1 Presentation on 16 Feb 2010

8/9/2019 1 Presentation on 16 Feb 2010

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Anesthetic Considerations inAnesthetic Considerations in

Cardiac Patients UndergoingCardiac Patients UndergoingNon Cardiac SurgeryNon Cardiac Surgery

Amit KochetaAmit KochetaDNB TraineeDNB Trainee

Anesthesia and Critical CareAnesthesia and Critical CareBMHRC, BhopalBMHRC, Bhopal


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IntroductionIntroduction Administering anaesthesia to patientsAdministering anaesthesia to patients

with preexisting cardiac disease is anwith preexisting cardiac disease is aninteresting challengeinteresting challenge

Most common cause of periMost common cause of peri--operativeoperativemorbidity and mortality in cardiacmorbidity and mortality in cardiacpatients is ischemic heart diseasepatients is ischemic heart disease(IHD)(IHD)

Care of these patients requireCare of these patients requireidentification of risk factors, preidentification of risk factors, pre--

operative evaluation & optimization,operative evaluation & optimization,medical therapy, monitoring and themedical therapy, monitoring and thechoice of appropriate anestheticchoice of appropriate anesthetictechnique and drugs.technique and drugs.


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Risk factorsRisk factors

Risk factorsRisk factors Influencing periInfluencing peri--operative cardiac morbidity are:operative cardiac morbidity are:

1.1. Recent myocardial infarctionRecent myocardial infarction2.2. Congestive cardiac failureCongestive cardiac failure

3.3. Peripheral vascular diseasePeripheral vascular disease4.4. Angina pectorisAngina pectoris5.5. Diabetes mellitusDiabetes mellitus6.6. HypertensionHypertension7.7. HypercholesterolemiaHypercholesterolemia8.8. DysrrhythmiasDysrrhythmias

9.9. AgeAge10.10. Renal dysfunctionRenal dysfunction11.11. ObesityObesity12.12. Life style and smokingLife style and smoking


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Risk stratificationRisk stratification

A number of risk indices have been developed.A number of risk indices have been developed.

A cardiac risk index to be useful, it has to be applicableA cardiac risk index to be useful, it has to be applicableto all and be consistently accurate.to all and be consistently accurate.

In 1996, a 12In 1996, a 12--member task force of the Americanmember task force of the AmericanCollege of Cardiology and the American HeartCollege of Cardiology and the American HeartAssociation (ACC/AHA) published guidelines regardingAssociation (ACC/AHA) published guidelines regardingthe perioperative cardiovascular evaluation of patientsthe perioperative cardiovascular evaluation of patients

undergoing non cardiac surgery.undergoing non cardiac surgery.

In Nov 2009, these guidelines were updated based onIn Nov 2009, these guidelines were updated based onnew data.new data.


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Risk indicesRisk indices

Risk indices developedRisk indices developedbefore 1990before 1990

Risk indices developed inRisk indices developed inlast decadelast decade

1.1. American Society ofAmerican Society of

Anesthesiologists (ASA)Anesthesiologists (ASA)2.2. New York Heart AssociationNew York Heart Association

(NYHA)/ Canadian Cardio(NYHA)/ Canadian Cardio--vascular Society (CCS)vascular Society (CCS)

3.3. GoldmanGoldman

4.4. CoopermanCooperman5.5. DetskyDetsky

6.6. LarsenLarsen

7.7. PedersenPedersen

8.8. VanzettoVanzetto

1.1. American College of CardiologyAmerican College of Cardiology

(ACC)/ American Heart(ACC)/ American HeartAssociation (AHA)Association (AHA)

2.2. American College of PhysiciansAmerican College of Physicians(ACP)(ACP)

3.3. LeeLee

4.4. ACCF / AHA (Updated 2007 &ACCF / AHA (Updated 2007 &2009)2009)

5.5. European Society of CardiologyEuropean Society of Cardiology(ESC) and endorsed by the(ESC) and endorsed by theEuropean Society ofEuropean Society of

Anesthesiology (ESA) (2009)Anesthesiology (ESA) (2009)


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ASA Physical Status AssessmentASA Physical Status Assessment

Class I: Healthy patient/elective operationClass I: Healthy patient/elective operation

Class II: Patient with mild systemicClass II: Patient with mild systemicdiseasedisease

Class III: Severe systemic disease thatClass III: Severe systemic disease thatlimits activity but is not incapacitatinglimits activity but is not incapacitating

