ABSTRACT
Step 2: Determine the Presence of Active Cardiac Disease or Active Clinical Risk Factors of Cardiac Disease There remains a persistent underestimation of cardiac disease in women when evaluating cardiac risk preoperatively ( Table 1 ). In patients with established cardiovascular disease, preoperative assessment must include any recent change in symptoms including shortness of breath, palpitations, fatigue, or chest pain. Any history of unstable angina, MI, significant arrhythmias, or severe cardiac valvular disease all increase risk of a perioperative cardiac event. In the Goldman series, although only 12 patients were included, MI within four weeks prior to a surgical procedure conferred a 33% increase in perioperative MI and mortality rate. Patients who had experienced an MI between six weeks and six months prior to surgery had a 20% increase in perioperative cardiovascular events ( Goldman et al. 1977, Charlson et al. 1994 ). Smoking, hyperlipidemia, and diabetes mellitus are important historical factors that encourage further investigation for cardiac disease and could lead to the discovery of subclinical disease. In the original ACC/AHA guidelines, the committee separated clinical risk factors into major, intermediate and minor risk factors (Eagle et al. 2002) ( Table 1 ). The presence of one or more active cardiac conditions with major clinical risk warrants further investigation prior to proceeding with surgery. The intermediate risk category from the Revised Cardiac Index includes clinical risk factors including a history of heart disease, compensated or prior heart failure, cerebrovascular disease, diabetes mellitus, and renal insufficiency ( Lee et al. 1999 ). Patients within the intermediate risk category should have their functional capacity measured, and the degree of risk associated with the planned procedure should be determined to assess for the need for further testing or intra-operative monitoring ( Table 1 ). Advanced age (>70 years), abnormal ECG (LV hypertrophy, left bundle branch block (LBBB), ST-T abnormalities), rhythm other than sinus, and uncontrolled hypertension represent minor predictors, which are considered markers for cardiovascular disease but have not been proven to independently increase perioperative risk ( Lee et al. 1999 ).
