continue or cancel; if continue the workup warranted
PSTC:
71 y/o for lap hemi-colectomy for obstructive lesion. EGD done two days ago shows obtructive lesion colon. H/o Pulm HTN (44mmHg),
mod.TR, mod. MR, eF= 45%(6mo ago), METS>4, but SOB at rest. No JVD, Hepatomegaly, peripheral edema.
What is Continue to surgery ; A-line, Edwards
Emergent procedure= threat to life or limb if not in OR < 6 hours, no/very limited/minimal clinical evaluation. Urgent procedure = threat to limb or life if not in the OR in 6-24 hours, time for limited clinical evaluation. Time-sensitive procedure (most oncologic procedures) = a delay of >1-6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome. Elective procedure = could be delayed up to 1 year.
Low risk procedure = risk of major adverse cardiac event (MACE) or MI of <1%.
Elevated risk procedure = risk of MACE > 1%.
2. Clinical Risk Factors: Recommendations
1. Valvular Heart Disease
- If patient has at least moderate valvular stenosis or regurg -> preop echo, if no preop echo within 1 year or change in clinical status or physical exam since last evaluation
- If patient meets standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity, valvular intervention before elective non-cardiac surgery will reduce periop risk.
- Elevated-risk noncardiac surgery with intraop and postop hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS/MR , asymptomatic severe AR with normal LVEF. or asymptomatic severe MS if valve morphology is not favorable for perc mitral balloon commissurotomy.
2. Other clinical risk factors
- Chronic pulmonary vascular targeted therapy should be continued, unless contraindicated/not tolerated, in patients with PHTN for noncardiac surgery.
- Unless the risks of the delay outweigh the potential benefits, preop evaluation by a PHTN specialist before noncardiac surgery can be beneficial, particularly for those with features of increased periop risk
3.2 Stepwise approach to CAD (known or risk factors for):
1. If emergency -> clinical risk stratification (that may influence periop management) and proceed to surgery with appropriate monitoring.
2. If surgery urgent/elective and ACS -> refer for cardiology eval and mgmt according to GDMT (goal-directed medical therapy) according to UA/NSTEMI and STEMI CPGs (clinical practice guidelines)
3. If risk factors for stable CAD -> estimate periop risk of MACE on the basis of the combined clinical/surgical risk. This can use the ACS NSQIP risk calculator (
www.surgicalriskcalculator.com) or incorporate the RCRI.
4. If risk of MACE <1% -> proceed to surgery without further testing.
5. If elevated risk of MACE (>1%), determine functional capacity with an objective measure or scale, such as the DASI (Duke Activity Status Index). If moderate/good/excellent (>= 4 METs) functional capacity, proceed to surgery without further eval.
6. If poor (< 4 METs) or unknown functional capacity -> pharmacological stress testing if it will impact patient decision making or periop care. If unknown functional capacity, exercise stress testing reasonable to perform. If stress test abnormal, consider coronary angiography and revascularization; the patient can then proceed to surgery with GDMT, or consider alternative strategies, such as noninvasive treatment for the indication of surgery, or palliation. If stress test is normal, proceed to surgery according to GDMT.
7. If testing will not impact decision making or care, proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment for the indication of surgery or palliation.