Class IV: Incapacitating systemic diseaseClass IV: Incapacitating systemic disease

that is a constant threat to lifethat is a constant threat to life Class V: Moribund patient not expected toClass V: Moribund patient not expected to

survive 24 hours with or without operationsurvive 24 hours with or without operation


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Goldman cardiac risk indexGoldman cardiac risk index

Cardiac ComplicationRate :Cardiac ComplicationRate :--00 -- 5 points = 1 % 65 points = 1 % 6 12 points = 7 %12 points = 7 %

1313 25 points = 14 % > 26 points = 78 %25 points = 14 % > 26 points = 78 %

S. NoS. No Cardiac Risk VariablesCardiac Risk Variables PointsPoints

1.1. Third heart sound or jugularThird heart sound or jugular

venous distensionvenous distension

1111

2.2. Recent myocardial infarctionRecent myocardial infarction 1010

3.3. Non sinus rhythm or premature atrial contractionNon sinus rhythm or premature atrial contractionon ECGon ECG

77

4.4. More than 5 premature ventricular contractionsMore than 5 premature ventricular contractions 77

5.5. Age more than 70 yearsAge more than 70 years 55

6.6. Emergency operationsEmergency operations 44

7.7. Poor general medical conditionPoor general medical condition 33

8.8. Intrathoracic, intraperitoneal or aortic operationIntrathoracic, intraperitoneal or aortic operation 33

9.9. Aortic stenosisAortic stenosis 3 3


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Eagle criteria for cardiac riskEagle criteria for cardiac risk

assessmen

tassessmen

t1.1. Age more than 70Age more than 70

yrsyrs11 3 : sendforforangiographyangiography

2.2. DiabetesDiabetes 11

3.3. AnginaAngina 11

4.4. Q waves on ECGQ waves on ECG 11

5.5. VentricularVentriculararrhythmiasarrhythmias

11


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American College of Cardiology/AmericanAmerican College of Cardiology/AmericanHeart Association (ACC/AHA) guidelinesHeart Association (ACC/AHA) guidelines

The ACC/AHA guidelines provide a framework for screening andThe ACC/AHA guidelines provide a framework for screening andidentifying patients who are at high risk for perioperative cardiacidentifying patients who are at high risk for perioperative cardiacevents (PCE).events (PCE).

History, physical examination and preoperative ECG form the basisHistory, physical examination and preoperative ECG form the basisfor risk stratification.for risk stratification.

According to the AHA/ACC guidelines, risk for PCE depends on theAccording to the AHA/ACC guidelines, risk for PCE depends on thepatients medical history, current functional status, and the specificpatients medical history, current functional status, and the specificsurgical procedure.surgical procedure.

The ACC algorithm employs a strategy, using the urgency ofThe ACC algorithm employs a strategy, using the urgency ofsurgery, history of previous coronary evaluation or treatment,surgery, history of previous coronary evaluation or treatment,clinical risk predictors, surgeryclinical risk predictors, surgery--specific risk, and a patientsspecific risk, and a patientsfunctional capacity.functional capacity.


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PatientPatientEvaluationEvaluation


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HistoryHistory1. Presence, severity, and reversibility of coronary artery disease1. Presence, severity, and reversibility of coronary artery disease

Risk factorsRisk factors1.1. AgeAge2.2. HypertensionHypertension3.3. Diabetes mellitusDiabetes mellitus4.4. CholesterolCholesterol5.5. Cigarette smokingCigarette smoking

Angina patternsAngina patterns

1.1. Stable or unstable (new, crescendo, at rest)Stable or unstable (new, crescendo, at rest)2.2. MedicationsMedications

Previous myocardial infarctionPrevious myocardial infarction Myocardial functionMyocardial function

1.1. NYHA classificationNYHA classification2.2. Exercise capacityExercise capacity3.3. Pulmonary edemaPulmonary edema

4.4. Pulmonary hypertensionPulmonary hypertension DysrhythmiasDysrhythmias

1.1. PalpitationPalpitation

Associated cardiovascular diseasesAssociated cardiovascular diseases1.1. Cerebral, carotid, aorticCerebral, carotid, aortic2.2. Peripheral vascular diseasePeripheral vascular disease claudicationclaudication


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2.Valvular heart disease2.Valvular heart disease1.1. Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND2.2. HemoptysisHemoptysis3.3. Embolic eventsEmbolic events4.4. Heart failureHeart failure5.5. Arrhythmia.Arrhythmia.

