Pre-operative work up

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ASA class

ASA I Normal, healthy Healthy, non smoking, minimal EtOH  
ASA II Mild systemic disease - without substantive functional limitations current smoker, well-controlled DM/HTN, obesity, mild lung disease  
ASA III Severe systemic disease - substantive functional limitations poorly controlled DM/HTN, COPD, morbid obesity, EtOH abuse, pacemaker, mod reduction in EF, ESRD on dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.  
ASA IV Severe systemic disease, constant threat to life recent (< 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia, severe valve dysfunction, severe reduction of EF, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis  
ASA V Moribund - not expected to survive without the operation ruptured AAA, massive trauma, intracranial bleed with mass effect, ischemic bowel with multiple organ/system dysfunction  
Emergency delay in treatment of the patient would lead to a significant increase in the threat to life or body part  

 

Goldman Multifactorial Cardiac Risk Index

  • 0-5 pts: < 1% risk of major postoperative cardiac complications
  • 6-25 pts: 9%
  • > 25 pts: 22%.

Risk Factor

Points
Preoperative third heart sound or jugular venous distention indicating active heart failure 11
Myocardial infarction in the past 6 months 10
≥5 Premature ventricular complexes/min before surgery 7
Rhythm other than sinus 7
Age ≥70 years 5
Emergency surgery 4
Significant aortic stenosis 3
Intraperitoneal, intrathoracic, or aortic surgery 3
Markers of poor general medical condition (e.g., renal dysfunction, liver disease, lung disease, electrolyte imbalance) 3

Pre-operative cardiac work-up

Recommended, May be considered

No cardiac risk factors

Cardiac risk factors present

Low risk: cardiac event risk < 1%

  • Superficial surgery
  • Breast, thyroid
  • Dental, eye
  • Reconstructive
  • Carotid asymptomatic
  • Orthopedic - minor (meniscus)
  • Urology or gynecology - minor (TURP)
  

EKG

Intermediate risk: 1-5%

  • Intraperitoneal - splenectomy, hiatal hernia, cholecystectomy
  • Carotid symptomatic
  • Peripheral arterial angioplasty
  • Endovascular aneurysm repair
  • Head and neck surgery
  • Neurological or orthopedic - major (hip and spine)
  • Urology or gynecology - major
  • Renal transplant
  • Intra-thoracic - non major

Good functional capacity: 

  • EKG in > 65 yo

Poor functional capacity:

  • EKG
  • Stress

EKG
Stress


Echo for valvular disease

High risk: > 5%

  • Aortic and major vascular
  • Open lower limb revascularization, amputation, or thromboembolectomy
  • Duodeno-pancreatic surgery
  • Liver resection, bile duct surgery
  • Esophagectomy
  • Repair of perforated bowel
  • Adrenal resection
  • Total cystectomy
  • Pneumonectomy
  • Pulmonary or liver transplant
  • EKG (> 65 yo)
  • Echo
  • Stress
  • BNP/trop

EKG
Echo
Stress
BNP/trop

Echo for valvular disease
Stress test if ≥ 3 risk factors

 

 

Recommended

Consider

Not recommended

EKG

Risk factors + intermediate or high-risk surgery

No risk factors + > 65 years old + intermediate or high-risk surgery

Asymptomatic + no risk factors + low-risk surgery

Echo

Known or suspected valvular disease + intermediate or high-risk surgery

High-risk surgery

 

Stress testing

Poor functional capacity + ≥ 3 risk factors + high-risk surgery

High cardiac risk + surgery within 1 year of revascularization

Poor functional capacity + 1-2 risk factors + intermediate or high-risk surgery

Low-risk surgery

Not required for revascularization in past 6 years + clinically stable

Biomarkers (BNP, trop)

 

High-risk patients

Non-cardiac surgery

Coronary angiography

Same indications as non-surgical setting (no evidence that prophylactic pre-op revascularization improves perioperative outcome in asymptomatic or stable CAD patients)

