seminar is basd on 2014 AHA guidelines and latest ASRA guidelines 4th edition , 2018

1. Pre-op evaluation, preparation of
cardiac patients for non cardiac
surgeries
PRESENTER : DR RAJESH
MUNIGIAL
MODERATOR : DR SHIVAKUMAR
K P
HOD : DR ARUN KUMAR A
SSIMS & RC , DAVANGERE,
KARNATAKA

2. INTRODUCTION
 Administering anaesthesia to patients with
preexisting cardiac disease is an interesting
challenge.
 Most common cause of peri-operative
morbidity and mortality in cardiac patients is
ischaemic heart disease(IHD).
 IHD is number one cause of morbidity and
mortality all over the world.

3.  Patients with coronary artery diseases
undergoing non-cardiac surgery are at
an increased risk for peri-operative
complications such as myocardial
ischaemia, MI, cardiac failure,
arrhythmias, cardiac arrest and
increased morbidity and mortality

4.  Worldwide 1 in every 30-40 adults undergo
major non cardiac surgery annually , and
more than 10 million of 2,00,000,000
patients having surgery suffer a major
cardiac complication in first 30 days .

5. Pre op evaluation
The purpose of pre-operative evaluation is
 To evaluate a patient's current medical
status,
 To provide clinical risk profiling,
 To decide on further testing,
 To treat the modifiable risk factors and
 To plan the management of cardiac
illness during the peri-operative period.

6. Why there is perioperative
risk ?
 Major hemodynamic stress,
 Changes in cholinergic activity,
 Changes in catecholamine activity,
 Body temperature fluctuations,
 Pulmonary function is altered,
 Fluid shifts,
 Pain.

7. Risk factors: Influencing peri-
operative cardiac morbidity are:

8.  Recent myocardial infarction
 Congestive cardiac failure
 Peripheral vascular disease
 Angina pectoris
 Diabetes mellitus
 Hypertension
 Hypercholesterolemia
 Dysrrhythmias
 Age
 Renal dysfunction
 Obesity
 Life style and smoking

9. Recent MI
 • Incidence of perioperative re-infarction
is 37% if the time elapsed is less than 3
months,
 • 16% when time elapsed is 4-6 months
and
 • 5% when time elapsed is more than 6
months.
 • This is the basis for recommendation to
wait for 6 months after MI for elective
major surgery

10. Evaluation of cardiac risk
The cornerstone of preoperative cardiac
evaluation includes :-
 review of history ,
 physical examination,
 diagnostic tests,
 knowledge of the planned surgical
procedure.

11. GRADES OF DYSPNEA AS GIVEN BY
NYHA

12. History and physical
examination
Angina -stable/unstable?
Dyspnea
Exercise tolerance
History of MI
( acute – 1-7 days previously , recent – 7-
30 days)
Previous PCI or CABG or pacemaker
Presence of prosthetic valves
Detailed medication history
h/o syncope
Cough

14. Physical examination
General examination :
Cyanosis, pallor, dyspnea during conversation
or with minimal activity, poor nutritional status,
obesity, skeletal deformities, tremor & anxiety
are just a few of the clues of underlying
disease or CAD.
HEIGHT , WEIGHT , BMI
VITALS : HR, BP ,RR , SPO2

15. CARDIAC EXAMINATION
 Signs and symptoms of LV
dysfunction (breathlessness, fatigue ,
cough , chest pain , hemoptysis ,
thromboembolic events)
 Carotid bruit
 Orthostatic hypotension
 Jugular venous distension
 Peripheral edema
 Auscultation : S3 gallop or rales

16. Metabolic equivalents (METs)
are how functional status is expressed.
 One MET is defined as resting or basal
oxygen consumption of a 40-year-old, 70-
kg man.
 Exercise tolerance : 1 metabolic
equivalent-represents rate of energy
consumption at rest (3.5 ml/kg/min)

17. Metabolic equivalents of functional capacity
METs Equivalent level of exercise
1 Eating , working at computer or dressing
2 Walking downstairs , walking in house or cooking
3 Walking one or two blocks on level ground
4 Raking leaves or gardening
5 Climbing one flight of stairs, dancing or bicycling
6 Playing golf or carrying cubs
7 Playing single tennis
8 Rapidly climbing stairs or slowly jogging
9 Jumping rope slowly or cycling moderately
10 Swimming quickly, running or jogging briskly
11 Skiing cross country or playing full court basket ball
12 Running rapidly for moderate to long distances

18. On the basis of METs, functional capacity is
classified as
 poor (<3 METs),
 moderate (4-6 METs),
 good (7-10 METs), and
 excellent (>10 METs).
 Patients having functional status of less than 4
METs are at increased risk of perioperative
complications.
 Patients who have good or excellent functional
capacity with METs of greater than 4 do not
require any further testing and should proceed
for surgery.
 Also patients scheduled for low-risk procedure
do not require any testing at all.

