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Chapter 7. Cardiac Risk Stratification for Noncardiac Surgery, Lee's Score, NYHA Classification

Sumeet Goswami, MD, MPH; Amit Goswami, MD

Table 7-1 Lee’s Revised Cardiac Risk Index
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Table 7-1 Lee’s Revised Cardiac Risk Index
  • High-risk type of surgery
  • History of ischemic heart disease
  • History of congestive heart failure
  • History of cerebrovascular disease
  • Preoperative treatment with insulin
  • Preoperative serum creatinine >2 mg/dL

Rates of major cardiac complications in the validation cohort with 0, 1, 2, or ≥3 of these factors were 0.4%, 0.9%, 7%, and 11%, respectively.

Based on the American College of Cardiology/American Heart Association guidelines on perioperative evaluation for noncardiac surgery, cardiac risk factors can be segregated into two categories: active cardiac conditions (formerly known as major risk factors) and clinical risk factors (formerly known as intermediate risk factors) (Tables 7-2 and 7-3). Noncardiac surgical procedures are also stratified based on cardiac risk (Table 7-4).

Table 7-2 Active Cardiac Conditions
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Table 7-2 Active Cardiac Conditions
ConditionsExamples
Unstable coronary syndromeUnstable or severe angina
Recent myocardial infarction (within 30 days)
Decompensated heart failureNYHA functional class IV; worsening or new-onset heart failure
Significant arrhythmiasHigh-grade atrioventricular block (Mobitz type II or third degree)
Symptomatic ventricular arrythmias
Supraventricular arrhythmias with uncontrolled ventricular rate (HR greater than 100 bpm at rest)
Symptomatic bradycardia
Severe valvular diseaseSevere aortic stenosis (mean gradient >40 mm Hg, valve area <1 cm2 or symptomatic)
Symptomatic mitral stenosis
Table 7-3 Clinical Risk Factors
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Table 7-3 Clinical Risk Factors
  • History of ischemic heart disease
  • History of compensated heart failure
  • History of cerebrovascular disease
  • Diabetes mellitus
  • Renal insufficiency
Table 7-4 Cardiac Risk Stratification for Noncardiac Surgical Procedures
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Table 7-4 Cardiac Risk Stratification for Noncardiac Surgical Procedures
Risk stratificationProcedure examples
Vascular (reported cardiac risk often more than 5%)Aortic and other major vascular surgery
Peripheral vascular surgery
Intermediate (cardiac risk generally 1–5%)Intraperitoneal and intrathoracic surgery
Carotid endarterectomy
Head and neck surgery
Orthopedic surgery
Prostate surgery
Low (cardiac risk generally less than 1%)Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
Ambulatory surgery

The stepwise approach to perioperative cardiac assessment is based on the presence of cardiac risk factors, risk stratification of the surgical procedure, and patient’s functional capacity (Figure 7-1). Diagnostic evaluation and treatment is indicated for patients with active cardiac conditions (Table 7-2) such as unstable angina or decompensated heart failure. Additional diagnostic testing such as a stress test should also be considered in patients undergoing vascular procedures (Table 7-4) who suffer from three or more clinical risk factors (Table 7-3) and have poor functional capacity.

Figure 7-1. Stepwise Approach to Perioperative Cardiac Assessment
image
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(A) See Table 7-3. (B) consider perioperative beta-blockade. Reprinted with permission ...

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