Preoperative evaluation of the patient with cardiac disease for noncardiac operations
Defining comorbid conditions
The clinician needs to identify any active cardiac conditions (Table 106-1) or clinical risk factors that have been associated with adverse outcomes. Active cardiac conditions are defined as unstable coronary syndromes, decompensated systolic or diastolic heart failure, significant arrhythmias, and severe valvular heart disease. Clinical risk factors are independent risk factors that are associated with poor outcomes and include history of ischemic heart disease (suggestive history, symptoms, or Q waves on electrocardiogram), history of prior or compensated heart failure (suggestive history, symptoms, or examination findings), history of stroke or transient ischemic attack, insulin-dependent diabetes mellitus, and renal insufficiency (serum creatinine concentration >2 mg/dL).
Table 106-1
Active Cardiac Conditions That Mandate Preoperative* Evaluation and Treatment
| 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 AV block Mobitz type II AV block Third-degree AV block Symptomatic ventricular arrhythmias Supraventricular arrhythmias, including AF, 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) |
*Before noncardiac operations.
†According to Campeau L. Letter: Grading of angina pectoris. Circulation. 1976;54:522-523.
‡May include “stable” angina in patients who are sedentary.
§The American College of Cardiology (ACC) National Database Library defines “recent” myocardial infarction (MI) as occurring >7 days but ≤30 days previously.
Reprinted, with permission, from Fleisher L, Beckman J, Brown K, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007;50:e159-241.
Assessing surgical risk
Evaluation of surgical risk is crucial. Surgical procedures have been classified as low-risk, intermediate-risk, and high-risk vascular operations (Table 106-2). Understandably, procedures with differing levels of stress (alterations in heart rate, blood pressure, intravascular volume, blood loss, and pain) are associated with differing levels of morbidity and mortality risks. Ophthalmologic and superficial procedures represent the lowest risk and very rarely result in morbidity and death. The intermediate-risk category (includes endovascular abdominal aortic aneurysm repair and carotid endarterectomy) represents procedures with associated morbidity and mortality risks that vary depending upon the surgical location and extent of procedure. Major vascular procedures are the highest risk procedures and mandate further investigation. In the revised ACC/AHA guidelines, vascular surgery is now the only surgical category listed as high risk or generally associated with a greater than 5% risk of perioperative cardiac complications.
Table 106-2
Surgical Risk* Stratification for Patients with Preexisting Cardiac Disease
| Level of Risk | Procedure Examples |
| High (vascular procedures)† | Aortic and other vascular operations Peripheral vascular operations |
| Intermediate‡ | Intraperitoneal and intrathoracic operations Carotid endarterectomy Head and neck operation Orthopedic operations Prostate operations |
| Low§ | Endoscopic procedures Superficial procedures Cataract operations Breast operations Ambulatory operations |
*Combined incidence of cardiac death and nonfatal myocardial infarction.
†Reported cardiac risk often >5%.
‡Reported cardiac risk generally 1%-5%.
