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Evaluation of the Cardiac Status of the Surgical Patient
Medical Clinics of North America September, 1938. New York Number
CLINIC OF DR. CHARLES A. POINDEXTER FROM THE DEPARTMENT OF MEDICINE, NEW YORK POSTGRADUATE MEDICAL SCHOOL AND HOSPITAL, COLUMBIA UNIVERSITY EVALUATION OF THE CARDIAC STATUS OF THE SURGICAL PATIENT
THE successful outcome of an operative procedure to relieve a surgical condition in a patient who has also a damaged heart requires more than a mere delineation of cardiac diagnosis. The problem requisitions the skill and judgment of the internist, the surgeon and the anesthetist in order to conquer the condition needing surgical interference as well as to allay the fear and anxiety of the patient. The fear and anxiety that accompanies the problem of determining the surgical potentialities of a cardiac patient continues because of the general fear of heart disease and because of the often repeated difficulty of distinguishing surgical shock from primary cardiac failure. Postoperative heart failure has long been an old "hold-all" into which has poured unfortunate failures of judgment and technic. There are two factors upon which evaluation rests. Both are of equal importance. The first of these concerns the skill with which the operative procedure is performed; that is, the skill of the surgeon and his helper, the anesthetist. It is to be assumed that the surgeon's and anesthetist's skills are of the best, but it is well to emphasize the point that it is not what is done, but who does it that may determine the outcome. All of the careful analyses of the patient's functional capacity, all of the preoperative and postoperative care amount to nothing if skill is not present. Often, too much emphasis is placed upon the immediate operation and anesthetic instead of calculating, as well as one possibly can, what the postoperative VOL. 22-95
150 $
CHARLES A. POINDEXTER
complications are likely to be and the chances of their occurrence. The actual risk of the operative procedure itself is not very great, rarely more so than in the patient with a normal heart. It is a stormy postoperative course that wears the patient down. The second important factor is a careful analysis of the patient's cardiac status. Statistical studies such as those recently published by Butler, Feeney and Levine1 show us that providing we use certain sensible criteria, which draw the careful distinction between cardiac disease and cardiac failure, the risk in cardiacs is only slightly above that to be expected in persons with a normal heart. The New York Tuberculosis and Heart Association2 has published the Criteria for Classification and Diagnosis of Heart Disease. Its value is that it makes possible a plan for constructing the diagnosis in a manner that makes one arrive at a jUdgment. This classification takes into consideration: (1) etiology, (2) anatomical variations from normal, (3) physiological findings and (4) functional classification. All four factors are important, for before evaluating the individual one must be able to diagnose correctly. After all, the subjective findings such as dyspnea, palpitation, etc., are not always .due to organic heart disease. They are merely the signs of an embarrassed circulation which may result from a . multitude of causes other than organic heart disease. One must first, therefore, ascertain the status of the patient as far as the first three items above mentioned are concerned. Then one comes to the fourth and, for our purposes, perhaps the most important. It is the advances of recent years that have taught us to think in terms of physiological concepts. By that I mean physiological in the true sense-a science which deals with living things, i. e., not how a heart appears when dead, but what are its capabilities in terms of work when alive. In cardiac disease this concept draws attention not necessarily to the disease alone, but also to failure of the heart. This important factor has been interpolated into the proper analysis as the functional classification.
