How are cardiac risk factors assessed during dermatologic preoperative evaluation and management?

Updated: Mar 16, 2020
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Answer

Answer

The patient's capacity to increase cardiac output in response to intraoperative and postoperative challenges may be the most fundamental determinant in the final outcome after complex operations. The presence of congestive heart failure, unstable angina, or recent myocardial infarction should prompt a thorough cardiac workup before an extensive elective operation involving regional or general anesthesia. Most patients require either stress thallium echocardiography or dobutamine echocardiography to determine whether coronary ischemia is reversible. This test maybe followed by angiography to precisely define anatomical lesions of the coronary arteries that would be potentially amenable to revascularization with either intraluminal stents or open cardiac bypass surgery.

Several risk factors are useful predictors of fatal or life-threatening complications of cardiac origin after noncardiac operations. Diabetes mellitus, smoking, hypertension, hyperlipidemia, stable angina pectoris, remote myocardial infarctions, ST-segment or T-wave changes on electrocardiogram, bundle-branch blocks, mitral valvular disease, and cardiomegaly are conditions that must not be ignored. However, these conditions are apparently less pertinent determinants of cardiac risk than had been previously thought. The Goldman criteria (see Table 1 below) take precedence over the aforementioned risk factors.

Table 1. Weighting of Cardiac Risk Factors (Open Table in a new window)

Criteria

Points

Historical

 

-Age older than 70 years

5

-Myocardial infarction in previous 6 months

10

Examination

 

-S3 gallop or jugular venous distension

11

-Significant aortic valvular stenosis

3

Electrocardiogram

 

-Premature atrial contractions or rhythm other than sinus

7

-More than 5 premature ventricular contractions per minute

7

General status (3 points if any below apply)

3

-Abnormal blood gas levels

 

-Abnormal potassium/bicarbonate levels

 

-Abnormal renal function

 

-Liver disease or bedridden

 

Operation

 

-Emergency

4

-Intraperitoneal, intrathoracic, aortic

3

Total possible points

53

Of the 53 total possible points in the scheme of weighting cardiac risk factors, 28 points are attributable to conditions that are potentially treatable. Surgical procedures should be deferred until the patient's overall cardiac status improves, including potential revascularization. For patients with myocardial ischemia, elective surgery should be postponed and urgent surgery should be preceded by coronary artery bypass. The risk of reinfarction during an elective procedure performed within 3 months after a myocardial infarction exceeds 30%, while the infarction rate decreases to 4.5% after 6 months.

Thromboembolism is an extremely infrequent but potentially lethal event. Patients with a clear history of prior thrombosis or embolism, those likely to have a prolonged operation (with special emphasis on procedures that temporarily interfere with lower extremity blood flow), and those undergoing certain reconstructive operations of the hip are at increased risk. Clinicians can reduce the risk of thromboembolism by having the patient use pneumatic compression stockings, by advising the patient to exercise, and by having the patient ambulate early. Generally, heparin or levoxin are not required for simple ambulatory procedures. Orthopedists commonly begin warfarin (Coumadin) therapy in their patients 1 day after total hip and knee replacements without a loading dose. This therapy is continued until the patient is fully ambulatory.

Virtually all studies of systemic anticoagulation in patients undergoing general surgical operations have shown an increase in wound complications from bleeding. Systemic anticoagulation with low-dose heparin should be reserved for patients with morbid obesity or a history of prior pulmonary embolism or deep venous thrombosis. Low molecular weight heparin compounds have shown advantages over conventional low-dose heparin in the prevention of thromboembolic events in patients who are at high risk and have sustained trauma and in those undergoing knee and hip replacement procedures.


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