Peri-operative cardiac risk assessment

 

AHA/CCA Approach

 

List:

1.      Define functional capacity

2.      Identify risk factors

3.      Plug into calculator

4.      Decide how to proceed

 

1. Define functional capacity:

METs

      1: self-care

      4: one flight of stairs, walk 6km/h

      4-10: two flights of stairs, heavy housework

      >10: sports

DASI

      Self-care

      Various intensities of ambulation

      Various intensities of housework

      Various intensities of recreational activity

Conversion

      DASI x 0.43 + 9.6 = VO2

      VO2 / 3.5 = METs

 

2a. Identify patient risk factors:

Global

      Elderly

      ASA ++

      Poor functional status

Specific

      IHD

      Heart failure

      CVD

      T2DM insulin

      CKD

      (AF)

      (Obesity)

 

2b. Identify surgical risk factors:

Low

      Day case

      Endoscopy

      Superficial

      Cataracts

      Breast

Mod

      Carotid endarterectomy

      Head and neck

      Orthopaedic

      Prostate

High

      Intraperitoneal

      Intrathoracic

      Supra-inguinal vascular

 

3. Calculate risk:

Scoring:

Low risk: <1% MACE

Mod risk: 1-5% MACE

High risk: >5% MACE

RCRI

      High risk surgery (as above)

      IHD

      Heart failure

      CVD

      T2DM insulin

      CKD (creat >180)

MICA

      Age

      Functional status

      ASA

      Creat

      Surgery type

NSQIP

      Complex online tool

      General inputs: e.g. age, ASA, emergency vs elective

      Specific inputs: comorbidities

      General output: complication, death, rehab facility

      Specific outputs: CVS complication, wound infection, VTE

 

4. Decide how to proceed:

Go ahead if any of:

      Emergency surgery

      Low risk

      Asymptomatic at >4 METs

      Not for PCI/CAGs

Do Stress TTE if all of:

      Moderate or high risk

      Exercise capacity <4 METs or unknown

      Would be for PCI/CAGs

 

5. Ignore all the above

Problem

      Peri-op AMIs are almost always type 2 events

      Prophylactic PCI and CAGs are unhelpful for most patients

      Prophylactic studies have excluded patient with left main or triple vessel disease

Recommendation

      Do stress TTE if the patient needs it anyway (e.g. angina FI)

      Do PCI/CAGs if the patient needs it anyway (e.g. LMCA or TVD)

      If unsure, discuss with PMU or a cardiologist

 

Canadian Approach

 

NT-proBNP:

Indications

      >65y

      45-65y with CVS disease

      RCRI 1

If abnormal BNP
(or canít get one)

      ECG in recovery

      Daily TNI for 48-72 hours

      Consider HDU or similar

If abnormal TNI

      Lifelong aspirin

      Lifelong statin

 

Other recommendations:

Tests

      No TTE

      No stress test

      No angiography

Medications

      Continue aspirin only if a) recent stent b) for CEA

      Donít start a beta blocker soon before surgery

      Withhold ACEi and ARB on day of surgery

 

 

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