Cardiac Risk Assessment – Preoperative Evaluation Guidelines and Risk Stratification Tools

Cardiac Risk Assessment - correct answer The risk of preoperative complications depends on
the condition of the patient prior to surgery, the prevalence of co-morbidities, and the
magnitude and duration of the surgery
Types of Risk Assessments for cardiac risk (7 of them) - correct answer Goldman Cardiac Risk
Index (1977)
Detsky Risk Index (1986)
American College of Physicians (1997)
American Heart Association/American College of Cardiologists (2002)
Revised Cardiac Risk Index (Lee, 1999 then revised in 2007)
NSQIP Perioperative MI and Cardiac Arrest Risk Calculator (2011)
NSQIP Universal Surgical Risk Calculator (2013)
Detsky's Modified Cardiac Risk Index - correct answer
How does hypertension increase risk of ischemic heart disease (IHD)? - correct answer 1)
Arterial wall injury (from stress) and thrombosis


2) Chronic increase in BP leads to LV hypertrophy and diastolic dysfunction
True or false: Hypertension has a greater impact on CVA risk than MI risk - correct answer TRUE
Change in ___________ flow to ____________ flow leads to thrombosis - correct answer 1st
blank: laminar


2nd blank: turbulant
Increased perioperative risk with DBP > ___________ - correct answer 110




side note: they need to be better managed. We aren't saying they cant go to the OR, but they
can't go today. Go see cardiologist
-140/90 ACC. If its too low everyone strokes out
Risk factors for primary hypertension (8) - correct answer - increased Age
- African American race

,- Alcohol Consumption of >2 drinks/day
- Obesity
- Excessive dietary intake of sodium
- Tobacco use (increase risk of MI)
- Genetic/family history
- stress
What percentage of the hypertensive population dose primary (essential) hypertension effect?
- correct answer 95%
Resistant Hypertension - correct answer Unable to achieve BP <140/90 despite treatment with
>3 different anti-hypertensives at maximally tolerated dose


Increased interest in endothelian antagonists; aldosterone antagonists and SNS targeted
antagonists (including devices)


Focus on the renal system's role in resistant hypertension
After we vasodilate a hypertensive patient, they become _____________ - correct answer
hypovolemic


side note: normotensive patients have move volume (more elasticity, bigger space)
Most common vasoconstrictor in the body (written from lecture) - correct answer Endothelian
A
Acute Hypertension - correct answer - Medication noncompliance
- Medication withdrawal
- Accelerated hypertension in a patient with
preexisting hypertension
- Reno-vascular hypertension
- Acute glomerulonephritis
Hypertensive Crisis - correct answer - SBP>180 or DBP>130 mmHg
- Requires immediate reduction

,- Persistent diastolic pressure > 130 mmHg
associated with acute vascular damage
- Evidence of end-organ damage (brain, heart,
kidneys, retina)
If your patient is having hypertensive crisis in pre-op, what do you do? - correct answer Send
them to ER. do NOT send them home.
End-organ ischemia: Brain - correct answer - Intracranial hemorrhage
- Hypertensive encephalopathy
- Stroke
-10-20% of all CVAs are due to hypertension
End-organ ischemia: Retina - correct answer - hemorrhages
- exudates
End-organ ischemia: Cardiovascular system - correct answer - Acute MI
- Acute heart failure
- Unstable angina
- Dissecting aortic aneurysm
End-organ ischemia: Kidney - correct answer - Hematuria
- Proteinuria
ABCD approach to medical management of HTN - correct answer A- Angiotensin inhibition
ACEI: Lisinopril
ARB: Losartan, candesartan
With diuretic
B - Beta antagonist
Atenolol
With diuretic
C - Calcium channel blocker
Amlodipine

, D - Diuretic
Thiazides, chlorthalidone
ACEI - correct answer start early to improve kidney function. If they already have bad kidneys,
ACEI are not good.
If patient is on a lot of BP meds, what can you expect with their BP during surgery? - correct
answer It will be up and down
Hypertension Assessment - correct answer What is the baseline BP? (not day of in pre-op)


Does the patient have any complications of untreated hypertension?


What end-organ damage should you be assessing? (what other meds are they on? not labs yet--
-a good H&P will tell you what they need/don't need for labs & tests)


How is the hypertension being managed?


What anti-hypertensive medications is your patient on?


At what point do you delay/cancel the anesthetic? **
Classification of HTN: NORMAL - correct answer SBP: <120
DBP: <80
Pre-HTN - correct answer SBP: 120-139
DBP: 80-89
Stage 1 HTN - correct answer SBP: 140-159
DBP: 90-99
Stage 2 HTN - correct answer SBP: 160-179
DBP: 100-109
Stage 3 HTN - correct answer SBP: 180-209
DBP: 110-119