Preoperative Assessment: Cardiac Comorbidities:
For the majority of common cardiac comorbidities, two main questions need to be answered at the end of a preoperative assessment:
- Does this patient need further investigations prior to his or her surgery?
- Is there anything that can be optimized before the procedure?
The ACC/AHA released guidelines in 2014 for perioperative cardiac evaluation in patients undergoing non-cardiac surgery. The recommendations are as follows:
- If it is a surgical emergency, proceed without further evaluation.
- If the patient is having an acute coronary event (STEMI/NSTEMI), treat the patient according to goal directed medical therapy. Once treated, the need for further testing is assessed by using the guidelines below.
- For non-emergency surgical/non-ACS patients, the need for further testing is assessed by using the guidelines below.
Elevated Risk (RCRI = 3 or more)
- METS >= 4
- No further testing needed; proceed with surgery
- METS < 4 OR unknown
- If further testing will impact management: stress test +/- revascularization.
- If further testing will not impact management: proceed with surgery.
Low Risk (RCRI)
- No further testing required; proceed with surgery.
Intraoperative management of patients aims at optimizing the balance between oxygen supply to the heart and oxygen demand by the heart. Oxygen supply can be improved with increased oxygen saturation (for example, by increasing the FiO2), increasing oxygen carrying capacity (hemoglobin), and maintaining adequate coronary artery perfusion (avoid hypotension) Decrease oxygen demand by the heart by avoiding hypertension (increases afterload) and controlling the heart rate (avoid tachycardia).
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