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Table 1.4. Risk of myocardial infarction.

Table 1.4. Risk of myocardial infarction.

Class 1 Angina with strenuous exercise

Class 2 Angina with moderate exercise

Class 3 Angina after climbing 1 flight of stairs or walking 1 block

Class 4 Angina at rest presence of inadequately treated cardiac failure. The mortality rate from perioperative myocardial infarction is high (40-60%). Previously 6 months was considered the minimum time between uncomplicated myocardial infarction and elective surgery, but recent data supports a 3-month minimum period. In the event that surgery cannot be delayed, a full assessment of cardiac function is required and intraoperative monitoring using transoesophageal echo (TOE) or Swan-Ganz catheter may be desirable. Postoperatively, the patient should be cared for on an intensive care unit for the first 24 h because the risk of reinfarction continues in the postoperative period (15% in the first 48 h). In the elective patient, evidence of significant ischaemic changes on stress testing may be followed by coronary angiography and possible percutaneous coronary stents or coronary bypass grafting prior to elective surgery. Prophylactic perioperative beta-blockade has been shown to reduce risk in patients with proven coronary artery disease, although specific protocols are uncommon in clinical practice. A titration of heart rate to ^65 bpm has been widely supported.

Angina

The clinical assessment of the severity of angina may be based on the grading system devised by the New York Heart Association (Table 1.4). Patients in classes 1 and 2 undergoing low or intermediate risk surgery are at no increased risk with surgery but should have exercise electrocardiograms (ECGs) prior to surgery. Anti-anginal medication should be continued through the preoperative period. Patients in classes 3 and 4, especially those scheduled for intermediate- or high-risk non-cardiac surgery should be considered for coronary angiography and possible revascularisation or coronary stent percutaneous trans luminal coronary angioplasty (PTCA) prior to elective surgery. This is because of the high incidence of myocardial infarction when elective surgery is performed on this group, however to date, no randomised controlled clinical trial has assessed the overall benefit of prophylactic coronary grafting to lower cardiac risk during non-cardiac surgery.

Table 1.5. Classification of hypertension.

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