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Perioperative Cardiovascular Evaluation

for Noncardiac Surgery

By :Mahmoud M Othman MD,


Prof of Anesthesia & SICU,
Mansoura faculty of Medicine.
General Approach

 Team Work
– Patient
– Primary care physician
– Anesthesiologist
– Surgeon
– Medical consultant
Preoperative Clinical Evaluation
 Identification of serious cardiac disorder
– CAD, CHF, Arrhythmias
(Initial history, Physical examination, ECG)
 Define disease severity, stability, and prior treatment
 Functional capacity
 Age
 Comorbid conditions
(DM, peripheral vascular disease, renal dysfunction, chronic
pulmonary disease)
 Type of surgery
– Consider higher risk
• vascular procedures
• prolonged complicated thoracic, abdominal and head
and neck procedures
Further Preoperative Testing to
Assess Coronary Risk
CAD is the most frequent cause of
perioperative cardiac mortality and
morbidity after noncardiac surgery
 Step-wise Bayesian strategy
clinical markers
prior coronary evaluation and treatment
functional capacity
surgery-specific risk
Stepwise Approach to Preoperative Cardiac
Assessment
Need for Postoperative risk
noncardiac emergency stratification and
O.R. risk factor management
surgery
Urgent or elective no

Coronary Recurrent
revascularization yes symptoms or
within 5 yrs signs
no yes

Recent yes Recent coronary favorable result and


coronary angiogram or no change in symptoms O.R.
evaluation stress test?
Unfavorable result
no and change in symptoms
Clinical
predictors

Major Intermediate Minor or No


Stepwise Approach to Preoperative Cardiac
Assessment
Major clinical predictors
•Unstable coronary syndromes
Major clinical predictors
•Decompensated CHF
•Significant arrhythmias
•Severe valvular disease

delay or cancel Coronary


noncardiac surgery angiography

Medical management Subsequent care


and risk factor modification dictated by findings
and treatment results
Stepwise Approach to Preoperative Cardiac
Assessment
Intermediate clinical predictors

Poor Moderate or excellent


(<4METs) (>4METs)

High surgical Intermediate or low Low surgical


risk precedure surgical precedure risk procedure

Noninvasive Low risk O.R. Postoperative risk stratification


testing and risk factor reduction

High risk
Consider coronary
angiography Intermediate clinical predictors
•Mild angina pectoris
•Prior MI
Subsequent care •Compensated or prior CHF
dictated by findings
and treatment results •DM
Stepwise Approach to Preoperative Cardiac
Assessment
Minor or no clinical predictors

Poor(<4METs) Moderate or excellent(>4METs)

High surgical Intermediate


risk procedure surgical risk
procedure

Noninvasive testing low risk O.R. Postoperative management


High risk
Minor clinical predictors
Consider coronary angiography •Advanced age
•Abnormal ECG
Subsequent care by findings •Rhythm other than sinus
and treatment results •Low functional capacity
•History of stroke
•Uncontrolled systemic hypertension
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
(Myocardial Infarction, Congestive Heart Failure, Death)

 Major
Unstable coronary syndromes
– Recent myocardial infarction with evidence of important ischemic
risk by clinical symptoms or noninvasive study
– Unstable or severe angina(Canadian Cardiovascular Society Class
III or IV)
Decompensated CHF
Significant arrhythmias
– High grade atrioventricular block
– Symptomatic ventricular arrhythmias in the presence of underlying
heart disease
– Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
(Myocardial Infarction, Congestive Heart Failure, Death)

 Intermediate
Mild angina pectoris(Canadian Cardiovascular Society Class I or II)
Prior myocardial infarction by history or pathological waves
Compensated or prior CHF
DM
 Minor
Advanced age
Abnormal EKG(LVH, LBBB, ST-T abnormalities)
Rhythm other than sinus(eg, atrial fibrillation)
Low functional capacity(eg, unstable to climb one flight or stairs with
a bag of groceries)
History of stroke
Uncontrolled systemic hypertension
Estimated Energy Requirements for Various
Activities

