Preop Cardiac Evaluation

Preoperative risk stratification has 3 steps:
Step 1. Get an EKG
Step 2. Determine the need for an echo
Step 3. Determine the need for stress testing and left heart catheterization

Step 4. Write a note using .gmepreop

Step 5. Speak with Anesthesia Board Runner about the case

Step 2: Is an echo needed?

(Protocol established by Anesthesiology, Cardiology, and Perioperative Medicine)

Consider limited TTE for LVEF evaluation (ordered as “Adult Echo” then “Limited 2D”) in patients with:

1.Potential for LV dysfunction which may alter the management approach by anesthesiology:

A.Unquantifiable METS or METS <4 and one of the following:

•Abnormal ECG (pathologic Q-waves, significant ST-segment changes, severe LVH)

•Multiple CAD risk factors including DM on insulin or CKD with creatinine > 2

B.Dyspnea of unknown origin

C.Known heart failure with worsening dyspnea or other clinical change since last echo

Or

2.Significant left-sided valve disease which may alter the management approach by anesthesiology:

A.Suspected moderate to severe aortic or mitral valve stenosis or regurgitation

B.Known aortic or mitral valve disease of at least moderate severity if a significant change in clinical status  or physical exam is reported since last echo

Step 3: Is a stress test needed?

First, calculate the risk of MACE (major adverse cardiac event):

MACE Calculator

Then calculate METs (metabolic equivalents):

Then follow this algorithm (from the 2014 AHA/ACC Guideline):

ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CPG, clinical practice guideline; DASI, Duke Activity Status Index; GDMT, guideline-directed medical therapy; HF, heart failure; MACE, major adverse cardiac event; MET, metabolic equivalent; NB, No Benefit; NSQIP, National Surgical Quality Improvement Program; PCI, percutaneous coronary intervention; RCRI, Revised Cardiac Risk Index; STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; and VHD, valvular heart disease.


Full ACA/AHA Guideline here:http://circ.ahajournals.org/content/130/24/e278