ACC AHA Guidelines on Perioperative Cardiac Assesement
-
Upload
menaga-vasudewan -
Category
Health & Medicine
-
view
866 -
download
3
Transcript of ACC AHA Guidelines on Perioperative Cardiac Assesement
Overview• Drafted out by American College of Cardiology (ACC) and American Heart
Association (AHA) initially in 1980 then revised again in 2002, 2007 and 2011.
• Comprising almost 20 topics relating to cardiac issues for patients undergoing non cardiac surgery.
• Eg : preoperative noninvasive evaluation of LV function; preoperative resting
12-lead ECG; noninvasive stress testing before non-cardiac surgery; reoperative coronary revascularization; betablocker therapy; statin therapy; preoperative ICU monitoring; use of volatile anesthetic agents; prophylactic
Nitroglycerin, maintenance of normothermia; glucose control; use of pulmonary artery catheters; intraoperative and postoperative ST-segment monitoring; surveillance for perioperative myocardial infarction; and the
tissue of when patients with cardiac stents can safely undergo elective surgery
Purpose
• Quick reference for decision making
• lower the risk of surgery
• evaluation of the patient’s current medical status
• make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire preoperative period
• provide a clinical risk profile can be of use in making treatment decisions that may influence short- and long-term cardiac outcomes
GOALS
– IDENTIFICATION OF PATIENTS WITH UNSTABLE CARDIOVASCULAR CONDITION
– IDENTIFICATION OF PATIENTS WITH KNOWN AND SYMPTOMATIC Coronary Heart Disease (CHD)
– IDENTIFICATION OF PATIENTS AT RISK OF CHD» PVD» HTN» DM» SMOKING» HYPERCHOLESTROLEMIA
CLASSIFICATION OF RECOMMENDATIONS
CLASS 1Benefit >>> Risk
SHOULD
CLASS II ABENEFIT >> RISK
REASONABLE
CLASS II BBENEFIT > RISK
MAYBE CONSIDERED
CLASS IIIRISK > BENEFIT
SHOULD NOT
LEVEL A Multiple (3-5) population risk
LEVEL BLimited (2-3) population risk
LEVEL CVery limited (1-2) population risk
PREOPERATIVE CARDIAC EVALUATION
• Evaluation
History taking
• to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent or past MI, decompensated HF, significant arrhythmias, and severe valvular disease
• history of a pacemaker or implantable cardioverter defibrillator
• Accurate recording of current medications used, including herbal and other nutritional supplements, and dosages
.
• Determine ASA status , surgery classification and functional capacity.
Status State
Class 1 No organic, physiologic, biochemical, or psychiatric disturbance.
Class 2 Mild to moderate systemic disturbance that may or may not be related to the reason for surgery Eg : Essential HTN, DM, Morbid Obesity, Anemia
Class 3 Severe systemic disturbance that may or may not be related to the reason for surgery, (does limit activity)Eg ; Uncontrolled HTN, DM with vascular complications, COPD with func. Limitation, angine pectoris, Hx of MI
Class 4 Severe systemic disturbance that is life-threatening with or without surgery Eg : CHF, advanced pulmonary, renal/hepatic dysfunction
Class 5 Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort)Eg : Uncontrolled hemorrhage from ruptured abdominal aneurysm, cerebal trauma, pulmonary embolism.
Emergency (E) Any patient in whom an emergency operation is required
Risk Stratification
5 FACTORS FOR RISK STRATIFICATION
– Recency Of Coronary Revascularization
– Recency Of Last Favourable Cardiac Evaluation
– Presence Of Comorbidities-clinical Predictors
– Functional Status
– Risk Of Proposed Surgery
1-CORONARY REVASCULARISATION
• Complete coronary surgical revascularization -5 yrs
• PCI-- > 6months-5 yrs
• No recurrent Symptoms or signs of ischemia
• Clinical status is stable
No further cardiac testing is necessary
2-Coronary evaluation
• Past 2 years
• Invasive/non invasive tech
– Favorable– No definite change or new symptom
No further cardiac testing is necessary
3-Clinical predictors
• Major– Unstable coronary syndromes
• recent MI with evidence for ischemia ( >7 days & < 30days)• unstable or severe angina
– Decompensated CHF– Significant arrhythmia
• high grade AV block• symptomatic ventricular arrhythmia • supraventricular arrhythmia with uncontrolled rate
– Severe valvular disease
• Intermediate– Mild angina pectoris (Canadian class I or II)– Prior MI by history or pathological Q waves– Compensated or prior CHF– Diabetes mellitus– Renal impairment (creatinine > 2mg per dL)– Anemia – Pulmonary Disease (obstructive/restrictive)
• Minor– Advanced age– abnormal ECG (LVH, LBBB, ST-T change)– Rhythm other than sinus– Low functional capacity– History of stroke– Uncontrolled systemic hypertension
Functional Capacity
• Functional capacity can be expressed as metabolic equivalents (METs); the resting or basal oxygen consumption (Vo2) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min, or 1 MET.
