Identify whether the patient has low or elevated perioperative risk of
major adverse cardiac event (MACE) based upon combined clinical and
surgical risk evaluation
The
ACC guideline recommends use of a validated tool in order to assess for
risk of major adverse cardiac events (MACE) during and after surgery.
Such tools include factors about the patient’s health as well as factors
about the surgery’s known risks so as to come to an overall impression
of risk.
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For patients with a low risk of perioperative MACE, no
further cardiac evaluation is recommended and patient may proceed. For
patients with an elevated risk, further cardiac consideration ensues in
Step 4 of the algorithm. The ACC guideline offers three evaluation tool
options:
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1) The RCRI is the simplest and is included here in its entirety owing to its
concise nature below. A score of 0 or 1 on the RCRI indicates low risk
of MACE. 1 point each for:
creatinine > 2.0 mg/dL
heart failure
insulin dependent diabetes mellitus
suprainguinal vascular surgery, intrathoracic surgery, or intraabdominal surgery
history of stroke or TIA
ischemic heart disease
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2) The American College of Surgeons NSQIP Surgical Risk Calculator can be found online here: http://riskcalculator.facs.org/
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3) The American College of Surgeons NSQIP MICA (MI or Cardiac Arrest) calculator can be found as a spreadsheet download here: http://www.surgicalriskcalculator.com/miorcardiacarrest and can also be found as the “Gupta [lead author 2011 Circulation study] Perioperative Cardiac Risk” calculator at this link.
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What
about cataract surgery? The risk calculators might make a typical
cataract surgery patient (e.g. 78 y.o., CAD, CKD, DM) seem to have
elevated MACE risk. However, the current guideline points out that some
surgeries, ophthalmologic and plastic surgery are named, have very low
risk of MACE even for high risk patients. And the previous ACC guideline
of 2007 explicitly identified low risk procedures (endoscopic,
superficial, cataract, breast, and “ambulatory” procedures) as having
less than 1% total cardiovascular mortality rates even in high risk
patients. Thus, there is basis for clinicians to forego further cardiac
evaluation steps for cataract patients and the like.
Note that the 2014 ACC guideline algorithm has a choice of
Low Risk lead to Step 4 on the algorithm and choice of Elevated Risk
lead to Step 5.
The
steps in the 2007 ACC algorithm were sequential numbered steps in an
evaluation process. However, in 2014 the steps in the algorithm are
really numbered nodes in the decision tree. Moving from "step 3" to
"step 5" doesn't really skip step 4, it skips node 4 on the decision
tree. In case you're wondering.
