Cardiac morbidity: Pre-op factors
Clinical - Cardiovascular
Revised Cardiac Index
Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery [Lee et al.]
0.4% risk of cardiac complications
0.9% risk of cardiac complications
7% risk of cardiac complications
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]https://en.wikipedia.org/wiki/Revised_Cardiac_Risk_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
High grade AV block
Mobitz II AV block
3rd degree block
Symptomatic ventricular arrythmia
SVR with HR>100 at rest
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.