3. Prior cardiac evaluation3. Prior cardiac evaluation1.1. Non invasive testNon invasive test2.2. AngiographyAngiography

4.Medications4.Medications1.1. HistoryHistory2.2. Current medicationsCurrent medications3.3. EffectivenessEffectiveness

5. Co5. Co--existing noncardiac diseasesexisting noncardiac diseasesi.i. Peripheral vascular diseasePeripheral vascular diseaseii.ii. Cerebro vascular diseaseCerebro vascular disease

iii.iii. Chronic obstructive pulmonary disease in patients with history of cigaretteChronic obstructive pulmonary disease in patients with history of cigarettesmokingsmoking

iv.iv. Renal dysfunction may be associated with chronic hypertensionRenal dysfunction may be associated with chronic hypertensionv.v. DiabetesDiabetes-- May be the cause of silent MIMay be the cause of silent MIvi.vi. Anaemia, polycythemia, thrombocytosis when present will need carefulAnaemia, polycythemia, thrombocytosis when present will need careful

management.management.


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Physical examinationPhysical examination

Vital signsVital signs1.1. Pulse (Regularity, radial, carotid, femoral)Pulse (Regularity, radial, carotid, femoral)2.2. Blood pressureBlood pressure3.3. Pulse pressurePulse pressure4.4. RespirationRespiration

Cardiac examinationCardiac examination1.1. JVPJVP2.2. Peripheral edemaPeripheral edema3.3. Displaced apical impulseDisplaced apical impulse cardiomegalycardiomegaly

4.4. S3 gallop (increased LVEDP)S3 gallop (increased LVEDP)5.5. S4 (decreased compliance)S4 (decreased compliance)6.6. Apical systolic murmur (papillary muscle dysfunction)Apical systolic murmur (papillary muscle dysfunction)7.7. Pulmonary edemaPulmonary edema8.8. MurmursMurmurs


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Diagnostic testsDiagnostic tests

Chest X rayChest X ray CardiomegalyCardiomegaly Signs of ventricular dysfunctionSigns of ventricular dysfunction

Increased pulmonary vascular markingsIncreased pulmonary vascular markings EdemaEdema

EffusionsEffusions

ECGECG Myocardial ischaemia / infarctionMyocardial ischaemia / infarction

Comparison with previous ECGComparison with previous ECG ST changes (depression, elevation)ST changes (depression, elevation) T wave changes (inversions)T wave changes (inversions) Q wave (significance, location)Q wave (significance, location)

Chamber enlargementChamber enlargement LVH (voltage, strain criteria)LVH (voltage, strain criteria)

DysrhythmiasDysrhythmias Conduction abnormalityConduction abnormality


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EchocardiographyEchocardiography to knowto know

ejection fraction,ejection fraction,

any valvular lesion ,any valvular lesion ,

wall motion abnormalities,wall motion abnormalities,

LV function and pressure gradients,LV function and pressure gradients,


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Holter monitoringHolter monitoring

Treadmill testTreadmill test Thallium scintigraphyThallium scintigraphy to detectto detect

myocardium at risk,myocardium at risk,

Radionuclide ventriculographyRadionuclide ventriculography Dobutamine stress test (DST)Dobutamine stress test (DST) forfor

evaluating inducible ischemia in patientsevaluating inducible ischemia in patients

who have poor functional capacitywho have poor functional capacity Coronary angiographyCoronary angiography in patientsin patients

where DST is positive should be done.where DST is positive should be done.


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AnaestheticAnaesthetic

managementmanagement


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Anaesthesia goalsAnaesthesia goals

Stable haemodynamicsStable haemodynamics

Prevent MI by optimizing myocardial oxygenPrevent MI by optimizing myocardial oxygensupply and reducing oxygen demandsupply and reducing oxygen demand

Monitor for ischaemiaMonitor for ischaemia

Treat ischemia or infarction if it developsTreat ischemia or infarction if it develops

NormothermiaNormothermia Avoidance of significant anemia.Avoidance of significant anemia.


