Algorithm of Romero and de Virgilio for Preoperative Cardiac Risk Assessment

Initial Evaluation

Need for surgery:

(1) emergency

(2) urgent

(3) nonurgent

Major clinical predictors for increased perioperative cardiac risk:

(1) recent myocardial infarction (> 7 days but <= 1 month)

(2) unstable or severe angina (Canadian Class III or IV)

(3) decompensated congestive heart failure

(4) significant dysrhythmias (high-grade AV block, symptomatic dysrhythmias, or supraventricular tachycardia with uncontrolled ventricular rate)

(5) severe valvular disease

Cardiac risk factors (Eagle et al):

(1) age > 70 years

(2) history of angina

(3) prior myocardial infarction history or the presence of Q waves on ECG

(4) diabetes mellitus

(5) history of ventricular ectopy requiring therapy

(6) history of congestive heart failure

Level of cardiac risk associated with the procedure (see 06.03.04):

(1) low

(2) moderate

(3) high

Algorithm

Sequential rules for a person being evaluated for noncardiac surgery:

(1) If the person requires emergent surgery, then take to the operating room immediately.

(2) If the person has a major clinical predictor for increased perioperative cardiac risk, then perform a coronary angiogram prior to surgery.

(3) If the person has had a coronary revascularization procedure within the past 5 years and does not have new cardiac symptoms, then the person can proceed to surgery.

(4) If the person has (a) had a coronary revascularization procedure within the past 5 years and had onset of new cardiac symptoms, (b) had a coronary revascularization procedure 5 or more years ago, or (c) not had a cardiac revascularization procedure, then (a) determine the number of cardiac risk factors and (b) the risk of the procedure.

If high risk surgery with >= 2 risk factors and the dobutamine stress echocardiogram is positive, then the options are:

(1) cancel surgery

(2) modify the operation t a less risk procedure

(3) proceed to the OR with a beta blocker

(4) perform a coronary angiogram