THE CARDIAC STATUS OF THE SURGICAL PATIENT
1507
FUNCTIONAL CLASSIFICATION OF PATIENT
Class I.-Patients with organic heart disease able to carry on ordinary physical activity without discomfort. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or chest pain. Patients in this class do not show physical signs of cardiac insufficiency and rarely signs of active heart infection. Class Il-Patients with organic heart disease unable to carry on ordinary physical activity without discomfort. I I A .-Activity slightly limited. Ordinary physical activity causes undue fatigue, palpitation, dyspnea or chest pain. Patients in this class rarely show physical signs of cardiac insufficiency or signs of active heart infection. II B.-Activity greatly limited. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or chest pain. Patients in this class usually show one or more physical signs of cardiac insufficiency or the anginal syndrome or signs of active heart infection. Class Ill-Patients with organic heart disease and with symptoms or signs of cardiac insufficiency at rest, unable to carry on any physical activity without discomfort. There is fatigue, palpitation, dyspnea or chest pain at rest. Patients in this class show marked physical signs of cardiac insufficiency or the anginal syndrome or signs of active heart infection. This classification is not stationary but concerns the status at the time of the examination. The patient may improve and gain a place in a higher bracket. This functional classification can only be arrived at by a very careful history making which appraises the individual's subjective, as well as objective, reaction to the ordinary strain of life. The history tabulates, for example, the presence of fatigue, dyspnea, pain and palpitation, and the amount of effort necessary to bring these symptoms about. It measures their severity and whether they are growing worse or better over a period of time. The history must be so directed as to discover positive findings of vague statements. By that I mean, the number of flights of stairs, the· subway steps, the elevated stairs, a hill on the farm, the number of blocks on a level street, the influence of cold wind, and of emotional stress. All these, and more, must be carefully evaluated in comparison with the normal reaction. One
CHARLES A. POINDEXTER
must critically listen to the patient's story, for imp,essive and important as the stethoscope or electrocardiogram may be, they do not carry the factor of safety or reserve that is ascertained by what the patient is able to do. The findings of the so-called "functional tests" may be added to these if necessary. With a few notable exceptions, the type of cardiac lesion is not necessarily important, certainly not so much so as what the heart is able to do. As Marvin3 has said, "a damaged heart, whatever its physical signs, is the equivalent of a normal one for anesthesia and operation if it is carrying on an adequate circulation under ordinary circumstances of life." Emergency cases cannot be evaluated for it is to be understood that they must be done and "no cardiac status per se is a contraindication to an emergency operation." With certain exceptions, which will be mentioned later, it seems that the following general indications hold good. Class I.-Patients that are in this group, with proper care, should be able to withstand any procedure that a normal heart would withstand. Naturally, care should be taken to safeguard against any undue strain. Class 11 A.-Patients in this group should not be operated upon unless there is a definite and serious need. Although the chances for the successful outcome for the ordinary procedure are good, care should be taken to avoid any procedure which is likely to have a prolonged febrile convalescence, or stormy postoperative course. One should be particularly careful in this group, and even more careful in the group following, to weigh the ultimate prognosis against the misery and possible benefits of the surgical procedure. Of course, the latter problem must usually be solved by that omnipotent master known as judgment. It is well, however, to bear in mind an old statement, "a patient is better off half cured than all dead." Class 11 B.-Patients in this group should fall into the almost emergency class. Operation should be deferred if pqssible until they are sufficiently improved by rest and metlication to fit into one of the above brackets. Any operative procedure is contraindicated unless it is aimed to help relieve their cardiac condition or unless it is unavoidable. Their chances of operative recovery are less than those in the 11 A group. Class I1I.-Patients in this group should not be operated
THE CARDIAC STATUS OF THE SURGICAL PATIENT
1509