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Clinical predictors of increasedClinical predictors of increasedperioperative cardiovascular risk (myocardial infarction,perioperative cardiovascular risk (myocardial infarction,

congestive heart failure, death)congestive heart failure, death)

Major clinical predictorsMajor clinical predictors

Unstable coronary syndromesUnstable coronary syndromes

Recent myocardial infarction with evidence of importantRecent myocardial infarction with evidence of importantischaemic risk by clinical symptoms or noninvasive studyischaemic risk by clinical symptoms or noninvasive study Unstable or severe angina (Canadian class III or IV)Unstable or severe angina (Canadian class III or IV)

Decompensated congestive heart failureDecompensated congestive heart failure Significant arrhythmiasSignificant arrhythmias

HighHigh--grade atrioventricular blockgrade atrioventricular block Symptomatic ventricular arrhythmias in the presence ofSymptomatic ventricular arrhythmias in the presence ofunderlying heart diseaseunderlying heart disease

Supraventricular arrhythmias with uncontrolled ventricular rateSupraventricular arrhythmias with uncontrolled ventricular rate

Severe valvular diseaseSevere valvular disease


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Intermediate clinical predictorsIntermediate clinical predictors

Mild angina pectoris (Canadian class I or II)Mild angina pectoris (Canadian class I or II) Prior myocardial infarction by history or pathologic Q wavesPrior myocardial infarction by history or pathologic Q waves Compensated or prior congestive heart failureCompensated or prior congestive heart failure Diabetes mellitusDiabetes mellitus Renal insufficiencyRenal insufficiency

Minor clinical predictorsMinor clinical predictors

Advanced ageAdvanced age Abnormal ECG (left ventricular hypertrophy, left bundle branch block,Abnormal ECG (left ventricular hypertrophy, left bundle branch block,

STST--T abnormalities)T abnormalities)

Rhythm other than sinus (Rhythm other than sinus (e.g.,e.g., atrial fibrillation)atrial fibrillation) Low functional capacity (Low functional capacity (e.g.,e.g., inability to climb one flight of stairs with ainability to climb one flight of stairs with a

bag of groceries)bag of groceries) History of strokeHistory of stroke Uncontrolled systemic hypertensionUncontrolled systemic hypertension


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SurgerySurgery--specific risk factorsspecific risk factors

High (Reported cardiac risk often greater than 5%)High (Reported cardiac risk often greater than 5%)

Emergent major operations, particularly in the elderlyEmergent major operations, particularly in the elderly Aortic and other major vascular surgeryAortic and other major vascular surgery Peripheral vascular surgeryPeripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluidAnticipated prolonged surgical procedures associated with large fluid

shifts and/or blood lossshifts and/or blood loss

Intermediate (Reported cardiac risk generally less thanIntermediate (Reported cardiac risk generally less than

5%)5%) Carotid endarterectomyCarotid endarterectomy Head and neck surgeryHead and neck surgery Intraperitoneal and intrathoracic surgeryIntraperitoneal and intrathoracic surgery Orthopaedic surgeryOrthopaedic surgery Prostate surgeryProstate surgery

L

ow (R

eported cardiac risk gen

erally less than

1%)L

ow (R

eported cardiac risk gen

erally less than

1%) Endoscopic proceduresEndoscopic procedures Superficial procedureSuperficial procedure Cataract surgeryCataract surgery Breast surgeryBreast surgery


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PreoperativePreoperative



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Major Clinical PredictorsMajor Clinical Predictors


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Intermediate PredictorsIntermediate Predictors


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Minor PredictorsMinor Predictors


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J. Am. Coll. Cardiol. 2009;54;e13-e118 2009 ACCF/AHA Guidelines on Perioperative CardiovascularEvaluation and Care for Noncardiac Surgery


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European Heart Journal (2009) 30, 27692812 ESC GUIDELINES


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Beta blockersBeta blockers have been shown to behave been shown to beuseful in reducing perioperative morbidityuseful in reducing perioperative morbidity

and mortality in high risk cardiac patientsand mortality in high risk cardiac patientsand preferably titrated to a heart rate ofand preferably titrated to a heart rate of50 to 60 bpm.50 to 60 bpm.

a2 agonistsa2 agonists by virtue of theirby virtue of theirsympatholytic effects can be useful insympatholytic effects can be useful inpatients where beta blockers arepatients where beta blockers arecontraindicated.contraindicated.

NitroglycerineNitroglycerine lowers LVEDP bylowers LVEDP byreducing preload. It improves collateralreducing preload. It improves collateralcoronary flow and reduce systemic B.P.coronary flow and reduce systemic B.P.


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Coronary interventionCoronary intervention should be guidedshould be guided

by patients cardiac condition( unstableby patients cardiac condition( unstableangina, left main or equivalent CAD, threeangina, left main or equivalent CAD, threevessel disease, decreased LV function)vessel disease, decreased LV function)

and by the potential consequences ofand by the potential consequences ofdelaying the noncardiac surgery fordelaying the noncardiac surgery forrecovery after coronary revascularization.recovery after coronary revascularization.