19. RISK INDICES:
 ) ASA.
 2) NYHA/CCS.
 3) Goldman ( 1977).
 4) Detsky (1997 ).
 5) ACC / AHA ( Updated in 2014)
 6) ACP.
 7) Lee ( 1999 ).

24. THE AMERICAN HEART
ASSOCIATION EVIDENCE BASED
SCORING SYSTEM
CLASSIFICATION OF RECOMMENDATION :
Class I : conditions for which there is evidence , general
agreement or both that a give procedure or treatment is useful.
Class II: conditions for which there is conflicting evidence , a
divergence of opinion or both about the usefullness or efficacy of a
procedure or treatment
IIa: weight of evidence or opinion in favour of usefullness/efficacy
IIb: usefullness or efficacy is less well established by evidence /
opinion

25.  Class III: conditions for which there
is evidence , general agreement or
both that the procedure / treatment is
not useful / effective or in some cases
may be harmful

26. ECG
 The baseline ECG is normal in 25% to 50% of
patients with CAD but no prior MI
 The most common baseline abnormalities are non
specific ST-segment and T-wave changes.
 Prior infarction is often manifested by Q waves or
loss of R waves in the leads closest to the infarct.
 First-degree AV block, bundle-branch block, or
hemiblock may be present.

27.  A long rate-corrected QT interval (QT c >
0.44 s) may reflect the underlying ischemia,
drug toxicity (usually class Ia antiarrhythmic
agents, antidepressants, or phenothiazines),
electrolyte abnormalities (hypokalemia or
hypomagnesemia), autonomic dysfunction,
mitral valve prolapse, or, less commonly, a
congenital abnormality.
 Patients with a long QT interval are at risk of
developing ventricular arrhythmias—
particularly polymorphic VT (torsade de
pointes), which can lead to ventricular
fibrillation

29. SPECIALISED STUDIES
 HOLTER MONITORING:
Continuous ambulatory
electrocardiographic (Holter) monitoring
is useful in evaluating arrhythmias,
antiarrhythmic drug therapy, and
severity and frequency of ischemic
episodes
Holter monitoring has an excellent
negative predictive value for
postoperative cardiac complications.

30. Exercise electrocardiography
 The usefulness of this test is limited in patients with
baseline ST-segment abnormalities and those who are
unable to increase their heart rate (>85% of maximal
predicted) (target HR – 220 minus age)because of
fatigue, dyspnea, or drug therapy.

31.  The test is most sensitive (85%) in
patients with three-vessel or left main
CAD.
 A myocardial ischemic response at low
levels of exercise is associated with a
significantly increased risk of
perioperative complications and long-
term cardiac events
 Exercise-induced ventricular ectopy
frequently indicates severe CAD

32. Myocardial Perfusions Scans
and Other Imaging Techniques
 Myocardial perfusion imaging using thallium-201 or
technetium-99m is used in evaluating patients who cannot
exercise (eg, peripheral vascular disease) or who have
underlying ECG abnormalities that preclude interpretation
during exercise (eg, left bundle-branch block).
 If the patient cannot exercise, images are obtained before and
after injection of an intravenous coronary dilator (eg,
dipyridamole or adenosine) to produce a hyperemic response
similar to exercise
 Perfusion defects that fill in on the redistribution phase
represent ischemia, not previous infarction.
 The negative predictive value of a normal perfusion
scan is approximately 99%.

33. ECHOCARDIOGRAPHY
 Regional and global ventricular function
 Wall motion abnormalities
 Size of chambers
 Valve status
 PA pressures
 Ejection fraction
Dobutamine stress echocardiography
seems to be a reliable predictor of adverse
cardiac complications in patients who
cannot exercise.