Duke’s Activity Status Index
• 1 MET– Can you take care of
self? – Eat, dress, use toilet?– Walk indoors in house?– Walk a block or two on
level at 2-3 mph?– Do light housework like
dusting or dishes?
• 4 METs
• 4 METsClimb a flight of stairs,
walk up hill?Walk on level at 4 mph?Run a short distance?Heavy houseworkGolf, bowling, dancing,
doubles tennisSwimming, singles tennis
football, basketball, skiing
• >10 METs
1 MET = 3.5 ml/kg/mt VO2
>10 METs-Excellent7-10 good4-7 moderate≤ 4 poor
Classification of surgeries according to Risk.
• High (reported cardiac risk > 5%)
• emergent major operations, esp. in elderly
• aortic and other major vascular procedures
• peripheral vascular procedures
• anticipated prolonged procedure with large fluid shift/blood loss
• Intermediate (reported cardiac risk < 5%)
– carotid endarterectomy
– head and neck
– intraperitoneal & intrathoracic
– orthopedic
– prostate
• Low (reported cardiac risk < 1%)
– endoscopic procedures
– superficial procedure
– cataract
– breast
9 step algorithm
9 step algorithm
9 step algorithm9 step algorithm
Cardiac Conditions that Need Evaluation and Treatment Before Surgery
Condition Examples
Unstable coronary syndromes
Unstable or severe angina (CCS class III, IV) , Recent MI
Decompensated HF
Significant Arrhythmias High Grade AV Block, Mobitz II AV Block, 3rd Degree AV block, Symptomatic Ventricular Arrhythmias, Supraventricular Arrhytmias with HR > 100 bpm at rest, Symptomatic Bradycardia, Newly Recognized VT
Severe Valvular Disease Severe aortic stenosis, Symptomatic Mitral Stenosis (dyspnea on exertion, exertional presyncope or HF)
• Class IIA
• It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms‡ proceed to planned surgery.
• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for vascular surgery consider testing if it will change management.
• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control.
• It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.
• Class IIB
• Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery. ∥
• Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery. ∥
PREOP TESTING
• ECG
• DETECT LVH,BBB & CONDUCTION DEFECT
• PREVIOUS MI
• BASELINE FOR INTRA AND POST OP COMPARISON
• INCREASED PERIOP RISK• ST DEPRESSION MORE THAN .5 MM• LVH WITH STAIN PATTERN• LBBB
• EXERCISE STRESS TEST
• STRONGEST DETERMINANT OF RISK AND NEED FOR INVASIVE MONITORING
• LEAD SELECTION
• ECG CRITERIA– 1 M M OF J POINT DEPRESSION
– 2MM OF ST DEPRESSION AT 80 MS FROM J POINT
– ST ELEVATION
– NON ECG RESP• LOW ACHIEVED HR• SYSTOLIC HYPOTENSION• INABILITY TO EXERCISE FOR MORE THAN 3 MIN
PHARMACOLOGICAL STRESS TEST
• Two Categories– Dobutamine Stress Echo-incr. Mvo2
– New/Incr In Rwma– More Than 5/16 Lt Ventricular Segm Involvement
– Dipyridamole Thallium-mimics Coronary Art Dialatation Resp Associated With Exercise
– Infarcted Area-fixed Defect– Ischemic Area-reversible Defect
ECHOCARDIOGRAPHY
– LVEF– RWMA– Valvular Abn– Cong Cardiac Defects
CORONARY ANGIOGRAPHY
• Non Invasive Testing-high Risk Of Adverse Outcome
• Angina Unresponsive To adequate Medical Therapy
• Unstable Angina-intermediate And High Risk Sx
• High Clinical Predictor In High Risk Sx
PERIOP THERAPY
• BETA BLOCKERS– CVS EFFECTS
• ↓ HR-(diastolic Time)• ↓ Contractility• Plaque Stabilization- ↓ Shear Forces• Antiarrythmic Effect
– ELIGIBILITY CRITERIA• CLINICAL -ANY 2
– AGE>65– HTN– CHR SMOKER– SER CHOLESTROL>240 mg/dl– DM
• CARDIAC RISK INDEX CRITERIA– HIGH RISK SX PROCEDURE– IHD– CVA– DM– CRF
OTHER THERAPIES
• Alpha-2 Adrenergic Agonist
• Regional Anesthesia
– Epidural