1 MET Can you take care of yourself? 4 METs Climb a flight of stairs or walk
Eat. Dress, or use the toilet? up a hill
Walk indoors around the Walk on level ground at 4 mph
house? or 6.4 km/h?
Walk a block or two on level Run a short distance?
ground at 2-3 mphor 3.2-4.8 Do heavy work around the
km/hr house like scrubbing floors or
Do light work around the moving heavy furniture?
house dusting or washing Participate in moderate
dishes? recreational activities like golf,
4 METs
bowling, dancing, doubles
tennis, or throwing a baseball
or football?
Participate in strenuous sports
>10 METs like swimming, singles tennis,
football, basket ball, or skiing
Cardiac Event Risk† Stratification for Noncardiac
Surgical Procedures
High Intermediate
(reported cardiac risk (Reported cardiac risk generally <5%)
often >5%) •Carotid endarterectomy
•Emergent major operations, •Head and neck
particularly in the elderly •Intraperitoneal and intrathoracic
•Aortic and other major •Orthopedic
vascular •Prostatic
•Peripheral vascular Low‡
•Anticipated prolonged surgical (reported cardiac risk generally <1%)
procedures associated with •Endoscopic procedures
large fluid shifts and/or blood •Superficial procedures
loss •Cataract
•Breast
† Combind incidence of cardiac death and nonfatal myocardial infarction
‡ Further preoperative cardiac testing is not generally required.
Method of Assessing Cardiac Risk

 Resting Left Ventricular Function

 Exercise Stress Testing

 Pharmacological Stress Testing

 Ambulatory ECG monitoring

 Coronary Angiography
Method of Assessing Cardiac Risk

 Resting Left Ventricular Function


– Increased risk:
• Ejection fraction < 35%
• severe diastolic dysfunction

– CHF
– prior CHF or dyspnea of unknown etiology
Method of Assessing Cardiac Risk

 Exercise Stress Testing


– treadmill or bicycle stress and ECG analysis,
echocardiography
– degree of functional incapacity, symptoms of
ischemia, severity of ischemia(depth, time of
onset, duration of ST depression), evidence of
hemodynamic or electrical instability
correlated with increasing ischemic risk
Method of Assessing Cardiac Risk

 Pharmacological Stress Testing


– for patients who are unable to exercise
– Dipyridamole or adenosine with thallium
myocardial perfusion imaging
– Dobutamine echocardiography
 Ambulatory ECG Monitoring
 Coronary Angiography
Indications for Coronary Angiography in
Perioperative Evaluation Before (or After)
Noncardiac Surgery

Class I:Patients with suspected or proven CAD


– High-risk results during noninvasive testing
– Angina pectoris unresponsive to adequate medical
therapy
– Most patient with unstable angina pectoris
– Nondiagnostic or equivocal noninvasive test in a high-
risk noncardiac surgical procedure
Class I: conditions for which there is evidence for and/or general agreement that a procedure or a
treatment is of benefit
Indications for Coronary Angiography in
Perioperative Evaluation Before (or After)
Noncardiac Surgery