upon unless it is absolutely unavoidable, or unless it is done as a definite palliative procedure, such as total thyroidectomy. Additional physical findings other than those needed for functional classification may influence your opinion as to the patient's capacity for surgery. But of the physical findings of the patient it should be emphasized again that it is not so much the presence of heart murmurs, or enlargement, or character of tones that are important in the physical examination, but rather the careful search of the patient for the evidence of cardiac, or impending cardiac failure. The obvious signs of failure, such as peripheral edema, enlargement of the liver, cyanosis and so forth, are too well known to require further elucidation here. Such changes must be watched for that may have a bearing on postoperative complications in the patients that do not show extreme grades of failure. For example, moisture at the bases of the lungs, this so often presages cardiac failure and often 1p.ay form the favorable conditions for bronchopneumonia to start, in an area where there is diminished circulation. The liver size may be of great importance, particularly when after severe failure all other signs have improved yet the liver remains large. This usually indicates that failure may return very easily. It must be remembered that all these findings must be considered-the history, the physical examination, the fluoroscopic and the electrocardiographic examinations, and the indications given by the functional classification. There are certain exceptions to the above generalizations· and certain conditions which require emphasis. Age has considerable influence on risk-the younger the individual the better the chances. The effects of the repeated attacks of rheumatic disease and of advancing arteriosclerosis naturally increase the severity of the pathological changes. However, age alone should not contraindicate surgery. Extreme grades of stenosis, whether they be of the valve or of the coronary arteries, are not very likely to stand either sudden or prolonged strain. Mitral stenosis, due to rheumatic disease, is almost always accompanied by sufficient subjective and objective symptoms and signs to make one aware of the proper functional classification. However, there are occasional patients that have gradually limited their activities so that the history may be obscured. The functional test may be of
CHARLES A. POINDEXTER
particular value in these cases. Cases of extreme aortic stenosis are also poor risks, whether the lesion is due to rheumatic disease or arteriosclerosis. There are two factors responsible, one the physical burden this type of lesion places upon the heart, and the second, that the mouths of the coronary arteries are likely to be involved with a narrowing process. Patients with syphilitic heart disease are often unexpectedly bad risks, possibly because of the usual concomitant narrowing of the openings of the coronary arteries. In syphilitic heart disease one must also very carefully weigh the matter of prognosis against the benefit of operation. Once the syphilitic heart starts to fail it seldom, even with the best of treatment and rest, returns to its ability to maintain an adequate circulation. Even total thyroidectomy was of no benefit in decreasing the rapid downward course of the syphilitic patient that had started failure. The greatest risk in any kind of cardiac disease comes in coronary thrombosis. In the report of Butler, Feeney and Levine/ the mortality in this group was 44.5 per cent, as compared with 4.9 per cent in the total group, or 2.1 per cent in the valvular group. Part cif this may be due to the fact that these patients may be operated upon during an acute attack because of a mistake in diagnosis, as pointed out by Butler, Feeney and Levine. However, they should not be operated upon during an attack, or within a period of several months following if it is at all possible to avoid it. The mortality percentage of angina pectoris is about 7 per cent. The early case of angina is not so great a risk as those cases that have had one or more attacks of coronary thrombosis. The latter develop general cardiac failure with unpleasant frequency after operation, and when this failure develops, treatment seldom benefits them. This increased risk is likely to hold in all of the arteriosclerotic group, particularly is it true in cases showing the bundle branch block, as reported by Herrman and Herrman. 4 This particular diagnosis shows the value or' the electrocardiogram in emphasizing the status of the patient, for the lesion is seldom recognized without electrocardiographic assistance. Cardiac arrythmias often cause considerable concern to the patient and to the surgeon, although they are seldom serious.
THE CARDIAC STATUS OF THE SURGICAL PATIENT
15II
The one serious one, as far as risk is concerned, is that of complete heart block of organic nature. Auricular fibrillation in itself is not a contraindication to operation, providing that it is properly controlled by the use of digitalis. Butler, Feeney and Levine1 gave the mortality risk as being 3 per cent. Extrasystoles have no significance unless when accompanied by other findings. of advanced cardiac disease. Auricular flutter also forms no contraindication by itself, but it would be preferred that it is controlled before operation. Paroxysmal tachycardia does not contraindicate operation. Conclusion.-If a cardiac patient is selected by using the criteria mentioned, the patient's chances of surviving an operation are good. If allowance is made for modifying findings, the most simple and reliable guide is for the patient to be classified according to his functional capacity. The patient must be evaluated, not the risk. BIBLIOGRAPHY 1. Butler, S., Feeney, N., and Levine, S. A.: 12, 1930.
J.A.M.A., 95: 85-91, July
2. Criteria for Classification and Diagnosis of Heart Disease, New York Tuberculosis and Heart Association. 3. Marvin, H. M.: New Eng. Jour. Med., 199: 547-551, Sept. 20, 1928. 4. Herrman, G., and Herrman, L. G.: Texas State Jour. Med., 30: 183-191.
