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CARING FOR THE PEOPLE OF NORTHEAST MICHIGAN

GREAT LAKES HEART CENTER OF ALPENA

HOME PREOPERATIVE MEDICAL THERAPY NONCARDIAC SURGERY AND HEART DISEASE FOR COLLEAGUES

Active Cardiac Conditions Requiring Evaluation and Treatment Prior to Non Cardiac Surgery

CONDITION	EXAMPLE
Unstable coronary syndromes	Unstable or severe angina(CCS class III or IV) Recent MI
Decompensated HF (NYHA functional class IV; worsening or new-onset HF)
Significant arrhythmias	High-grade atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR greater than 100 bpm at rest) Symptomatic bradycardia Newly recognized ventricular tachycardia
Severe valvular disease	Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or CHF)

Evaluating Patients for Surgery (check all that apply)
TYPE OF SURGERY
Emergency surgery
Vascular surgery
Intrathoracic, intraabdominal, CEA or orthopedic
Endoscopy, breast or ambulatory surgery
CLINICAL RISK FACTORS

MI in the past 30 days, Class III-IV angina Class III-IV or recently diagnosed CHF High grade AV block (Mobitz II or higher), atrial fibrillation with rapid rates, symptomatic bradycardia, symptomatic or newly diagnosed VT Symtomatic or severe (valve area <1.0 sq. cm.) aortic stenosis or symptomatic mitral stenosis Diabetes
History of CAD or CHF
Renal failure
Peripheral vascular disease

FUNCTIONAL CAPACITY
Able to perform activities of daily living, walking at 2 mph, play golf using a cart
Able to go up and down stairs, mow grass with a pushmower, swim or play tennis

Use of Selected Tests Prior to Surgery
ECG
-Patients with at least 1 clinical risk factor who are undergoing vascular surgical procedures.
Patients with known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures.
-Patients without clinical risk factors for CAD undergoing surgical vascular procedures. (IIa)
-Patients with at least 1 clinical risk factor undergoing intermediate risk surgical procedures. (IIb)
Evaluation of Left Ventricular Systolic Function
(By Echocardiography, MUGA or Contrast Ventriculography)
-Patients in CHF or with a history of CHF who experience worsening dyspnea or a change in clinical status.
-Perioperatively for patients with unexplained dyspnea
-To reasses left ventricular function in patients previously diagnosed with a cardiomkyopathy. (IIb)
Echocardiography
-Patients with a history of CHF, or unexplained dyspnea.
-Murmurs suggestive of significant valve disorders.
Stress Testing
-In patients scheduled for vascular surgery who have 3 or more risk factors and poor functional capacity.
-In patients scheduled for intermediate risk surgery who have 1 or 2 risk factors and poor functional capacity. (IIb)
-In patients scheduled for vascular surgery who have 1 or 2 risk factors and good functional capacity. (IIb)
(Other Indications for Stress Testing)
-Evaluation of individuals at intermediate risk of CAD.
-Assesment of prognosis in individuals with known CAD.
-Demonstartion of ischemia prior to revascularization.
-Evaluation for adequacy of present medical treatment. -Objective quantification of exercise capacity
-Detection of restenosis post PTCA.