Step 2: Coronary Revascularization Within 5 Years

• yes
• no
• Note: for percutaneous coronary intervention (PCI), should probably delay noncardiac surgery:
• Angioplasty: at least 1 week to allow for healing of vessel injury
• Stenting: at least 2 weeks (4-6 wks better) to allow 4 wks of dual antiplatelet tx and reendothelialization of stent to be completed.

Step 2: Recurrent Signs or Symptoms

• yes
• no

Step 3: Recent Coronary Evaluation

• yes
• no

Step 3: Recent Coronary Angiogram or Stress Test

• favorable result and no change in sx
• unfavorable result or change in sx

Clinical Predictors
Increased Periop Risk for MI, HF, Death (perioperative MI mortality = 40-70%)

Major Major Major Major Major Major Major Major Major	unstable coronary syndromes MI < 1mo unstable or severe angina large ischemic burden decompensated heart failure significant arrythmias high-grade AV block symptomatic arrhythmia with underlying heart dz supraventric arrhythm with uncontrolled vent rate severe valvular disease
Intermediate Intermediate Intermediate Intermediate Intermediate	mild angina MI > 1mo compensated or prior CHF DM Cr > 2.0 mg/dL
Minor Minor Minor Minor Minor	advanced age abnormal ECG non-sinus rhythm low functional capacity h/o stroke uncontrolled HTN
None	none of the above

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Step 4: High Risk Patient
Consider either:

• delay or cancel surgery for medical management and risk factor modification

OR
• invasive testing

Step 6: Assess Functional Capacity (Intermediate Clinical Predictors)

• Estimation
• Poor (<4 METs)
• Moderate or excellent (>4 METs)

Step 6: Assess Surgical Risk (Intermediate Clinical Predictors)

• Definition
• High
• Intermediate or Low

Step 7: Assess Functional Capacity (Minor/No Clinical Predictors)

• Estimation
• Poor (<4 METs)
• Moderate or excellent (>4 METs)

Step 7: Surgical Risk Assessment (Minor/No Clinical Predictors)

• Definition
• High
• Intermediate or Low

Step 8: Noninvasive Testing
Testing Modalities:

• Resting LV Function
• indicatred if current or poorly contolled HF, unless earlier eval already showed severe LV dysfnct
• not a consistent predictor of periop ischemia
• Resting 12-lead ECG
• does not identify increased periop risk for low-risk surgeries
• indicated for recent CP or equivalent in clinically intermed- or high-risk pts having intermed- or high-risk surgery
• may be indicated in asymptomatic diabetics (Class IIa)
• probably less useful (Class IIb) in :
• pts with h/o revascularization
• asymptomatic males>45y or females>55y with 2 or more atherosclerotic risk factors
• h/o admission for cardiac causes
• Stress Testing (Exercise or Pharmacological)
• indicated (Class I) for:
• adults with intermediate probability of CAD
• prognostic assessment of pts undergoing initial evaluation for suspected or proven CAD; evaluation of subjects with significant change in clinical status.
• demonstration of proof of myocardial ischemia before coronary revascularization.
• evaluation of adequacy of medical therapy; prognostic assessment after an acute coronary syndrome (if recent evaluation unavailable).
• probably useful (Class IIa) for evaluation of exercise capacity when subjective assessment unreliable
• probably not useful (Class IIb) for:
• Diagnosis of CAD patients with high or low pretest probability: those with resting ST depression less than 1 mm, those taking digitalis therapy, or those with ECG criteria for left ventricular hypertrophy.
• Detection of restenosis in high-risk asymptomatic subjects within the initial months after percutaneous coronary intervention (PCI).
• Class III (NOT useful) for:
• exercise stress testing, diagnosis of patients with resting ECG abnormalities that preclude adequate assessment, e.g., pre-excitation syndrome, electronically paced ventricular rhythm, rest ST depression greater than 1 mm, or left bundle-branch block.
• Severe comorbidity likely to limit life expectancy or candidacy for revascularization.
• Routine screening of asymptomatic men or women.
• Investigation of isolated ectopic beats in young patients.