Class II:
– Intermediate-risk results during noninvasive testing
– Nondiagnostic or equivocal noninvasive test in a
lower-risk patients undergoing a high-risk noncardiac
surgical procedure
– Urgent noncardiac surgery in a patient convalescing
from acute MI
– Perioperative MI
Class II: conditions for which there is a divergence of evidence and/or
opinion about the treatment
Indications for Coronary Angiography in
Perioperative Evaluation Before (or After)
Noncardiac Surgery
Class III:
– Low-risk noncardiac surgery in a patient with known CAD and
low-risk results on noninvasive testing
– Screening for CAD without appropriate noninvasive testing
– Asymptomatic after coronary revascularization, with excellent
exercise capacity(>7METs)
– Mild stable angina in patients with good LV function, low-risk
noninvasive test results
– Patient is not a candidate for coronary revascularization because
of concomitant medical illness
– Prior technically adequate normal coronary angiogram within
previous 5years
– Severe LV dysfunction(e.g., EF<20%) and patient not considered
candidate for revascularization procedure
– Patient unwilling to consider coronary revascularization
procedure
Class III: conditions for which there is evidence and/or general agreement that the
procedure is not necessary
Management of Preoperative
Cardiovascular Conditions
 Hypertension
 Valvular Heart Disease
 Myocardial Heart Disease
 Arrhythmias and Conduction Abnormalities
Management of Preoperative
Cardiovascular Conditions
 Hypertension
– Severe HBP(DBP >110) should be controlled
before surgery when possible
– Continuation of preoperative antihypertensive
treatment is critical to avoid severe
postoperative hypertension.
– Consider the urgency of surgery and the
potential benefit of more intensive medical
therapy.
Management of Preoperative
Cardiovascular Conditions
 Valvular Heart Disease
– Symptomatic stenotic lesions(MS or AS):
associated with risk of perioperative severe
CHF or shock and often require percutaneous
valvotomy or replacement to lower cardiac risk.
– Symptomatic regurgitant lesions(AR or MR):
usually better tolerated perioperatively and may
be stabilized before surgery with intensive
medical therapy and monitoring
Management of Preoperative
Cardiovascular Conditions
 Myocardial Heart Disease
– Dilated and hypertrophic cardiomyopathy are
associated with an increased incidence of
perioperative CHF.
– Maximizing preoperative hemodynamic status
and providing intensive postoperative medical
therapy and surveillance.
Management of Preoperative
Cardiovascular Conditions
 Arrhythmias and Conduction Abnormalities
– careful evaluation for underlying
cardiopulmonary disease, drug toxicity, or
metabolic abnormality.
– Therapy: reverse any underlying cause and treat
the arrhythmia
Preoperative Coronary
Revascularization
 Coronary Artery Bypass Graft Surgery
 Coronary Angioplasty
Medical Therapy for Coronary Artery
Disease

 If patients require beta-blockers, calcium channel


blockers, or nitrates before surgery, continue them
into the operative and post-op period.
 The same is true for therapies used to control
CHF
 Beta-blockers reduce postoperative ischemia,
– Protection against ischemia may also reduce risk of MI
Anesthetic Considerations

 Anesthetic agent
– No one best myocardial protective anesthetic
technique.
– Opioid:cardiovascular stability, but need
postoperative ventilation
– Inhalational agent: myocardial depression
– Neuraxial block: sympathetic blockade
low level:minimal hemodynamic change
abdominal operation: profound effects(hypotension,
reflex tachycardia)
Anesthetic Considerations

 Perioperative pain management


– PCA(iv or epidural) leads to a reduction in
postoperative catecholamine surges and
hypercoagulability, both of which can
theoretically impact myocardial ischemia.
Anesthetic Considerations

 Intraoperative nitroglycerine
– Helpful or harmful
vasodilating properties of NTG with anesthetics can
cause significant hypotension and even myocardial
ischemia.
 Transesophageal echocardiography
– Guidelines for the use of TEE to diagnosis or
guide therapy are being developed by ASA
Perioperative Surveillance

 Pulmonary artery catheters


– recent MI complicated by CHF
– significant CAD with procedures assoc. with
significant hemodynamic stress.
– Systolic or diastolic LV dysfunction
– cardiomyopathy
– valvular disease with high risk operation
Perioperative Surveillance

 Intraoperative and postoperative ST


monitoring
– Intraoperative and postoperative ST changes
are strong predictors of perioperative MI in
patients at high risk who undergo noncardiac
surgery
– proper use of computerized ST-segment
analysis may improve sensitivity for detection
of myocardial ischemia
Perioperative Surveillance

 Surveillance for perioperative MI


– Clinical symptoms
– Postoperative ECG changes
– CK-MB, troponin-I, troponin-T, CK-MB
isoforms
– In patients with known or suspected CAD undergoing
high risk procedures, obtaining ECG at baseline,
immediately after the procedure, and for the first 2
postoperative days appears to be cost effective
– Use of cardiac enzymes is best reserved for patients
with clinical, ECG, or hemodynamic evidence of
cardiovascular dysfunction.
Postoperative Therapy and Long-
Term Management
 Postoperative management should include
assessment and management of modifiable risk
factors for CAD, heart failure, HBP, stroke, and
other cardiovascular diseases.
 Assessment for hypercholesterolemia, smoking,
hypertension, DM, physical inactivity, peripheral
vascular disease, cardiac murmur(s), arrhythmias,
perioperativeischemia, and MI may lead to
evaluation and treatments that reduce future
cardiovascular risk