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Medical Fitness of Patient-CV
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 | A history is very important in obtaining information about hypertension, diabetes, CHF, CAD, smoking, murmurs, previous MI, chest pain at rest or on exertion, previous bypass surgery or angioplasty. Always assess exercise tolerance (e.g. Can the patient go up 2 flights of stairs without stopping?) The likelihood that someone has myocardium at risk is affected by the presence or absence of risk factors for coronary disease (smoking, diabetes, hypercholesterolemia, positive family history, hypertension). |
| The guidelines of the American College of Cardiology/American Heart Association help in deciding which patients need further workup depending on patient characteristics and type of surgical procedure. These were published in Anesthesia and Analgesia, 1996, page 854-860. In working up a patient with coronary artery disease, risk factors are helpful in determining what kind of pre-op testing is needed, if any. |
| According to the ACC/AHA guidelines, the patient is evaluated beginning with whether they have recently been revascularized (CABG or stent) or have had a recent coronary evaluation. If either one has been done recently and no symptoms have recurred, the patient may proceed to the OR. If the patient has not had a recent (within 5 year) revascularization and no recent coronary evaluation has been done or if the results were unfavorable, or if there has been a change in symptoms, the presence of minor, intermediate, or major clinical predictors are evaluated as follows: |
| Minor Clinical Predictors |
| Advanced age |
| Abnormal ECG |
| Rhythm other than sinus |
| Low functional capacity |
| History of stroke |
| Uncontrolled systemic hypertension |
| Intermediate Clinical Predictors |
| Mild angina pectoris |
| Compensated or prior CHF |
| Diabetes mellitus |
| Major Clinical Predictors |
| Unstable coronary syndromes |
| Decompensated CHF |
| Significant arrhythmias |
| Severe valvular disease |
| Those with major predictors should consider a delay or cancelation of non-emergent surgery. Those with intermediate or minor predictors should next have their exercise tolerance assessed, with the need for non-invasive testing dependent on the results |
| A history of myocardial infarction within the six months prior to the planned procedure confers significant additional risk for cardiac complications, as does unstable angina, most likely because they indicate the patient may have additional myocardium 'at risk.' Other factors increasing risk significantly are: |
| History of CHF |
| Critical aortic stenosis (more on this later) |
| Emergency operation |
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