35. CORONARY ANGIOGRAPHY
 coronary angiography should be
performed only to determine if the
patient may benefit from percutaneous
coronary angioplasty or coronary
artery bypass grafting prior to
noncardiac surgery.
 In evaluating fixed stenotic lesions,
occlusions greater than 50% to 75%
are generally considered significant

36. Recommendations for peri-operative coronary
angiography
The Class 1 recommendations for pre-operative
coronary angiography apply only to the patients with
 Evidence for high risk of adverse outcome based
on non-invasive test results
 Angina pectoris unresponsive to medical therapy
 Unstable angina, particularly when facing
intermediate- or high-risk non-cardiac surgery
 Equivocal non-invasive tests results in patients
with high clinical risk undergoing high-risk surgery.

38. Indications for pre-operative
coronary artery revascularisation are
as follows:
 Acceptable coronary revascularisation risk and
viable myocardium with left main coronary
artery stenosis
 Three vessel coronary artery disease with left
ventricular dysfunction
 Left main equivalent (high-grade block in the
left anterior descending artery and circumflex
artery)
 Intractable coronary ischaemia despite
maximal medical therapy.

39. Previous PCI / CABG
 Recommended time intervals to wait for
elective non cardaic surgery
Procedure Time to wait
Angioplasty without stenting 2-4 wks
Bare metal stent placement At least 6wks , preferable : 12wks
CABG At least 6 wks , prefrable 12 wks
Drug eluting stent placement At least6 months

40. Associated other comorbidties
Respiratory disease, smoking and obstructive sleep apnoea
syndromes
Routine pre-operative diagnostic spirometry and chest X-ray are
not recommended
Continuous positive airway pressure use in the pre-operative
period in such patients may be helpful in reducing hypoxic
events
Pre-operative incentive spirometry can be of benefit in upper
abdominal surgery to prevent post-operative pulmonary
complications.
Malnutrition should be corrected.
Smoking should be stopped at least 4 weeks prior to
surgery, and preferably for 6-8 weeks prior.

41. RENAL DISEASE
 Calculated glomerular filtration rate is
superior to serum creatinine for the
identification of patients with pre-
existing renal impairment.
 Urine output should be monitored
throughout the peri-operative period,
and adequate fluid management
should be done.

42. Diabetes milletus
 Routine pre-operative blood sugar
testing is not necessary in established
well-monitored diabetic patients when
they properly maintain their glycaemic
status/glycated haemoglobin (HbA1c).
Obesity : STOP BANG questionnaire

43. Clinical predictors of increased peri-
operative cardiovascular risk

44. SURGERY SPECIFIC RISK
FACTORS

46.  Prevention of ischemia The
dominant mechanism of acute
coronary syndrome in the
perioperative period is demand
ischemia, rather than acute coronary
or stent thrombosis.

48. Types of surgery
 Emergency :Life or limb is threatened
if not in operating room within 6 hours
 Urgent : Life or limb is threatened if
not in operating room within 24 hours
 Time sensitive : Delay of 1-6 weeks
for further evaluation would negatively
affect outcome
 Elective : delay for upto 1 year

49. s

53.  Perioperative beta blockade started within 1
day or less before noncardiac surgery prevents
nonfatal MI but increases risks of stroke, death,
hypotension, and bradycardia.
 Beginning beta blockers <1 day before surgery
is at a minimum ineffective and may in fact be
harmful
 Starting the medication 2 to 7 days before
surgery preferred,
 Only few data support the need to start beta
blockers >30 days beforehand

54. Recommendations for aspirin
therapy
Class IIa :
 Continuation of aspirin during peri op
period of non cardiac surgery in
patients already receiving aspirin .

55. Recommendations for statin
therapy
 Class I : continue statin therapy during the
periop period of non cardiac surgery in
patients already receiving statins
 Class IIa : preop initiation of statin therapy
should be considered in patients
undergoing vascular surgery , ideally at
least 2 weeks before surgery .

56. Alpha 2 agonists
 Class III: No Benefit
 1. Alpha-2 agonists for prevention
of cardiac events are not
recommended in patients who are
undergoing non-cardiac surgery.

57. Perioperative Calcium Channel
Blockers
 significantly reduced ischemia and supraventricular
tachycardia.
 reduced death/MI.
 The majority of these benefits were attributable to
diltiazem.
 Dihydropyridines and verapamil did not decrease the
incidence of myocardial ischemia, although verapamil
decreased the incidence of SVT.
 CCBs with substantial negative inotropic effects, such
as diltiazem and verapamil, may precipitate or worsen
HF in patients with depressed EF and clinical HF.

