Preoperative Risk Assessment for Major Adverse Cardiac Event

Perioperative risk assessment for MACE:

Patient’s likelihood of coronary artery disease is:

_ Low Intermediate High

Based on the following Risk factors:

_ DM HTN Hyperlipids Tobacco use within 15 years FHx of CAD Postmenopausal

Patient is with the following exercise tolerance:

_ Poor/1 MET (Examples: can perform ADLs, walk indoors around house, walk on level ground at 2 mph, light housework, wash dishes)

_ Fair/4 METs (Examples: Climb one flight of stairs, Walk on level ground at 4 mph, Run a short distance, Vacuum, lift furniture, Golf, doubles tennis, dancing)

_ Excellent/10 METs (Examples: Swimming, Running, Singles tennis, Basketball, Skiing)

Patient is awaiting the following risk surgery:

_ Low (<1% of a MACE) (Examples: Cataract, Breast lumpectomy, Endoscopy, Superficial biopsy)

_ Intermediate (1-5% of a MACE) (Examples: Carotid endarterectomy, Peripheral vascular (infrainguinal), Head and neck, Orthopedic, Abdominal/GYN, Urologic, Thoracic)

_ High (>5% of a MACE) (Examples: Emergency (esp. elderly), Extensive w large volume shifts, Prolonged surgery (>5 hrs), Most neurosurgery, Aortic/Peripheral vascular (suprainguinal))

Type of surgery:

_ Patient with no active cardiac conditions defined as:

_ Patient with the following active cardiac conditions:

-Recent MI (7 to 30 days) with evidence of ischemic risk on basis of clinical symptoms or results of noninvasive studies

-Unstable or severe angina (including stable angina among patients unusually sedentary, DOE)

-Marked arrhythmias (eg. with hemodynamic instability, high-degree heart block, symptomatic VT, SVT w uncontrolled rate (HR>100)

-Severe valvular disease (eg. AS with valve area <1 cm² or symptomatic MS)

_Patient with none of the following clinical risk factors:

_Patient with the following clinical risk factors:

-Hx of heart disease

-Hx of CVA, TIA

-Compensated /prior CHF

-DM

-CKD (Cr ≥ 2)

_ No RCRI indicators listed below are present:

_ RCRI indicators that are present are:

-High risk surgery

-CAD (angina or CP better w/ NTG, remote MI >3-6 months, path q wave, etc)

-Hx of CVA, TIA

-Hx of CHF

-DM requiring insulin

-CKD (Cr ≥ 2)

-Intrabdominal or high risk surgery

Giving the patient a RCRI score of:

[ ] 0 (0.4%) [ ] 1 (0.9%) [] 2 (6.6%) []≥ 3 (11%)

_Gupta Cardiac Risk:

http://www.qxmd.com/calculate-online/cardiology/gupta-perioperative-cardiac-risk

_ACS NSQIP Surgical Risk Calculator Risk:

http://riskcalculator.facs.org/

Therefore, based on the 2014 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery combined with the above calculated risks for MACE, I recommend:

_ That the patient may proceed to surgery without further cardiovascular risk stratification

_ That the patient requires further cardiovascular risk stratification: _

_ Perioperative medications are not indicated. Please continue chronic medications and hold those recommended by the surgeon for the timeframe the surgeon recommends.

_ Perioperative B-Blockade if:

_ Perioperative Statin if:

_ Perioperative Alpha blocker (III-B) No benefit, not indicated unless BP/HR failed on BB

_ That the patient receive endocarditis PPx of:

_ In regards to Diabetic meds, if NPO:

Orals: Hold

Insulin: Hold short acting insulin the morning of the procedure. Use half the long acting insulin the night before or morning of the procedure

_ In regards to antiplatelet/anticoagulation medications:

Hold aspirin 7 days prior to the procedure, resume when OK with surgeon

Others:

_ Stress dose steroids:

That the patient receive DVT PPx per the surgeon if indicated

That the patient use an incentive spirometer post-op if indicated by the surgeon