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
Full ACA/AHA Guideline here:http://circ.ahajournals.org/content/130/24/e278
Posted 4/9/17 (A Bernard/S Priest); Reviewed 9/26/24 (A Bernard)