An algorithm for preoperative cardiac risk assessment

One discussion last week involved cardiac arrest in the setting of hernia repair. The reference below was highlighted in the chief resident’s presentation.

Reference: Rafiq A, Skylar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgeryHealth Services Insight. 2017 Feb 20; 9: 1178632916686074. doi: 10.1177/1178632916686074.

Summary: Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient’s medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks.

That being said, this review by Rafiq et al (2017) aims to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.

The ideal approach toward perioperative cardiac risk assessment requires a multidisciplinary team or a dedicated perioperative team of physicians. This leads expert physicians in this field to be involved in patient care with improved communications among primary physicians, anesthesiologist, surgeons, the patient, family members of the patient, cardiologist, and all other ancillary departments of health care involved.

Figure 1: Algorithm for perioperative cardiac risk assessment prior to noncardiac surgery (p.2)

algorithm cardiac

The authors state that it is important to stress the fact that a majority of these recommendations are based, to a large extent, on observational studies and clinical experience. There are only few RCTs that address this matter. It is prudent that more randomized trials are needed to improve on current recommendations, hence leading to further improvement in patient care and management in the perioperative period.

Mortality risk reduction associated with PTH reduction for Secondary Hyperparathyroidism

One discussion this week included parathyroid hormone (PTH) levels.

Reference: Komaba H, et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney International. 2015 Aug;88(2):350-359. doi: 10.1038/ki.2015.72

Summary: In a nationwide study of 114,064 hemodialysis patients, Komaba et al asked if PTx for severe SHPT improves survival of dialysis patients.  They compared patient outcomes by PTH levels, and by those with a history of parathyroidectomy (PTx) (6,6280) and those without PTx (107,436).



Excess PTH is shown to increase cardiac fibrosis; elevations in serum calcium, phophorus, and PTH levels are associated with death and cardiovascular events primarily due to vascular calcification (p.350).



For cardiovascular death, there was a significant increase in the multivariate-adjusted HR for patients with intact PTH levels < 60 pg/ml (HR, 1.11; 95% CI, 1.02–1.20) and those with intact PTH levels >500 pg/ml (HR, 1.41; 95% CI, 1.20–1.64). In contrast, such an increased risk of mortality was not observed in patients with a history of PTx, despite the fact that these patients had severe SHPT preoperatively.