Chapter 56
Preoperative Cardiac Evaluation
1. What is the natural history of perioperative cardiac morbidity?
2. What is the cause of perioperative cardiac morbidity?
3. What are the strongest predictors of perioperative cardiac events?
For some specific patients, surgery represents a very high risk of cardiac complications and either therapy should be initiated preoperatively or the benefits of surgery must significantly outweigh the risks if the decision is to proceed to surgery. According to the 2009 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guidelines on Perioperative Cardiovascular Evaluation, active cardiac conditions for which the patient should undergo evaluation and treatment before noncardiac surgery include unstable coronary syndromes, active heart failure, severe valvular disease, and severe arrhythmias. Specific conditions within these general categories are shown in Table 56-1. Analysis of administrative data suggests that the elevated risk of a recent MI continues for at least the first 60 days.
TABLE 56-1
ACTIVE CARDIAC CONDITIONS FOR WHICH THE PATIENT SHOULD UNDERGO EVALUATION AND TREATMENT BEFORE NONCARDIAC SURGERY (CLASS I, LEVEL OF EVIDENCE B)
CONDITION | EXAMPLES |
Unstable coronary syndromes | Unstable or severe angina∗ (CCS class III or IV)† |
Recent MI‡ | |
Decompensated HF (NYHA functional class IV; worsening or new-onset HF) | |
Significant arrhythmias | High-grade atrioventricular block |
Mobitz II atrioventricular block | |
Third-degree atrioventricular heart block | |
Symptomatic ventricular arrhythmias | |
Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 beats/min at rest) | |
Symptomatic bradycardia | |
Newly recognized ventricular tachycardia | |
Severe valvular disease | Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm2, or symptomatic) |
Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF) |
∗According to Campeau L: Grading of angina pectoris [letter]. Circulation 54:522-523
†May include stable angina in patients who are unusually sedentary.
‡The American College of Cardiology National Database Library defines recent MI as more than 7 days but less than or equal to 1 month (within 30 days).
Modified from Fleisher LA, Beckman JA, Brown KA, et al: ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary, J Am Coll Cardiol 50:1716, 2007.
4. What is the revised cardiac risk index (RCRI) and how is it used clinically?