Cardiac risk assessment prior to non-cardiac surgery resident survival guide

Overview

Cardiac complications are potential risks of non-cardiac surgeries and interventions. Non-cardiac surgery is associated with a 7% to 11% overall complication rate, approximately half of which are cardiac in nature. The risk of peri-operative complications is dependent on both the patient's co-morbidities and the type of surgery/intervention. The goal of pre-operative cardiac assessment is to identify patients with ischemic heart diseases, valvulopathies, left ventricular dysfunction, or arrhythmias, all of which might are associated with hemodynamic instability and cardiac stress and may affect the metabolic supply-demand balance during and following the surgery.

Algorithm for Cardiac Risk Evaluation and Perioperative Management

Shown below is an algorithm summarizing the Cardiac Risk Evaluation and Perioperative Management of according the the 2014 European Society of Cardiology (ESC) / European Society of Anesthesiology (ESA) guidelines.

Abbreviations: MI: Myocardial infarction; BP: Blood Pressure, VT: Ventricular tachycardia; HF: Heart failure; AV: Atrioventricular; ECG: Electrocardiogram; CV: Cardiovascular; CEA: Carotid endarterectomy; CAS: Carotid artery stenting; DAPT: Dual antiplatelet therapy; MET: Metabolic equivalent; ACEI: Angiotensin converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; SBP: Systolic blood pressure; NT-proBNP: N-terminal of the prohormone brain natriuretic peptide; BMS: Bare metal stent; DES: Drug eluting stent

Is the surgery an emergency?

Yes

No

Transfer to operating room

Is the surgery urgent?

No

Yes

Does the patient have either active OR unstable cardiac disease? ❑ MI within 30 days or current unstable or severe angina ❑ Decompensated HF ❑ Significant arrhythmia ❑ Mobitz II AV block ❑ 3rd degree AV block ❑ New VT ❑ Symptomatic VT ❑ SVT with Heart rate > 100 bpm ❑ Symptomatic bradycardia ❑ Severe aortic stenosis ❑ Symptomatic mitral stenosis

Evaluate for patient or surgical specific factors that would dictate approach for pre-operative assessment ❑ Peri-operative medical management ❑ Peri-operative ECG surveillance for cardiac events ❑ Continue chronic CV medical therapy

Transfer to operating room

Yes

No

❑ Evaluate the approach for peri-operative care based on surgical urgency and extent of cardiac condition ❑ Plan the approach for peri-operative care with multidisciplinary team, involving the anesthesiologist and surgeon

Determine the risk of the surgical procedure

Intermediate or high risk ❑ Intermediate risk (risk 1% to 5%) ❑ Intraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy ❑ Carotid symptomatic (CEA or CAS) ❑ Peripheral arterial angioplasty ❑ Endovascular aneurysm repair ❑ Head and neck surgery ❑ Neurological surgery or orthopedic surgery: major (hip surgery or spine surgery) ❑ Urological surgery or gynecological surgery: major ❑ Renal transplant ❑ Intra-thoracic surgery: non-major ❑ High risk (risk > 5%) ❑ Aortic surgery or major vascular surgery ❑ Open limb revascularization or amputation or thromboembolectomy ❑ Duodeno-pancreatic surgery ❑ Liver resection or bile duct surgery ❑ Esophagectomy ❑ Repair of perforated bowel ❑ Adrenal resection ❑ Total cystectomy ❑ Pneumonectomy

❑ Low risk (risk < 1%) ❑ Superficial surgery ❑ Breast surgery ❑ Dental surgery ❑ Thyroid surgery ❑ Eye surgery ❑ Reconstructive surgery ❑ Carotid asymptomatic (CEA or CAS) ❑ Gynecology surgery: minor ❑ Orthopedic surgery: minor (meniscectomy) ❑ Urological surgery: minor (transurethral resection of the prostate) ❑ Identify patient risk factors for CV diseases ❑ Recommend lifestyle interventions ❑ Recommend medical therapy according to guidelines based on patient risk factors ❑ Obtain preoperative baseline ECG