CLINIC OF DR. CHARLES A. POINDEXTER FROM THE DEPARTMENT OF MEDICINE, NEW YORK POSTGRADUATE MEDICAL SCHOOL AND HOSPITAL, COLUMBIA UNIVERSITY EVALUATION OF THE CARDIAC STATUS OF THE SURGICAL PATIENT
THE successful outcome of an operative procedure to relieve a surgical condition in a patient who has also a damaged heart requires more than a mere delineation of cardiac diagnosis. The problem requisitions the skill and judgment of the internist, the surgeon and the anesthetist in order to conquer the condition needing surgical interference as well as to allay the fear and anxiety of the patient. The fear and anxiety that accompanies the problem of determining the surgical potentialities of a cardiac patient continues because of the general fear of heart disease and because of the often repeated difficulty of distinguishing surgical shock from primary cardiac failure. Postoperative heart failure has long been an old "hold-all" into which has poured unfortunate failures of judgment and technic. There are two factors upon which evaluation rests. Both are of equal importance. The first of these concerns the skill with which the operative procedure is performed; that is, the skill of the surgeon and his helper, the anesthetist. It is to be assumed that the surgeon's and anesthetist's skills are of the best, but it is well to emphasize the point that it is not what is done, but who does it that may determine the outcome. All of the careful analyses of the patient's functional capacity, all of the preoperative and postoperative care amount to nothing if skill is not present. Often, too much emphasis is placed upon the immediate operation and anesthetic instead of calculating, as well as one possibly can, what the postoperative VOL. 22-95
150 $
CHARLES A. POINDEXTER
complications are likely to be and the chances of their occurrence. The actual risk of the operative procedure itself is not very great, rarely more so than in the patient with a normal heart. It is a stormy postoperative course that wears the patient down. The second important factor is a careful analysis of the patient's cardiac status. Statistical studies such as those recently published by Butler, Feeney and Levine1 show us that providing we use certain sensible criteria, which draw the careful distinction between cardiac disease and cardiac failure, the risk in cardiacs is only slightly above that to be expected in persons with a normal heart. The New York Tuberculosis and Heart Association2 has published the Criteria for Classification and Diagnosis of Heart Disease. Its value is that it makes possible a plan for constructing the diagnosis in a manner that makes one arrive at a jUdgment. This classification takes into consideration: (1) etiology, (2) anatomical variations from normal, (3) physiological findings and (4) functional classification. All four factors are important, for before evaluating the individual one must be able to diagnose correctly. After all, the subjective findings such as dyspnea, palpitation, etc., are not always .due to organic heart disease. They are merely the signs of an embarrassed circulation which may result from a . multitude of causes other than organic heart disease. One must first, therefore, ascertain the status of the patient as far as the first three items above mentioned are concerned. Then one comes to the fourth and, for our purposes, perhaps the most important. It is the advances of recent years that have taught us to think in terms of physiological concepts. By that I mean physiological in the true sense-a science which deals with living things, i. e., not how a heart appears when dead, but what are its capabilities in terms of work when alive. In cardiac disease this concept draws attention not necessarily to the disease alone, but also to failure of the heart. This important factor has been interpolated into the proper analysis as the functional classification.
