patient is having an MI/having ACS. If yes, treat as appropriate. If no, proceed to step 3.
- Determine risk of MACE using clinical/surgical risk calculation (RCRI, NSQIP).
- If less than 1% (low risk), proceed to surgery
- If greater than 1%, proceed to 4.
- Determine the patient’s functional capacity using metabolic equivalents.
- If greater than or equal to 4, patient can proceed to surgery
- If less than 4, proceed to step 5
- If unknown, proceed to step 5
- For patients with poor or unknown functional capacity, determine whether further testing will actually change perioperative management or change decision making.
- If no, then proceed to surgery
- If yes, then obtain pharmacologic stress testing; proceed to 6.
- If stress test is:
- Positive: Consider coronary revascularization
- Negative: Proceed to surgery.
- Fleisher, Lee A., et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.” Journal of the American College of Cardiology, vol. 64, no. 22, 2014. Link
- Jaeber, Wael. “Cardiac Risk Stratification for Noncardiac Surgery.” Center for Continuing Education, The Cleveland Clinic Foundation, June 2014 Link
- Keys to the Cart for September 1, 2019 Link
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