Case 1: Does this patient need a stress test?

Preoperative Care of Patients with Kidney Disease
Author:
V. Dimov, M.D.

A 67 yo male with HTN, HPL, CHF EF 35% and CKD with Cr 2.4 mg/dL is here for preoperative evaluation for total knee replacement (TKR). He is able to walk 1-2 blocks at a ground level but not to climb up a flight of stairs due to shortness of breath. He denies chest pain and has no history of CAD.

Does he need a stress test?

A stress test may be considered but according to the 2007 ACC/AHA guidelines, a perioperative beta blocker may be sufficient. His physical activity level is less than 4 METs and he has 2 risks factor from the RCRI for adverse cardiovascular outcome.

Patient risk is assessed with the modified Revised Cardiac Risk Index (RCRI, Circulation. 1999;100:1043-1049):

Ischemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Insulin therapy for diabetes
Preoperative serum creatinine >2.0 mg/dL

4CD is a mnemonic to remember the risk factors in RCRI:

CAD
CHF
CVA
CKD
DM

The "HIP" shortcut

Many patients have 1 or 2 risk factors from the RCRI and you can use the following shortcut to determine who needs a non-invasive cardiac testing, which in most cases is a stress test.

The shortcut to noninvasive testing is remembered by the mnemonic HIP:

H igh risk surgery, e.g. vascular surgery
I ndex risk factors -- 4CD (CAD, CHF, CVA, CKD, DM)
P oor functional class

If a patient has 2 out of 3 of the above variables, a stress test can be considered.

Our patient has METs 2.75 and CKD with Cr higher than 2, which gives him 2 out 3 points from the HIP shortcut to noninvasive testing.

Note: The "HIP" shortcut is valid for patients who are scheduled to have high risk or intermediate risk surgery. Patients scheduled for low risk surgery can usually proceed with the operation without the need to have a stress test first.

Summary

CKD with serum creatinine higher than 2 mg/dL is an intermediate predictor of adverse cardiovascular outcome, in the same class as angina pectoris, old MI, CHF and DM.

References

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. Circulation, 2007.
The preoperative cardiovascular evaluation of the intermediate-risk patient: New data, changing strategies. David H. Wesorick MD, and Kim A. Eagle MD. The American Journal of Medicine, Volume 118, Issue 12 , December 2005, pages 1413.e1-1413.e9, doi:10.1016/j.amjmed.2005.07.068.
Systematic Review: Prediction of Perioperative Cardiac Complications and Mortality by the Revised Cardiac Risk Index. Ann of Int Med, January 5, 2010 vol. 152 no. 1 26-35.
New Risk Calculator for Prediction of Cardiac Risk After Surgery http://goo.gl/ayTv5 - Surpasses Revised Cardiac Risk Index (RCRI)?
Image source: Kjetil Lenes, public domain.

Published: 05/31/2006
Updated: 01/10/2011

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