Consider the patient's functional capacity ❑ Ask about activities that require minimal amounts (up to 4) of metabolic equivalents (METs) ❑ Can you take care of yourself (eat, dress or use the toilet)? ❑ Can you walk indoors around the house? ❑ Can you walk 100 meters on level ground at 3 to 5 km per hour? ❑ Ask about activities that require moderate amounts (between 4 and 10) of metabolic equivalents (METs) ❑ Can you climb two flight of stairs or walk up a hill? ❑ Can you do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? ❑ Ask about activities that require high amounts (> 10) of metabolic equivalents (METs) ❑ Can you participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

Evaluate need for additional therapy for the following conditions: ❑ Known ischemic heart disease (IHD) or myocardial ischemia ❑ Consider titration of low-dose beta blocker therapy (starting ideally more than 1 day (preferably more than 1 week and up to 30 days) prior to planned surgery) ❑ Administer ANY of the following beta-blocker agents if the patient has no contraindications to beta-blocker therapyBeta blockers are contraindicated in bradycardia, heart block, decompensated heart failure, hypotension, asthma, severe chronic obstructive pulmonary disease ❑ Atenolol 50 mg PO once daily, OR ❑ Metoprolol succinate 100 mg PO controlled and extended release once daily, OR ❑ Bisoprolol 5 mg PO once daily ❑ Increase beta-blocker dose as needed to achieve target resting HR and SBP ❑ Target resting HR = 60 to 70 bpm ❑ Target SBP > 100 mm Hg ❑ Avoid hypotension or bradycardia ❑ Continue beta-blocker therapy for several months following surgery/intervention (unknown optimal duration) ❑ Known HF and systolic dysfunction ❑ Consider pre-op ACEI or ARB at least 1 week prior to surgery/intervention ❑ Transiently discontinue ACEI or ARB 1 day before surgery/intervention in patients known to be hypertensive ❑ Resume ACEI or ARB once blood volume and pressure are stable post-operatively ❑ Patient undergoing vascular surgery ❑ Consider initiation of statin therapy for at least 2 weeks before surgery/intervention using statins with long half-life ❑ Atorvastatin 20 mg PO once daily ❑ Lovastatin 20 mg PO once daily ❑ Continue statin therapy for at least 1 month following surgery ❑ Monitor for any of hepatotoxicity, myositis, or rhabdomyolysis

Unknown METs OR > 4 Metabolic equivalents (METs)

≤ 4 METs

Re-evaluate risk of surgical procedure

❑ Intermediate risk (risk 1% to 5%) ❑ Intraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy ❑ Carotid symptomatic (CEA or CAS) ❑ Peripheral arterial angioplasty ❑ Endovascular aneurysm repair ❑ Head and neck surgery ❑ Neurological surgery or orthopedic surgery: major (hip surgery or spine surgery) ❑ Urological surgery or gynecological surgery: major ❑ Renal transplant ❑ Intra-thoracic non-major

❑ Consider non-invasive stress testing if patient has at least one clinical risk factor according to cardiac risk index ❑ Ischemic heart disease (suggested by angina pectoris and/or previous MI) ❑ HF ❑ History of stroke of transient ischemic attack ❑ Renal dysfunction (defined as either serum creatinine > 2 mg/dL OR creatinine clearance < 60 mL/min/1.73m2 ❑ Diabetes mellitus requiring insulin therapy

❑ High risk (risk > 5%) ❑ Aortic surgery or major vascular surgery ❑ Open limb revascularization or amputation or thromboembolectomy ❑ Duodeno-pancreatic surgery ❑ Liver resection or bile duct surgery ❑ Esophagectomy ❑ Repair of perforated bowel ❑ Adrenal resection ❑ Total cystectomy ❑ Pneumonectomy

