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Cardiovascular Risk Assessment

Last modified: 17 July 2023, 4:32:31 PM AEST

Gems1 / 16

accurate risk PREDICTION is difficult
effective risk REDUCTION strategies are elusive
competing interests\n
- ATT vs bleeding risk
\n
Main risk is postoperative\n
- Intraop, we can control every number
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Summary2 / 16

DASI is best
NT-proBNP also good for 12-month mortality
no role for CPET now
6MWT is non-inferior to CPET
all patients 40+ should have\n
- DASI
- NT-proBNP
\n

Guidelines3 / 16

\n
guidelines provide
\n
- universal framework
- common language
- set of treatment priorities
\n
\n
3 major guidelines
\n
- American = ACC/AHA 2014 Periop CV evaluation\n
  - low risk = <1% MACE
  - \"elevated\" risk = >1% MACE
  \n
- European = ESC/ESA 2014 CV assessment
- Canadian = CSC 2016 = Periop CV risk assessment\n
  - incorporates NT-proBNP
  \n
\n

Magnitude4 / 16

POP CV complications / MACE\n
- major cause of morbidity and mortality
- 3rd biggest killer if it was a disease
\n

Functional capacity5 / 16

1 MET = 3.5 mL/kg/min for 40 yo 70 kg male
excellent = 10 METS
moderate = 4-6 METS
4 METS = VO2max 14 mL/kg/min

Risk of what?6 / 16

death
MACE
complications = major / minor
PATIENT-CENTRED outcomes\n
- recovery
- disability
- QOL
\n

Why assess?7 / 16

guide decision making
preop\n
- inform patient = SDM
- surgical planning = type of procedure
\n
intraop\n
- monitoring
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postop\n
- destination
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When?8 / 16

only if it changes management\n
- type of surgical procedure
- monitoring during / after surgery
- date of procedure until optimisation
\n

How?9 / 16

history of functional capacity
structured questionnaires
risk calculators
biomarkers
exercise tests
imaging

1:History10 / 16

\n
IHD
\n
- severity + stability
- functional capacity
- treatment
\n
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Heart failure
\n
- NYHA classification
\n
\n
self-reported exercise tolerance is inaccurate
\n
\n
METS study = Measure of Exercise Tolerance before major Surgery
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Physical examination
\n
- Significant findings
- LVF = S4 (diastolic failure)
- RVF = ⬆JVP, oedema
- HR and rhythm
- HTN = ⬆DBP
- atherosclerosis = carotid bruit, xanthelasma
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2:Structured Questionnaires11 / 16

DASI\n
- predicts 12-month DFS, 30-day mortality and MI, 12-month mortality
- why is it so good?
- it's a holistic questionnaire
- what they do on a daily basis
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3:Risk Calculators12 / 16

\n
Goldman = Original Cardiac Risk Index
\n
- 1977
\n
\n
Parsonnet
\n
- 1989
\n
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RCRI
\n
- \n
  Lee 1999
  \n
- \n
  6 variables (5 patient + 1 surgical)
  \n
- \n
  https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk
  \n
- \n
  under-predicts in vascular patients
  \n
- \n
  over-estimates in high-risk patients
  \n
- \n
  C = IHD
  \n
- \n
  C = HF
  \n
- \n
  D = CVA
  \n
- \n
  E = DM on insulin
  \n
- \n
  F = CKD (Cr > 177)
  \n
- \n
  Surgery (intraperitoneal, intrathoracic, suprainguinal vascular)
  \n
  - major surgery\n
    - emergencies
    - vascular
    - prolonged + large fluid shifts
    \n
  \n
- \n
  Predictors
  \n
  - 0 = 0.4% MACE (30-day mortality, MI, cardiac arrest)
  - 1 = 1.0%
  - 3+ = 11+% MACE (30-day mortality, MI, cardiac arrest)
  \n
- \n
  Revised 2017
  \n
  - 0 = 3.9%
  - 3+ = 15%
  \n
\n
\n
NSQIP
\n
- https://riskcalculator.facs.org/RiskCalculator/
- time-consuming = many fields
- some co-morbidities aren't there, eg. liver failure
\n
\n
MICA = NSQIP Myocardial Infarction and Cardiac Arrest risk index
\n
- http://www.surgicalriskcalculator.com/miorcardiacarrest
\n
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P-POSSUM
\n
- under-predicts in elderly
- can only be used postop
- Physiology Score, Operative Severity Score, Morbidity, Mortality
- http://www.riskprediction.org.uk/index-pp.php
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\n
EuroSCORE 1999
\n
- 20 variables
- in-hospital mortality after cardiac surgery
- additive and logistic models, now out of date (due to changing data)
\n
\n
EuroSCORE II 2012
\n
- 18 variables
- estimate of in-hospital death after cardiac surgery
- patient + cardiac + operation factors
- http://www.euroscore.org/calc.html
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4:Biomarkers13 / 16

NT-proBNP\n
- elevated in Entresto usage
- 3000 = 5 LR for death/MI
\n
BNP\n
- 250 = 3.9 LR for death/MI
\n
Troponin

5:Exercise tests14 / 16

CPET\n
- poorly correlates with mortality
- may have a role in predicting moderate and serious complications after NCS
\n
6MWT

6:Imaging15 / 16

Exercise ECG
Stress TTE
Myocardial perfusion imaging
Left heart catheterisation / angiography
CTCA\n
- over-estimates cardiac risk
- may lead to\n
  - unnecessary postponement
  - unnecessary referral for CR
  \n
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Risk Scores16 / 16

\n
Strengths
\n
- objective, better than clinical judgement
- allows SDM with patient and surgeon
- improved preop planning
\n
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Weaknesses
\n
- not predictive for individual patients
- may not apply to hospital / population
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