One of my interests is perioperative care. I have always been interested in the debate over which preoperative tests to order and what patients need which preoperative medication. Clearly, cardiac disease is the most significant of these disorders to evaluate, and I would wager that everyone reading this has dealt with a patient with cardiac disease. Of every category of disease we treat, cardiac disease is the most universal, perhaps even more so than diabetes. It was interesting to me, then, to note the intersection between cardiac disease and perioperative issues during an unfortunate patient encounter I had some time ago. This event forced me to further consider the role of a podiatrist in their patient’s medical care during the time of surgery.

This incident involved taking a 45-year-old diabetic patient into surgery for an amputation due to complications resulting from his diabetes. Just after anesthesia induction and before the anesthesiologist had a chance to intubate the patient, he went into pulseless electrical activity. Just before the code was called, I could hear the ever-declining rate of beeping from the anesthesia machinery. Looking back on this, I can say it was not a pleasant sound. The code was called, chest compressions begun, and the surgical team revived the patient successfully. The patient survived the event, but this situation had all of us involved revisiting the role of cardiac risk assessment in preoperative patients.

As it turns out, the cardiologist on the case related that the medical team would not have been able to predict what occurred from this patient’s history. It is also important for us to consider that although this patient was medically managed by the internal medicine team, the patient’s health was also my responsibility. As a result, we performed an internal review and created a preoperative checklist that not only included cardiac arrest but also other disease evaluations. I’ll tell you more about that checklist in future editorials. But for now, let’s talk more specifically about the cardiac risk assessment. My disclaimer here is that I am obviously not a cardiologist, and anyone who uses the information below should obtain guidelines from appropriate experts.

Many of you will recall the old Goldman cardiac risk classification. A relatively newer modification has been adopted, which is called the Relative Cardiac Risk Index (RCRI). This index, plus some other information, can help us identify patients at risk for major cardiac events.

First, look at the Duke Activity Scale.¹ This scale attempts to describe functional capacity and correlates that with the risk of perioperative cardiac events. Functional capacity is described in terms of METS, or metabolic equivalents.

To determine functional capacity, the provider asks the patient various questions about what physical activities they are capable of performing. The provider then determines the number of METs. Anything greater than 4 METs correlates with a relatively lower risk of major cardiac events.

Next comes the RCRI², which looks at six factors, shown below.

The RCRI correlates with major adverse cardiac events (MACE = MI, CHF, V-fib, and asystole) as follows:

	0 of 6 risk factors = 0.5% risk
	1 of 6 risk factors = 1.3% risk
	2 of 6 risk factors = 4-6.6% risk
	3 of 6 risk factors = 9-11% risk

Putting these two components together, we can use the following steps to determine if surgery is safe for our patients, or if they need further workup.

That’s it. Not so hard when you look at it. Now, I’m not asking any podiatrist to be either a medical doctor or cardiologist. However, we do need to be aware of current medical practice guidelines, as they affect our patients and we need to be capable of speaking the same language as the rest of the medical community. Additionally, the more of us double checking these various complex aspects of care, the less likely it will be that our patients have unanticipated complications. Also, on a final note from a medical legal standpoint, it cannot hurt to show that we evaluated a patient’s risk.

Remember, none of this is foolproof, but it’s much better than doing nothing. I hope that what occurred with my patient never happens with yours, but now you have another tool for evaluaion.

*Approved for 16 CME/CECH Credit Hours

PODIATRISTS: This activity has been planned and implemented in accordance with the standards and requirements for approval of providers of continuing education in podiatric medicine through a joint provider agreement between the New York College of Podiatric Medicine and PRESENT e-Learning Systems.

The New York College of Podiatric Medicine (NYCPM) is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. The NYCPM has approved this activity for a maximum of 16 continuing education contact hours.

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Professional Education Services Group (PESG) designates this live educational activity for AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. A maximum of 16 AMA PRA Category 1 Credits^TM will be awarded.

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