Clinical Question Can this patien...

Clinical Question

Can this patient safely suffer noncardiac surgery?

Evidence Summary

Guidelines from the American society of Physicians (ACP) (1) and the American corporation of Cardiology/American Heart Association (ACC/AHA) (2) address the preoperative evaluation of patients for noncardiac surgery The ACP guideline was issued in 1997 and popularly is being revised. The ACC/AHA guideline, which was written in 1996 and updated in 2002 forms the basis of the accompanying patient rencounter form.

The decision to proce with surgery begins with an assessment of risk. The physician should assess the patient's preoperative risk factors and the risks associated with the planned surgery The patient brush form in this Point-of-Care Guide uses the ACC/AHA classification of high, intermediate, and grave surgical procedure risk, and provides examples for each category.

Careful attention must be given to specific risk factors that increase the patient's risk of surgical complications or death from the planned surgery A number of studies (3-5) have validated clinical decision authoritys for the assessment of cardiac risk. The cogitation by Lee and colleagues (5) is the greatest in number recent, simplest and, arguably, best-validated decision support tool. Lee's Simple Cardiac Risk Index and its interpretation are included in the patient conflict form as an aid in decision-making.

The ACC/AHA guideline (2) advocates an approach that considers major, intermediate, and minor predictors of increased preoperative cardiovascular risk (see accompanying table). If a major risk predictor is ready nonemergency surgery should be delayed for medical management, risk-factor modification, and possible coronary angiography.

Functional status should be assessed in patients who have undivided or more intermediate risk predictors. Poor functional status is defined as les than 4 metabolic equivalents (METs) Patients with poor functional status may be able to do light work around the house, like as dusting or washing dishes, and can walk a arrest or two on level mould at a rate of 2 to 3 miles by hour (mph); however, they may be unable to climb a flight of stairs, walk up a hill, walk upon level ground at a rate of 4 mph or race a short distance. Examples of activities that require more than 4 MET include golf bowling, dancing, doubles tennis, throwing a ball, and heavy work around the house. (2) Patients with poor functional status should bear noninvasive testing unless low-risk surgery is planned.

Patients with fit or excellent functional status require noninvasive testing no other than if they are having high-risk surgery Finally, patients with minor risk predictors or no risk predictors should have noninvasive testing if they have poor functional status and are about to pass through high-risk surgery.

The selection of noninvasive testing be pendents on the clinical situation. (2) Exercise stres testing is approveed in patients who are able to exercise and have a normal resting electrocardiogram (ECG); exercise echocardiography or perfusion imaging is commended if the resting ECG is abnormal. Nuclear or echocardiographic pharmacologic stres imaging is commended in patients who are unable to exercise and do not have second-degree atrioventricular obstruct bronchospasm, theophylline dependence, valvular dysfunction, or marked hypertension. In other clinical situations, the physician should seek counsel a cardiologist for recommendations upon how to proceed.

The patient brush form includes an abbreviated version of the ACC/AHA algorithm for bedside use. However, physicians are vehemently encouraged to refer to the thorough ACC/AHA guideline (2) and its more detailed algorithm for preoperative cardiac assessment. The clash form links Lee's Simple Cardiac Risk Index (5) to the ACC/AHA guideline's major, intermediate, and minor cardiac risk predictors.

Finally, the ACC/AHA guideline (2) provides a reminder for physicians to consider perioperative beta blockade and measures to make less the risk of venous thromboembolism. profitable evidence supports the use of beta blocker in patients at high cardiac risk who are to bear vascular procedures, patients who have newly required beta blockers to curb symptoms of angina, patients with symptomatic arrhythmias or hypertension, and patients in whom preoperative assessment identifies untreated hypertension, known coronary disease, or major risk factors for coronary disease. (2)

Applying the Evidence

Mr Smith is a 72-year-old woman who is planning to be exposed to elective cholecystectomy. She has diabetes mellitus that is well controll with oral medication, is an active walker, and has no known history of cardiovascular disease or renal insufficiency.What is her cardiac risk?

Answer: Elective cholecystectomy is moderate-risk surgery The patient's Simple Cardiac Risk Index score is cipher (0.4 percent risk of complications), she appears to have suitable functional status, and she has simply one intermediate risk predictor (diabetes mellitus). The algorithm would indicate that she be cleared for surgery The patient's physician should consider perioperative beta blockade and measures to intercept venous thromboembolism.