Cardiac Risk Assessment Prior to Surgery

Key elements:
- Emergency surgery?  I.e. trauma.  Basically, no time to worry about cardiac risk à go straight to surgery.
- If nonemergent surgery with low risk surgery (i.e. cataract surgery), or good functional capacity (> 4 METS – i.e. walking up a flight of stairs), or with no risk factors as below, then proceed to surgery.

Otherwise, you assess risk factors via the RCRI index:
1. Coronary Artery Disease – h/o MI, angina, Q waves on EKG, etc
2. History of CHF
3. History of CVA or TIA
4. Diabetes on insulin
5. CKD with Cr > 2
6. High risk surgery = intraperitoneal, intrathoracic, vascular surgery)

• RCRI of 0-1 -> no beta blockers or stress test needed
• RCRI of 2 – beta block, no stress test.  With beta blocker, the earlier you can start, the better, and aim to titrate to HR in the 60s, and continue for up to 30 days post-op.  Do NOT slam on high doses of beta blocker right before the surgery, otherwise you can cause hypotension, MI, and strokes (as seen in the POISE trial Lancet 2008).
• RCRI of 3 or more – beta block, consider stress test if it will change management (which is quite rare, as most of the time the surgeries you are being consulted for are fairly urgent, and it is counterproductive to get a stress test, cath, etc in the meantime, especially if your patient is then going to need ASA/Plavix after stent).

(Chanu Rhee MD, 1/10/11)