Preoperative cardiovascular risk assessment
Preoperative cardiovascular risk assessment
Preoperative cardiovascular risk assessment requires a thorough history, physical examination, and determination of daily functional capacity to identify signs and symptoms of coronary ischemia, heart failure, and coronary or valve disease (Smilowitz & Berger, 2017). Risk calculators, such as the Revised Cardiac Risk Index (RCRI), identify patients with low risk (<1%) and higher risk (≥1%) for major adverse cardiovascular events during the procedure, admission, or within 30 days of surgery (Smilowitz & Berger, 2017). 6 factors are incorporated in determining RCRI: high‐risk surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, diabetes mellitus on insulin, and creatinine >2 mg/dL (Dakik, Sbaity, Msheik, Kaspar, Eldriani, Chehab, Hassan, Mailhac, Makki & Tamim, 2020).
The American University of Beirut (AUB‐HAS2) Cardiovascular Risk Index is a recently developed method of calculating preoperative cardiovascular risk. It is derived from 6 elements: history of heart disease, symptoms of angina or dyspnea, age ≥75 years, hemoglobin <12 mg/dL, vascular surgery, and emergency surgery (Dakik et al., 2020). Several large scale studies have found the AUB-HAS2 superior to the more commonly used RCRI in a broad range of surgical subpopulations (Dakik et al., 2020).
Cardiovascular testing is rarely indicated in low risk patients, though stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs) if and when the results from the testing would change the perioperative medical, anesthesia, or surgical approaches (Smilowitz & Berger, 2017).
Recently, my preceptor and I had a patient needing clearance prior to a surgeon’s recommendation of small bowel resection secondary to obstruction. My preceptor demonstrated how to use both the RCRI and the AUB-HAS2; both modalities suggested a low risk of adverse cardiac events and so the patient was cleared for surgery. The gentleman had the procedure and recovered well with no unexpected events and was discharged home on post-op day 6.
References
Dakik, H. A., Sbaity, E., Msheik, A., Kaspar, C., Eldriani, M., Chehab, O., Hassan, O. A., Mailhac, A., Makki, M. & Tamim, H. (2020). AUB-HAS2 cardiovascular risk index: Performance in surgical subpopulations and comparison to the revised cardiac index. Journal of the American Heart Association, 9(10). https://doi.org/10.1161/JAHA.119.016228.
Smilowitz, N. R. & Berger, J. S. (2020). Perioperative cardiovascular risk assessment and management of noncardiac surgery: A review. JAMA, 324(3), 279-290. doi:10.1001/jama.2020.7840.
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