Patients who underwentPatients who underwentPCIPCI had betterhad betteroutcome after noncardiac surgery.outcome after noncardiac surgery.


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Preanaesthetic considerationsPreanaesthetic considerations

Preoperative visit to the patient is veryPreoperative visit to the patient is veryimportant.important.

Patient should be explained about the riskPatient should be explained about the riskof surgery and anaesthesia.of surgery and anaesthesia.

Continue the medications till the day ofContinue the medications till the day ofsurgery like beta blockers, calcium channelsurgery like beta blockers, calcium channelblocker, digitalis etc.blocker, digitalis etc.

Anticoagulants should be stopped.Anticoagulants should be stopped.


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PremedicationPremedication

Allaying anxiety in cardiac patients is ofAllaying anxiety in cardiac patients is ofparamount importance.paramount importance.

Any combination of benzodiazepine likeAny combination of benzodiazepine likeLorazepam and opioid like morphineLorazepam and opioid like morphineshould be given one hour prior to arrival inshould be given one hour prior to arrival inoperation theatre.operation theatre.


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IntraoperativeIntraoperative



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MonitoringMonitoring1.1. ECG, three leads ( II,V4,V5 or V3,V4,V5 ) improvesECG, three leads ( II,V4,V5 or V3,V4,V5 ) improves

recognition of ischaemia. The ST segment trendingrecognition of ischaemia. The ST segment trendingsystem also helps in the detection of ischaemiasystem also helps in the detection of ischaemia

2.2. Blood pressureBlood pressure

3.3. Pulse oximetryPulse oximetry

4.4. CapnographyCapnography

5.5. Temperature monitoringTemperature monitoring

6.6. Urine output monitoringUrine output monitoring

7.7. Central venous pressureCentral venous pressure

8.8. Pulmonary artery pressure and cardiac output can bePulmonary artery pressure and cardiac output can bemeasured with pulmonary artery catheter as requiredmeasured with pulmonary artery catheter as required

9.9. TEE (transesophageal echocardiography) is a sensitiveTEE (transesophageal echocardiography) is a sensitivemonitor for ischaemia. However TEE is not advocatedmonitor for ischaemia. However TEE is not advocatedfor routine usefor routine use


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Choice ofChoice of

anaestheticsanaesthetics


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General anaesthesiaGeneral anaesthesia

1.1. Intravenous anaestheticsIntravenous anaesthetics

ThiopentoneThiopentone It reduces myocardial contractility, preload and blood pressureIt reduces myocardial contractility, preload and blood pressure

and there is slight increase in heart rate.and there is slight increase in heart rate. It should be administered slowly and with caution.It should be administered slowly and with caution.

PropofolPropofol

It reduces arterial blood pressure and heart rate significantly.It reduces arterial blood pressure and heart rate significantly. There is dose dependent reduction in myocardial contractility.There is dose dependent reduction in myocardial contractility.

It can be used in with good ventricular function but is notIt can be used in with good ventricular function but is notgood induction agent for patients with CAD.good induction agent for patients with CAD.


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KetamineKetamine It is not good in IHD and valvular heart disease patients.It is not good in IHD and valvular heart disease patients. It is however a useful agent in situations like cardiac tamponadeIt is however a useful agent in situations like cardiac tamponade

and cyanotic heart disease.and cyanotic heart disease.

MidazolamMidazolam It produces decrease in mean arterial pressure and increase inIt produces decrease in mean arterial pressure and increase in

heart rate.heart rate. It provides excellent amnesia and is widely used for patient withIt provides excellent amnesia and is widely used for patient with

CADCAD

EtomidatEtomidat It causes minimum haemodynamics changes.It causes minimum haemodynamics changes. It is excellent for induction in patients with poor cardiac reserve.It is excellent for induction in patients with poor cardiac reserve.


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2. Narcotics2. Narcotics

Morphine is the preferred drug for its relativeMorphine is the preferred drug for its relativecardiac stability and very good analgesic effect.cardiac stability and very good analgesic effect.

It produces arterial and venous dilatation,It produces arterial and venous dilatation,resulting in reduction of afterload and preload.resulting in reduction of afterload and preload.

Newer narcotic analgesic agents like fentanyl,Newer narcotic analgesic agents like fentanyl,

alfentanyl and sufentanil also provide adequatealfentanyl and sufentanil also provide adequatecardiac stability and pain relief.cardiac stability and pain relief.


