PREOPERATIVE CARDIAC SCREENING

II. Review PMHx and ROS to identify prior cardiovascular disease including CAD, CHF, dysrhythmias, etc. as well as cardiovascular risk factors including peripheral vascular disease, DM, renal disease, and chronic pulmonary disease

III. Careful Px for similar purposes, specifically:

1. General appearance

2. BP both arms

3. Carotid pulse contours and bruits

4. JV pressure, hepatojugular reflux

5. Heart & lung exams

6. Abdominal exam for AAA and bruits

7. Extremities for edema & pulses

IV. Algorithm for determining appropriate preoperative cardiac workup

CLICK HERE to open a new window displaying flowchart diagrams from 2002 ACC/AHA guidelines--The comments below refer to these diagrams

1. Based on overarching principle of not doing workup for CAD if wouldn’t be indicated regardless of planned surgery or if pt would have contraindications to revascularization.

2. “Categories have been established as black and white, but it is recognized that individual patient problems occur in shades of gray.”

3. Cardiac risk level of surgical procedures for the purposes of this algorithm (risk of cardiac death or nonfatal MI) [note—risk levels may be a result of characteristics of the patients undergoing these procedures rather than just the “risk of procedure” itself]
1. High (risk often greater than 5%)
1. Emergent major operations, particularly in the elderly
2. Aortic and other major vascular surgery
3. Peripheral vascular surgery
4. Anticipated prolonged surgical procedures associated with large fluid shiftsand/or blood loss
2. Intermediate (risk generally less than 5%)
1. Carotid endarterectomy
2. Head and neck surgery
3. Intraperitoneal and intrathoracic surgery
4. Orthopedic surgery
5. Prostate surgery
3. Low (risk generally less than 1%)
1. Endoscopic procedures
2. Superficial procedure
3. Cataract surgery
4. Breast surgery

4. Estimated Energy Requirements for Various Activities (from 2002 ACC/AHA guidelines; Adapted from the Duke Activity Status Index (Am J Cardiol. 64:651, 1989) and AHA Exercise Standards (Circ. 91:580, 1995))
1. 1 MET: Can “take care of self” (eat, dress, use toilet, walk indoors around the house, walk 1-2blocks on level ground at 2-3 MPH)
2. 4 METS: Can do light work around the house like dusting or washing dishes;,climb a flight of stairs, walk on level ground @ 4 MPH, run a short distance
3. 4-10 METS: Heavy housework like scrubbing floors or lifting or moving heavy furniture, participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, throwing a baseball
4. 10 METS: Strenuous sports like swimming, singles tennis, football, basketball, or skiing

5. What type of stress test to do:
1. In most patients the test of choice is exercise ECG testing.
2. In patients with important abnormalities on their resting ECG (e.g., left bundle-branch block, left ventricular hypertrophy with “strain” pattern, or digitalis effect), other techniques such as exercise echocardiography or exercise myocardial perfusion imaging should be considered.
3. In pts unable to exercise adequately, use a non-exercise stress test (e.g. dipyridamole myocardial perfusion imaging or dobutamine echocardiography).
4. For high risk pts consider proceeding with coronary angiography rather than performing a noninvasive test.  

V. Other studies on this question

1. In a study in 770 pts with 1 or 2 cardiac risk factors randomized to stress testing vs. no stress testing before non-cardiac surgery (if got testing and extensive ischemia found; considered for revascularization); all pts received beta-blockers. There was no sig. diff. between the groups in 30d incidence of (cardiac death or MI). (J. Am. Coll. Cardiol. 48:964, 2006--JW)

 VI. Preoperative treatment of CAD with CABG & PTCA

1. "Patients undergoing elective noncardiac high- or intermediate-risk procedures who are found to have prognostic high-risk coronary anatomy and in whom long-term outcome would likely be improved by coronary bypass grafting should generally undergo revascularization” first
2. Indications for PTCA & CABG in the perioperative setting are generally considered to be identical to those for the use of PTCA & CABG in general.
3. Delaying surgery for at least a week after balloon angioplasty to allow for healing of the vessel injury at the balloon treatment site has theoretical benefits.  If a coronary stent is used in the revascularization procedure, it appears reasonable to delay elective noncardiac surgery for 2 weeks and ideally 4 weeks to allow for at least partial endothelialization of the stent, but not for more than 6 weeks or 8 weeks, when restenosis may begin to occur.
4. In a study in 510 pts with CAD (at least one vessel with 70% stenosis or worse, amenable to PTCA or CABG; all with LVEF 20% or better) undergoing major elective vascular surgery randomized to coronary revascularization or to medical therapy alone, after median 2.7y f/u, there was no sig. diff. in overall mortality or 30d incidence of (MI or death) ("CARP" trial; NEJM 351:2795, 2004--JW)
5. In a study in 101 pts with extensive ischemia randomized to revascularization vs. "optimal medical therapy" before electrive aortic or peripheral vascular surgery, there was no sig. diff. in 30d or 1y incidence of (death or MI) ("DECREASE" trial; J. Am. Coll. Cardiol. 49:1763, 2007-JW)
   1. In a follow-up report on the same cohort, after median 2.8y f/u, there was no sig. diff. in overall mortality (Am. J. Cardiol. 103:897, 2009-JW)

Sources include “2002 ACC/AHA guidelines”: Eagle KA, et al., ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). 2002. American College of Cardiology Web site)