Quick Guide for Pre-op Cardiac Assesment

Last weekend I was invited to give a lecture on Perioperative Cardiac Assesment at the POMR conference organised by the MOH at Mahkota Hotel, Melaka.
Interestingly my presentation was preceded by an Anaesthetist’s lecture on Medical assesment preop – which has some overlap of course.
Periop cardiac assessment should be simplified and made into a routine list in order to allow a more transparent and efficient process. Dr. Ng the Anaesthetist also recommended a ‘Preop Assesment clinic’ which is an excellent idea – therefore will reduce cardiologists burden in dealing with these routine cases!
The ESC and AHA/ACC have issued guidelines, much are in agreement with each other. One major area where they differ is in preop revascularisation – where AHA put level 1 recommendation on preop revascularisation (without category of surgery patient is undergoing) in patients with LMS or 3 vessel disease with angina. The ESC however put this at level IIb B for patients undergoing high risk surgery. I am more inclined to agree with the ESC standpoint, though of course, in practice we rarely allow patients with symptomatic angina going for surgery! The difference here is, prophylactic revascularisation in patients with CAD preoperatively – which has little role in changing the landscape of risk for surgery. Most of the time you can just keep them on statin and betablockers (both grade I recommendation) and if at all possible allow patients to undergo surgery without interrupting their aspirin (real challenge to surgeons).
In patients who are have unstable cardiac conditions – namely ACS, serious arrhythmia, decompensated CCF and severe valvular disease (critical AS/MS) – they should be treated before being sent to surgery regardless of categories.
Otherwise, for elective cases, you should assess their risk based on the risk of surgery itself. High risk surgery are emergency surgery or major vascular surgery like aortic aneurysm/bypass. Minor like Breast, Dental, Endocrine, Gynaecology, Orthopaedic knee surgery, urology, eye (sorry opththalmologist no more referral for cataract surgery!). The rest of surgery fall under intermediate risk.
Basically any patient undergoing low risk surgery should be able to proceed with very minimal or no cardiac assesment (after excluding those unstable cardiac conditions of course).
For intermediate or high risk surgery, assessment of patients functional status should be done, you just have to know their METS score. Someone who can live everyday live without restriction will have METS not less than 4. If they can exercise and exert themselves they are heading towards the tenner METS.
What if their functional status is not good or not evaluable like someone going for a total hip surgery, obviously has not exerted him or herself due to inability to mobilise? Then, you can further stratify them by evaluating their clinical cardiac risk factors that is presence of any of these – IHD (ESC further classifies to MI and angina), CCF, CVA, DM, CKD – those with 3 or more risk factors only should be subjected to non-invasive assessment like DSE and the like.
How about the much talked about routine echo preop? The ESC has put it clearly that Echo is only indicated in those undergoing high risk surgery (when their functional capacity is poor), or those undergoing any kind of surgery but suspected of having underlying unstable cardiac conditions.
So, if you stick to this guidelines, things will be more simplified while at the same time, your actions are backed up by evidence.