{"id":10012,"date":"2010-12-09T16:46:14","date_gmt":"2010-12-09T11:16:14","guid":{"rendered":"http:\/\/cardiophile.org\/?p=5435"},"modified":"2023-10-06T22:38:08","modified_gmt":"2023-10-06T17:08:08","slug":"cardiac-evaluation-before-non-cardiac-surgery-3","status":"publish","type":"post","link":"https:\/\/johnsonfrancis.org\/professional\/cardiac-evaluation-before-non-cardiac-surgery-3\/","title":{"rendered":"Cardiac evaluation before non-cardiac surgery"},"content":{"rendered":"<p><iframe loading=\"lazy\" width=\"560\" height=\"315\" src=\"https:\/\/www.youtube.com\/embed\/VkCkJEECyEE?si=_3OAALKh-pcus5Xo\" title=\"YouTube video player\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" allowfullscreen><\/iframe><\/p>\n<h2><span style=\"color: #008000;\">Cardiac evaluation before non-cardiac surgery<\/span><\/h2>\n<p>Cardiac events are the most common serious perioperative adverse events and may occur in 1% to 5% of the persons undergoing major surgical procedures, with actual incidence depending on the preoperative cardiac status of the individual. Purpose of preoperative evaluation is not just to give medical clearance for surgery, but to have an evaluation of person\u2019s current medical status to make perioperative recommendations on evaluation, management and risk of cardiac problems. The evaluation aims to provide a clinical risk profile to the person, non-physician caregivers, primary physician of the person, anesthesiologist and surgeon for making treatment decisions which may influence short- and long-term cardiac outcomes.<\/p>\n<p><span style=\"color: #0000ff;\"><strong>Active cardiac conditions which should be treated before non-cardiac surgery<\/strong><\/span><\/p>\n<p>Unstable coronary syndromes like unstable or severe angina (Class III \/ IV) \u00a0and recent myocardial infarction<br \/>\nDecompensated heart failure &#8211; Class IV, worsening or new-onset heart failure<br \/>\nSignificant arrhythmias like high-grade AV block, Mobitz type II AV block and complete AV block, symptomatic bradycardia, symptomatic ventricular arrhythmias and supra arrhythmias with uncontrolled ventricular rate above 100 per minute<br \/>\nSevere valvular diseases like severe aortic stenosis and symptomatic mitral stenosis<\/p>\n<p><span style=\"color: #0000ff;\"><strong>Functional capacity<\/strong><\/span><\/p>\n<p>Functional capacity has an important role in deciding further evaluation. A person classified as high risk due to age or known coronary artery disease, but asymptomatic and runs for 30 minutes daily may need no further evaluation while a sedentary person with no history of cardiovascular disease but with clinical factors that suggest increased perioperative risk needs more extensive preoperative evaluation.<\/p>\n<p><span style=\"color: #0000ff;\"><strong>Important factors in the history<\/strong><\/span><\/p>\n<p>History of pacemaker or implantable cardioverter defibrillator implantation has to be noted as these devices need special care perioperatively. History of orthostatic intolerance may give important clues to the cardiovascular status. Any recent change in symptoms of cardiovascular disease, current medications used, including herbal and nutritional supplements, and dosages have to be documented. Use of alcohol, tobacco, and over the counter or illicit drugs have also to be noted.<\/p>\n<p><strong><span style=\"color: #0000ff;\">Physical examination<\/span><\/strong><\/p>\n<p>Measurement of blood pressure, ideally in both arms, to check for any difference, checking carotid pulse contour and bruits, jugular venous pressure and pulsations are all important in preoperative cardiovascular evaluation.\u00a0Precordial palpation and auscultation, auscultation of the lungs, abdominal palpation and evaluation of extremities for edema and vascular integrity are essential. Look for anemia as it can exacerbate myocardial ischemia and aggravate heart failure.<\/p>\n<p><strong><span style=\"color: #0000ff;\">Revised cardiac risk index<\/span><\/strong><\/p>\n<p>Revised cardiac risk index by Lee et al [1] for the preoperative evaluation of cardiac risk is one among the several available. It comprises of six independent risk correlates:<br \/>\n1. Ischemic heart disease &#8211; history of myocardial infarction, positive treadmill test, use of nitroglycerin, current complaints of cardiac pain or ECG with abnormal Q waves.<br \/>\n2. Congestive heart failure &#8211; history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnoea, peripheral edema, bilateral rales, S3, or chest x-ray with pulmonary vascular redistribution.<br \/>\n3. Cerebral vascular disease &#8211; history of transient ischemic attack (TIA) or stroke.<br \/>\n4. High-risk surgery like abdominal aortic aneurysm, other vascular, thoracic, abdominal or major orthopedic surgery.<br \/>\n5. Diabetes mellitus requiring preoperative insulin therapy.<br \/>\n6. Preoperative serum creatinine more than 2 mg per deciliter.<\/p>\n<p><strong><span style=\"color: #0000ff;\">Minor predictors of cardiac risk<\/span><\/strong><\/p>\n<p>These are some recognized markers for cardiovascular disease like advanced age (more than 70 years), abnormal ECG features like left ventricular hypertrophy, left bundle branch block, ST segment and T wave abnormalities, rhythm other than sinus and uncontrolled systemic hypertension.<\/p>\n<p><strong><span style=\"color: #0000ff;\">Classification of functional capacity<\/span><\/strong><\/p>\n<p>Functional capacity can be classified as follows:<br \/>\nExcellent : &gt; 10 METs<br \/>\nGood : 7 to 10 METs<br \/>\nModerate : 4 to 7 METs<br \/>\nPoor : &lt; 4 METs<br \/>\nUnknown (cannot be assessed due to other factors which prevent assessment of functional capacity)<br \/>\nOne MET or metabolic equivalent is the basal metabolic requirement of an individual which comes to 3.5 ml oxygen per kilogram per minute.<\/p>\n<p><strong><span style=\"color: #0000ff;\">Supplemental preoperative evaluation<\/span><\/strong><\/p>\n<p>Assessment of risk for coronary artery disease and functional capacity can be done with a combination of\u00a012-Lead ECG and exercise stress testing.\u00a0Pharmacological stress testing is considered when exercise stress testing is not clinically feasible.\u00a0Avoid stress testing in unstable patient, consider coronary angiography if indicated.<br \/>\nAssessment of left ventricular function can be done by echocardiography which is widely available and more economical or rarely by radionuclide ventriculography or contrast ventriculography.<\/p>\n<p><strong>Please note that emergency surgery for life threatening conditions should not be deferred just because of perceived cardiovascular risk.<\/strong><\/p>\n<p><strong><span style=\"color: #0000ff;\">Reference<\/span><\/strong><\/p>\n<ol>\n<li>T H Lee, E R Marcantonio, C M Mangione, E J Thomas, C A Polanczyk, E F Cook, D J Sugarbaker, M C Donaldson, R Poss, K K Ho, L E Ludwig, A Pedan, L Goldman.\u00a0<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/10477528\/\">Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery<\/a>. Circulation. 1999 Sep 7;100(10):1043-9.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Purpose of preoperative evaluation is not just to give medical clearance for surgery, but to have an evaluation of patient\u2019s current medical status to make perioperative recommendations on evaluation, management and risk of cardiac problems.<\/p>\n","protected":false},"author":1,"featured_media":36618,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","footnotes":""},"categories":[9],"tags":[],"class_list":["post-10012","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-general"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Cardiac evaluation before non-cardiac surgery<\/title>\n<meta name=\"description\" content=\"Cardiac evaluation before non-cardiac surgery: An evaluation 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