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:
Emergent: Life or limb threat if no surgery <6 hours
Urgent: Life or limb threat if no surgery within 6 - 24 hours
Time Sensitive: Delay of surgery for >6 weeks will negatively affect outcome
Elective: Surgery could be delayed up to 1 year without harm
_ 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:
_ACS NSQIP Surgical Risk Calculator Risk:
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:
>/= RCRI 3 (IIb-C)
< RCRI 3 + (CAD, HF, HTN) (IIb-B)
Start >1 day early to a goal resting HR of 60
I will start the patient on _
_ Perioperative Statin if:
Consider in high risk procedure (IIb-c)
Vascular Surgery (IIa-B)
Continue if already on statin (I-B)
I will start the patient on _
_ 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