THE CARDIAC STATUS OF THE SURGICAL PATIENT
1507
FUNCTIONAL CLASSIFICATION OF PATIENT
Class I.-Patients with organic heart disease able to carry on ordinary physical activity without discomfort. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or chest pain. Patients in this class do not show physical signs of cardiac insufficiency and rarely signs of active heart infection. Class Il-Patients with organic heart disease unable to carry on ordinary physical activity without discomfort. I I A .-Activity slightly limited. Ordinary physical activity causes undue fatigue, palpitation, dyspnea or chest pain. Patients in this class rarely show physical signs of cardiac insufficiency or signs of active heart infection. II B.-Activity greatly limited. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or chest pain. Patients in this class usually show one or more physical signs of cardiac insufficiency or the anginal syndrome or signs of active heart infection. Class Ill-Patients with organic heart disease and with symptoms or signs of cardiac insufficiency at rest, unable to carry on any physical activity without discomfort. There is fatigue, palpitation, dyspnea or chest pain at rest. Patients in this class show marked physical signs of cardiac insufficiency or the anginal syndrome or signs of active heart infection. This classification is not stationary but concerns the status at the time of the examination. The patient may improve and gain a place in a higher bracket. This functional classification can only be arrived at by a very careful history making which appraises the individual's subjective, as well as objective, reaction to the ordinary strain of life. The history tabulates, for example, the presence of fatigue, dyspnea, pain and palpitation, and the amount of effort necessary to bring these symptoms about. It measures their severity and whether they are growing worse or better over a period of time. The history must be so directed as to discover positive findings of vague statements. By that I mean, the number of flights of stairs, the· subway steps, the elevated stairs, a hill on the farm, the number of blocks on a level street, the influence of cold wind, and of emotional stress. All these, and more, must be carefully evaluated in comparison with the normal reaction. One
CHARLES A. POINDEXTER
must critically listen to the patient's story, for imp,essive and important as the stethoscope or electrocardiogram may be, they do not carry the factor of safety or reserve that is ascertained by what the patient is able to do. The findings of the so-called "functional tests" may be added to these if necessary. With a few notable exceptions, the type of cardiac lesion is not necessarily important, certainly not so much so as what the heart is able to do. As Marvin3 has said, "a damaged heart, whatever its physical signs, is the equivalent of a normal one for anesthesia and operation if it is carrying on an adequate circulation under ordinary circumstances of life." Emergency cases cannot be evaluated for it is to be understood that they must be done and "no cardiac status per se is a contraindication to an emergency operation." With certain exceptions, which will be mentioned later, it seems that the following general indications hold good. Class I.-Patients that are in this group, with proper care, should be able to withstand any procedure that a normal heart would withstand. Naturally, care should be taken to safeguard against any undue strain. Class 11 A.-Patients in this group should not be operated upon unless there is a definite and serious need. Although the chances for the successful outcome for the ordinary procedure are good, care should be taken to avoid any procedure which is likely to have a prolonged febrile convalescence, or stormy postoperative course. One should be particularly careful in this group, and even more careful in the group following, to weigh the ultimate prognosis against the misery and possible benefits of the surgical procedure. Of course, the latter problem must usually be solved by that omnipotent master known as judgment. It is well, however, to bear in mind an old statement, "a patient is better off half cured than all dead." Class 11 B.-Patients in this group should fall into the almost emergency class. Operation should be deferred if pqssible until they are sufficiently improved by rest and metlication to fit into one of the above brackets. Any operative procedure is contraindicated unless it is aimed to help relieve their cardiac condition or unless it is unavoidable. Their chances of operative recovery are less than those in the 11 A group. Class I1I.-Patients in this group should not be operated
THE CARDIAC STATUS OF THE SURGICAL PATIENT
1509