61. ASRA RECOMMENDATIONS
IV HEPARIN
 Discontinue heparin infusion 4 to 6
hours and verify normal coagulation status
prior to neuraxial blockade
 Avoid neuraxial techniques in patients with
other coagulopathies
 Delay heparin administration for 1 hour
after needle placement
 Catheter removal after 4 to 6 hours after
last heparin dose .

62. SUBCUTANEOUS HEPARIN
Preoperative dose Prior to neuraxial block
5000 u BD/TID 4-6HRS
7500-10,000 U BD (TOTAL
<20000/DAY)
12 HRS
>10,000/DOSE OR >20000/DAY 24 HRS
POSTOP DOSE CATHETER
MAINTAINENCE
CATHETER
REMOVAL
DOSE POST
CATHETER
REMOVAL
LOW DOSE NO C/I 4-6HRS 1 HR

63. LMWH
 Anti factor Xa level is not predictive of risk of
bleeding
 With indwelling catheter antiplatelet drugs ,
standard heparin or dextran shouldn't be
given

 Patients receiving for more than 4 days
should have a platelet count prior to
neuraxial block or catheter removal

64. Time before
puncture/catheter
manipulation/
removal
Time after
puncture/catheter
manipulation/
removal
UFH (for prohylaxis ) 4-6hrs 1hr
UFH( for treatment) IV :4-6HRS
SC: 8-12HRS
1HR
1HR
LMWH (FOR
PROHYLAXIS)
12HR*(10-12) 4HR
LMWH (FOR
TREATMENT)
24HR 4HR

65. Newer anticoagulants*
DRUG PRIOR TO
NEURAXIAL
BLOCKADE
(hrs)*(48)
CATHETER
REMOVAL PIOR
TO FIRST DOSE
(hrs)
WITH
INDWELLING
CATHTER
DOSE TO BE
HELD
RIVAROXABAN 72 6 22-26HRS
APIXABAN 72HRS 6HRS 26-30HRS
EDOXABAN 72 6 22-28
BETRIXABAN 72 5 72

66. PERIOPERATIVE MANAGEMENT OF
PATIENTS ON WARFARIN
Preoperative
• Discontinue warfarin at least 5 days before
elective procedure
• Assess INR 1–2 d prior to surgery, if >1.5,
consider 1–2 mg oral vitamin K
• Reversal for urgent surgery/procedure,
consider 2.5–5 mg oral or IV vitamin K;
for immediate reversal, consider PCCs, fresh
frozen plasma

67. • Patients at high risk of thromboembolism
○ Bridge with therapeutic SC LMWH (preferred)
or IV UFH
○ Last dose of preoperative LMWH administered
24 h before surgery, administer half of the daily
dose
○ Intravenous heparin discontinued 4–6 h
before surgery
 • No bridging necessary for patients at low risk
of thromboembolism

68. DRUG PRIOR TO
NEURAXIAL
BLOCKADE
CATHTER
MAINTAINEN
CE
POSTOP* POST
CATHETER
REMOVAL
(IF LOADING
GIVEN)
TICLOPIDINE 10DAYS*(14) 1-2 days 24HRS IMMEDIATELY
(6HRS)
CLOPIDOGREL 5-7DAYS*(7) 1-2days 24HRS IMMEDIATELY
(6HRS)
PRASUGREL 7-10DAYS SHOULD
NOT BE
MAINATINED
24HRS IMMEDIATELY
(6HRS)
TICAGRELOR 5-7DAYS* SHOULD NOT
BE
MAINATINED
24 HRS IMMEDIATELY
(6HRS)

69. GP IIB/IIIA inhibitors & PDE
inhibitors
DRUG PRIOR TO
NEURAXIAL
BLOCKADE
POSTOP* CATHETER
REMOVAL
ABCIXIMMAB AVOID 4 WEEKS BASED ON
ONGOING RISK
OF
THROMBOEMBO
LISM
TIROFIBAN AVOID
EPTIFIBATIDE AVOID
CILIASTAOLE 2 DAYS 6HRS AFTER
CATHETER
REMVAL
PRIOR TO
REINSTITUTION

71. SUMMARY :
 Thorough history,
 Detailed physical examination,
 Judicious use of tests.
 Categorize patients into low,
intermediate & high risk category .
 Combine preop assessment with
periop risk reduction strategies &
optimize medical treatment to improve
outcome.

72. References :
 Miller’s anesthesia 9th edition
 Stoeltings anesthesia for coexisting
diseases

73. THANK YOU