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Cardiac patients for non cardiac sx (Algorithm (Step 1: CAD or known…
Cardiac patients for non cardiac sx
Categorise Procedures (2014 ACC/AHA guidelines)
Low risk - combined surg and patient characteristics predict risk of MACE <1% (e.g. cataract, plastic, endoscopy)
Elevated risk - procedures where combined surg and patient characteristics predict MACE risk>1% (open/vascular procedures)
Cardiac assessment tools
RCRI (revised cardiac risk index) - 2 or more of following RFs make a patient 'high risk'
High risk surgery (intraperitoneal, intrathoracic or supra-inguinal vascular procedures)
History of ischaemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Preop treatment with insulin
Preop serum creatinine> 2.0mg.dL
ACS NSQPI surg risk calculator - 22 questions about pt and procedure
Go to website (riskcalculator.facs.org)
Provides the % risk of MACE (amongst other risks)
Once patients periop risk MACE has been estimated - this info can be used in an algorithm
Algorithm
Step 1: CAD or known cardiac risk factors
IHD (hx AMI / +ve stress test / current chest pain / ECG with Q waves)
Renal impairment
CVD (hx TIA / CVA)
DM
HF (hx failure / PO / peripheral oedema)
Step 2: DO they have ACS? - evaluate and treat
Step 3: Estimate periop risk MACE
Low risk (<1%)
Endoscopic, superficial, cataract
Elevated risk (>1%)
No distinction btw elevated and high risk
Can lower risk by less invasive procedure (i.e. endovascular)
Emerg surgery raises risk
Validated calculators
RCRI
6 predictors: The 5 RFs for CAD plus high risk surgery (supra-ing vasc, intraperiton, intrathoracic)
0-1 low risk, 2+ high risk
NSQIP
21 predictors, large multicentre
Step 4: Low risk proceed to surgery
Step 5: Elevated risk - functional capacity assessment
1 MET: 3.5ml O2 /kg/min, resting oxygen consumption
If >4 METS no further testing - proceed to surgery
Step 6: If <4 METS or unknown - will further testing impact decision making or periop care?
Stress echo
Normal - proceed
Not normal - revascularise
Step 7: Proceed to surgery or non-surgical options