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3. Inhalational agents3. Inhalational agents

Isoflurane is recommended in patients with goodIsoflurane is recommended in patients with goodmyocardial contractility.myocardial contractility.

Halothane has the disadvantage of myocardialHalothane has the disadvantage of myocardialdepression and potential of dysrrhythmias.depression and potential of dysrrhythmias.

4.Nitrous oxide4.Nitrous oxide It provides stable haemodynamics in cardiacIt provides stable haemodynamics in cardiac

patients.patients.


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5. Muscle relaxants5. Muscle relaxants

Vecuronium produces minimum haemodynamicVecuronium produces minimum haemodynamicalterations and is short acting , therefore suitable for usealterations and is short acting , therefore suitable for usein cardiac patients.in cardiac patients.

Pipecuronium, mivacurium, doxacurium are newer nonPipecuronium, mivacurium, doxacurium are newer nondepolarizing muscle relaxants without any significantdepolarizing muscle relaxants without any significantcardiovascular side effects.cardiovascular side effects.

6.G

lycopyrrolate6.G

lycopyrrolate It is preferred over atropine since it produces lessIt is preferred over atropine since it produces less

tachycardia & should be used only if specificallytachycardia & should be used only if specificallyrequired.required.


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Regional anaesthesiaRegional anaesthesia

Patient should be nicely premedicated without anyPatient should be nicely premedicated without anyapprehension.apprehension.

Disadvantages of regional anaesthesia includeDisadvantages of regional anaesthesia include

hypotension from uncontrolled sympathetic blockade andhypotension from uncontrolled sympathetic blockade andneed for volume loading can result in ischemia.need for volume loading can result in ischemia.

Care should be taken while giving local anaestheticCare should be taken while giving local anaestheticbecause larger doses can cause myocardial toxicity andbecause larger doses can cause myocardial toxicity and

myocardial depression.myocardial depression.

Use of epinephrine with local anaesthetic is notUse of epinephrine with local anaesthetic is notrecommendedrecommended


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Managing IntraoperativeManaging Intraoperativecomplicationscomplications

Intraoperative ischaemiaIntraoperative ischaemia If patient is haemodynamically stableIf patient is haemodynamically stable

Beta blockers ( I/V metoprolol upto 15mg)Beta blockers ( I/V metoprolol upto 15mg)

I/V NitroglycerineI/V Nitroglycerine Heparin after consultation with surgeonHeparin after consultation with surgeon

If patient is haemodynamically unstableIf patient is haemodynamically unstable

Support with inotropesSupport with inotropes

Use of intraoperative balloon pump may beUse of intraoperative balloon pump may benecessarynecessary

Urgent consultation with cardiologist to plan forUrgent consultation with cardiologist to plan forearliest possible cardiac catheterizationearliest possible cardiac catheterization


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Post operativemanagementPost operativemanagement

Goals are same as intraoperativeGoals are same as intraoperative

i. Prevent ischaemiai. Prevent ischaemia

ii. Monitor for MIii. Monitor for MI

iii. Treatment for MIiii. Treatment for MI


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Conclusions (1)Conclusions (1)

Perioperative evaluation andPerioperative evaluation andmanagement results from goodmanagement results from good

communication between surgeon,communication between surgeon,anesthesiologist, primary careanesthesiologist, primary carephysician, and consultantphysician, and consultant


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Further cardiac testing andFurther cardiac testing andtreatments same as in nonoperativetreatments same as in nonoperative

setting, considering:setting, considering: The urgency of the noncardiacThe urgency of the noncardiac

surgerysurgery

PatientPatient--specific risk factorsspecific risk factors SurgerySurgery--specific considerationsspecific considerations


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Use Preoperative Tests When:Use Preoperative Tests When:

Clinical assessment suggestsClinical assessment suggestsintermediate risk and surgical risk notintermediate risk and surgical risk not

lowlow

Surgical risk is highSurgical risk is high

Results will affect patient managementResults will affect patient management


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Perioperative evaluation goals:Perioperative evaluation goals:Accurately estimate perioperative riskAccurately estimate perioperative risk

Lowering perioperative cardiac risk, ifLowering perioperative cardiac risk, ifpossiblepossible

Assess longAssess long--term riskterm risk

Address modifiable coronary risk factorsAddress modifiable coronary risk factors


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1 Presentation on 16 Feb 2010