upon unless it is absolutely unavoidable, or unless it is done as a definite palliative procedure, such as total thyroidectomy. Additional physical findings other than those needed for functional classification may influence your opinion as to the patient's capacity for surgery. But of the physical findings of the patient it should be emphasized again that it is not so much the presence of heart murmurs, or enlargement, or character of tones that are important in the physical examination, but rather the careful search of the patient for the evidence of cardiac, or impending cardiac failure. The obvious signs of failure, such as peripheral edema, enlargement of the liver, cyanosis and so forth, are too well known to require further elucidation here. Such changes must be watched for that may have a bearing on postoperative complications in the patients that do not show extreme grades of failure. For example, moisture at the bases of the lungs, this so often presages cardiac failure and often 1p.ay form the favorable conditions for bronchopneumonia to start, in an area where there is diminished circulation. The liver size may be of great importance, particularly when after severe failure all other signs have improved yet the liver remains large. This usually indicates that failure may return very easily. It must be remembered that all these findings must be considered-the history, the physical examination, the fluoroscopic and the electrocardiographic examinations, and the indications given by the functional classification. There are certain exceptions to the above generalizations· and certain conditions which require emphasis. Age has considerable influence on risk-the younger the individual the better the chances. The effects of the repeated attacks of rheumatic disease and of advancing arteriosclerosis naturally increase the severity of the pathological changes. However, age alone should not contraindicate surgery. Extreme grades of stenosis, whether they be of the valve or of the coronary arteries, are not very likely to stand either sudden or prolonged strain. Mitral stenosis, due to rheumatic disease, is almost always accompanied by sufficient subjective and objective symptoms and signs to make one aware of the proper functional classification. However, there are occasional patients that have gradually limited their activities so that the history may be obscured. The functional test may be of
CHARLES A. POINDEXTER
particular value in these cases. Cases of extreme aortic stenosis are also poor risks, whether the lesion is due to rheumatic disease or arteriosclerosis. There are two factors responsible, one the physical burden this type of lesion places upon the heart, and the second, that the mouths of the coronary arteries are likely to be involved with a narrowing process. Patients with syphilitic heart disease are often unexpectedly bad risks, possibly because of the usual concomitant narrowing of the openings of the coronary arteries. In syphilitic heart disease one must also very carefully weigh the matter of prognosis against the benefit of operation. Once the syphilitic heart starts to fail it seldom, even with the best of treatment and rest, returns to its ability to maintain an adequate circulation. Even total thyroidectomy was of no benefit in decreasing the rapid downward course of the syphilitic patient that had started failure. The greatest risk in any kind of cardiac disease comes in coronary thrombosis. In the report of Butler, Feeney and Levine/ the mortality in this group was 44.5 per cent, as compared with 4.9 per cent in the total group, or 2.1 per cent in the valvular group. Part cif this may be due to the fact that these patients may be operated upon during an acute attack because of a mistake in diagnosis, as pointed out by Butler, Feeney and Levine. However, they should not be operated upon during an attack, or within a period of several months following if it is at all possible to avoid it. The mortality percentage of angina pectoris is about 7 per cent. The early case of angina is not so great a risk as those cases that have had one or more attacks of coronary thrombosis. The latter develop general cardiac failure with unpleasant frequency after operation, and when this failure develops, treatment seldom benefits them. This increased risk is likely to hold in all of the arteriosclerotic group, particularly is it true in cases showing the bundle branch block, as reported by Herrman and Herrman. 4 This particular diagnosis shows the value or' the electrocardiogram in emphasizing the status of the patient, for the lesion is seldom recognized without electrocardiographic assistance. Cardiac arrythmias often cause considerable concern to the patient and to the surgeon, although they are seldom serious.
THE CARDIAC STATUS OF THE SURGICAL PATIENT
15II
The one serious one, as far as risk is concerned, is that of complete heart block of organic nature. Auricular fibrillation in itself is not a contraindication to operation, providing that it is properly controlled by the use of digitalis. Butler, Feeney and Levine1 gave the mortality risk as being 3 per cent. Extrasystoles have no significance unless when accompanied by other findings. of advanced cardiac disease. Auricular flutter also forms no contraindication by itself, but it would be preferred that it is controlled before operation. Paroxysmal tachycardia does not contraindicate operation. Conclusion.-If a cardiac patient is selected by using the criteria mentioned, the patient's chances of surviving an operation are good. If allowance is made for modifying findings, the most simple and reliable guide is for the patient to be classified according to his functional capacity. The patient must be evaluated, not the risk. BIBLIOGRAPHY 1. Butler, S., Feeney, N., and Levine, S. A.: 12, 1930.
J.A.M.A., 95: 85-91, July
2. Criteria for Classification and Diagnosis of Heart Disease, New York Tuberculosis and Heart Association. 3. Marvin, H. M.: New Eng. Jour. Med., 199: 547-551, Sept. 20, 1928. 4. Herrman, G., and Herrman, L. G.: Texas State Jour. Med., 30: 183-191.