• low
• high

Proceed With Surgery

• Go to operating room, proceed with surgery.
• Postop: risk stratification, risk factor management.

Invasive Testing

• Consider coronary angiography
• Subsequent care according to study findings, treatment results. May include:
• delay/cancel surgery,
• coronary revascularization (rare - for elective noncardiac high- or intermed-risk surgery with prognostic high-risk anatomy and whose long-term outcome would likely be improved by CABG), or
• intensified care.
• Coronary Angiography Indications
• Indicated (Class I) for pts with suspected or known CAD:
• Evidence for high risk of adverse outcome based on noninvasive test results
• Angina unresponsive to adequate medical therapy
• Unstable angina, particularly when facing intermediate-risk or high-risk noncardiac surgery
• Equivocal noninvasive test results in patients at high clinical risk undergoing high-risk surgery
• Class IIa (probably helpful)
• Multiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first).
• Mod-large ischemia on noninvasive testing but without high-risk features and lower left ventricular ejection fraction.
• Nondiagnostic noninvasive test results in patients at intermediate clinical risk undergoing high-risk noncardiac surgery.
• Urgent noncardiac surgery while convalescing from acute MI.
• Class IIb (probably not helpful)
• Perioperative MI.
• Medically stabilized class III or IV angina and planned low-risk or minor surgery.
• Class III
• Low Risk noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
• Asymptomatic after coronary revascularization with excellent exercise capacity (>= 7 METs).
• Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
• Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., left ventricular ejection fraction less than 0.20), or refusal to consider revascularization.
• Candidate for liver, lung, or renal transplant less than 40 years old, as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.

Hypertension

• Stage 3: SBP>=180mmHg and DBP >=110
• Elective surgery: control BP medically, usu over days-weeks
• Urgent surgery: control BP minutes-hours (esp. beta-blockers)

Valvular Disease

• Symptomatic Stenoses
• assoc with risk of periop HF or shock
• often require percutaneous valvotomy of valve replacement before noncardiac surgery
• Symptomatic Regurges
• usu better tolerated perioperatively
• stabilize preop with intensive medical tx and monitoring
• if pt can wait several weeks/months before noncardiac surgery
• may not be approp if severe regurg with decreased LV fnct (periop destabilization likely)
• then, treat definitively (valve repair/replacement), after noncardiac surg

Arrhythmias

• Evaluate for underlying cardiopulmonary dz, drug toxicity, or metabolic abnormality
• Tx
• if symptomatic or hemodynamically significant
• antiarrhythmics or pacing: indications same as in nonoperative setting
• Frequent PVCs and asymptomatic nonsustained VT: no increased risk of periop nonfatal MI or cardiac death

Perioperative Medical Therapy

• Tx indicated if beta-blockers required recently to control angina sx, or pts with symptomatic arrhythmias or HTN
• Beta-blockers (unless contraindicated)
• Class I for pts at high risk (ischemia on preop testing, having vascular surgery
• Class IIa for pts with untreated HTN, known CAD, or major risk factors for CAD
• Alpha-2 agonists (unless contraindicated): Class IIb for periop control of HTN, or known CAD or major risk factors for CAD

Perioperative Monitoring

• PAC likely helpful for pts with:
• recent MI complicated by HF
• signif CAD having surg assoc with significant hemodynamic stress
• high-risk surg and syst or diast LV dysfnct, cardiomyopathy, or valv dz
• ST-monitoring
• High-risk Pts
• intra- and post-op ST changes c/w ischemia are strong predictors of periop MI
• post-op ischemia is signif predictor of long-term risk of MI and cardiac death
• Low-risk pts: ST-depression often is NOT associated with regional wall motion abnormalities.