 

 
  • CXR
    • Acute cardiopulmonary findings, or potentially unstable chronic cardiopulmonary disease
    • > 70 yo, esp. if CXR < 6 mo not available
    • Chest surgery

Pre-operative pharmacological management

  • Beta-blockers: Continue long-term therapy. May consider in patients with high-risk surgery + ≥ 2 risk factors + known ischemic heart disease
    • Also continue clonidine as discontinuation can cause rebound hypertension
  • CCBs: Either way
  • ACEi/ARBs: hold 24 hrs before surgery - concern for intraoperative hypotension; AKI
    • (Practice varies; AHA guidelines recommend continuing ACEi/ARBs for non-cardiac surgeries)
    • Many continue for minor outpatient surgeries
    • Restart POD #1
  • Diuretics
    • Furosemide - hold the morning of surgery to avoid fluid shifts
    • Thiazides - either way. Doesn't cause as much fluid shift, and holding won't affect BP that much.
    • Restart POD #1
  • Statins: continue statin therapy. Consider initiation 2 weeks before vascular surgery
  • Antiplatelet:
    • Primary prevention (low CV risk) - discontinue aspirin 7-10 d before.
      • Clopidogrel half-life is 6 hrs; discontinue 5 d before
    • Secondary cardiovascular prevention - continue chronic aspirin (can consider discontinuation if difficult hemostasis is anticipated)
    • Bare metal stent - continue aspirin/dual antiplatelet-therapy for at least 1 month
    • Drug eluting stent - continue aspirin/dual antiplatelet for 12 months. Discontinue aspirin only if surgical bleeding risks are unacceptably high; continue aspirin whenever possible.
      • Stent thrombosis is platelet-mediated: aspirin must be continued whenever possible, even if clopidogrel must be interrupted
      • Cardiac complications peak 10 days after aspirin cessation (OR 3.1; OR 90 after stents)
      • Stent thrombosis after clopidogrel cessation within 18 months of DES placement has OR 14-57
  • Anticoagulation
    • Assessing thrombotic risk
    • Assessing bleeding risk - HASBLED
    • Warfarin
      • INR should be < 1.5 - discontinue 5 d before surgery (half life ~ 40 hrs)
        • May give low-dose vitamin K to lower INR if necessary
      • Bridge with heparin (IV unfractionated, or subq LMWH/Lovenox) while warfarin is held if risk factors for thromboembolic events are present
        • Afib with CHA2DS2VASC ≥ 2
        • Advanced age; female sex
        • Mechanical valve; recent biological valve; mitral valve repair in past 3 months
        • Recent VTE in past 3 months
        • Thrombophilia
      • Warfarin may be resumed 6-24 hrs after surgery if adequate hemostasis (takes few days to become therapeutic)
        • Bridging: resume in 24 hrs if low-risk; 48-72 hrs if high risk
    • NOACs
      • Discontinue 2-3 half-lives before surgery with average risk of bleeding; 4-5 half-lives before surgery with high risk of bleeding
        • Xarelto/rivaroxaban - 1-3 d
        • Eliquis/apixaban - 1 d for low-risk; 2 d for high-risk
        • Pradaxa/dabigatran - 1-2 d for normal CrCl, 3-5 d for CrCl < 50 mL/min
      • Assess anticoagulation status with aPTT, PT instead of INR
      • Do not require heparin bridging.
      • May restart 6-24 hrs after surgery if adequate hemostasis; if risky then wait 48-72 hrs

How long to postpone elective surgeries after PCI

  • Balloon angioplasty: > 2 weeks
  • Bare metal stent: > 1-3 months
  • Drug-eluting stent: > 12 months
  • New-generation DES: > 6 months
author: admin | last edited: April 19, 2022, 6:19 p.m. | pk: 22

  1. http://www.aafp.org/afp/2010/1215/p1484.html
  2. Peri-operative cardiac medication management in non-cardiac surgery