❑ Evaluate clinical risk factors ❑ Ischemic heart disease (suggested by angina pectoris and/or previous MI) ❑ HF ❑ History of stroke of transient ischemic attack ❑ Renal dysfunction (defined as either serum creatinine > 2 mg/dL OR creatinine clearance < 60 mL/min/1.73m2 ❑ Diabetes mellitus requiring insulin therapy

≥3

≤2

❑ Consider rest echocardiogram ❑ Consider pre-op cardiac troponins in high risk patients before major surgeries AND 48 to 72 hours after majory surgery ❑ Consider NT-proBNP and BNP (prognostic information of per-operative risk and risk of late cardiac events)

❑ Consider non-invasive stress testing

No/mild/moderate stress-induced ischemia

Extensive ischemia

❑ Perform individual peri-operative assessment (with consideration to potential benefit of surgical procedure, predicted adverse outcomes, and effect of medical therapy or coronary revascularization

Balloon angioplasty

Bare metal stent (BMS)

Drug-eluting stent (DES)

Coronary artery bypass graft (CABG)

❑ Plan surgery > 2 weeks following intervention ❑ Continue aspirin treatment

❑ Plan surgery >4 weeks following intervention ❑ Continue DAPT for at least 4 weeks

Old generation DES ❑ Plan surgery within 12 months following intervention New generation DES ❑ Plan surgery within 6 months following intervention

❑ Consider the need to discontinue aspirin therapy based on patient bleeding risk vs. thrombotic complications

Surgery

Do's

• Perform pre-operative risk assessment independently of an open or laparoscopic surgical approach
• Use clinical risk indices for peri-operative risk stratification
• Use either National Surgical Quality Improvement Program (NSQIP) or Lee risk index for cardiac pre-operative risk stratification
• Perform pre-operative ECG for patients who have risk factor(s) and are scheduled for intermediate or high-risk surgery
• Perform imaging stress testing before high-risk surgery among patients with more than 2 clinical risk factors and poor functional capacity (<4 METs)
• Assess the indications for pre-operative coronary angiography based on those for non-surgical setting
• Perform urgent angiography among patients with acute ST-segment elevation myocardial infarction (STEMI) requiring non-urgent, non-cardiac surgery
• Perform urgent early invasive strategy among patients with NSTE-ACS who require non-urgent, non-cardiac surgery according to risk assessment
• Perform pre-operative angiography among patients with proven myocardial ischemia and unstabilized chest pain with adequate medical therapy requiring non-urgent, non-cardiac surgery
• Continue beta-blocker therapy among patients currently receiving beta-blockers
• Continue peri-operative statin therapy using long half-life or extended-release formulations
• Continue aspirin therapy for 4 weeks after BMS implantation unless the risk of life-threatening surgical bleeding on aspirin is unacceptably high
• Send asymptomatic non-high risk patients who have undergone CABG in the past 6 years to non-urgent, non-cardiac surgery without angiographic evaluation
• Perform myocardial revascularization according to the applicable guidelines for management in stable CAD
• Consider late revascularization after successful non-cardiac surgery among patients with stable CAD
• Diagnose and treat NSTE-ACS if non-cardiac surgery can be postponed
• Manage NSTE-ACS aggressively among patients who have undergone non-cardiac surgery
• Use either new-generation DES, BMS, or even balloon angioplasty if PCI is indicated before semi-urgent surgery

Don'ts

• Don't routinely use pre-operative biomarker sampling for risk stratification
• Don't perform routine pre-operative ECG for patients who have no risk factors and are scheduled for low-risk surgery
• Don't perform routine echocardiography among patients undergoing intermediate- or low-risk surgery
• Don't perform imaging stress testing before low-risk surgery regardless of the patient's clinical risk
• Don't perform pre-operative angiography among cardiac stable patients undergoing low-risk surgery
• Don't initiate per-operative high dose beta-blockers without titration
• Don't initiate beta-blockers among patients scheduled for low-risk surgery
• Don't perform prophylactic myocardial revascularization before low- and intermediate-risk surgery among patients with proven ischemic heart disease