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

0.4% risk of cardiac complications

1

0.9% risk of cardiac complications

2

7% risk of cardiac complications

3

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

ACC/AHA Guidelines suggest the following, in order:

  1.  Decide whether this is an emergency surgery. If yes, proceed to OR.
  2.  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

  • Significant arrythmia:

  • High grade AV block 

  • Mobitz II AV block 

  • 3rd degree block

  • Symptomatic ventricular arrythmia

  • SVR with HR>100 at rest

  • Symptomatic bradycardia

  • 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.

34%

Answered correctly

2010

Year asked