Pre-op (Goldman) assess in CAD pts
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Goldman's scoring system
☐Myocardial infarction within 6 months
☐S3 gallop or jugular venous distention
☐Rhythm other than sinus rhythm or presence of PACs on preoperative EKG
☐>5 PVCs/minute at any time before surgery
☐Significant aortic stenosis
☐pO2<60 mmHg
☐pCO2>50 mmHg
☐Potassium<3.0 mmol/L
☐Bicarbonate<20 mmol/L
☐BUN>50 mg/dL (>18 mmol/L)
☐Creatinine>3.0 mg/dL (>260 µmol/L)
☐Elevated AST
☐Signs of chronic liver disease
☐Bed-ridden from noncardiac causes
☐Age>70 years
☐Intraperitoneal, intrathoracic, or aortic operation
☐Emergency operation
Category Minor surgery? >40 years and major noncardiac surgery Known CAD, aortic surgery or other high-risk category
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Pre-op (Goldman) assess in CAD pts

Cardiovascular disease (either suspected or known) in patients undergoing surgery requires appropriate assessment. In 1995, 27 million patients had surgery in the U.S., with 8 million of these having CAD or risk factors for CAD. Of these 8 million, 1 million had perioperative cardiac complications, at substantial cost in mortality and morbidity.

The issue is to appropriately stratify patients who may require little or no testing versus those who need extensive testing and even coronary revascularization prior to undergoing noncardiac surgery.

Goldman's scoring system is helpful in predicting patients at highest risk.

Points are assigned for the presence of the following:

  • Myocardial infarction within 6 months [10 pts]
  • S 3 gallop or jugular venous distention [11 pts]
  • Rhythm other than sinus rhythm or presence of PACs on preoperative EKG [7 pts]
  • >5 PVCs/minute at any time before surgery [7 pts]
  • Significant aortic stenosis [3 pts]
  • Presence of any of the following [3 pts]
    • pO 2 <60 mmHg
    • pCO 2 >50 mmHg
    • Potassium <3.0 mmol/L
    • Bicarbonate <20 mmol/L
    • BUN >50 mg/dL (>18 mmol/L)
    • Creatinine >3.0 mg/dL (>260 µmol/L)
    • Elevated AST
    • Signs of chronic liver disease
    • Bed-ridden from noncardiac causes
  • Age >70 years [5 pts]
  • Intraperitoneal, intrathoracic, or aortic operation [3 pts]
  • Emergency operation [4 pts]

An additional selection is required to determine risk:

  • Minor surgery?
  • >40 years and major noncardiac surgery
  • Known CAD, aortic surgery or other high-risk category

Class I = 0-5 pts

Class II = 6-12 pts

Class III = 13-25 pts

Class IV = >25 pts

Risk of Major Cardiac Complications

Class Minor surgery? >40 yrs & major non-cardiac surgery Known CAD, aortic surgery or other high risk
Class I 0.3% 1.2% 3%
Class II 1% 4% 10%
Class III 4% 12% 30%
Class IV 19% 48% 75%

Reference:

  • Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845-50.
  • Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333(26):1750-6.