Presentation on theme: "Preoperative Evaluation of Cardiac Patient for Noncardiac surgery"— Presentation transcript:
1 Preoperative Evaluation of Cardiac Patient for Noncardiac surgery Dr Balaji AsegaonkarMD,DNB (Anaesthesia)Consultant cardiac anaesthesiologistOzone Anaesthesia Group, Aurangabad.
2 CASE 1 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTSON DUAL ANTIPLATELATE AGENTSTO BE POSTED FOR TURP
3 CASE 2 70 YR MALE ,HYPERTENSIVE, DIABETIC & SEVERE OSTEOARTHRITIS. SMOKER FOR LAST 30 YRS.TO BE POSTED FOR TKR
4 CASE 3 80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCE TO BE POSTED FOR CATARACT
5 Let’s face it…The surgical population is older, sicker, on more medications, and having more & more cardiac interventions.There is a subset of your patients for whom the patient, the surgeon, or you may have questions about cardiovascular risk.
6 So what do you do?Guess?…Argue?…Worry?…Refer everyone cardiological investigationsOR do a thorough, focused exam.Followed by the individualized application of some authoritative guidelines……for evaluation, risk stratification, and management……and refer, delay, or cancel only when appropriate.
7 Authoritative guidelines…..? Evidence based medicine.Based on research findings, expert opinion, and consensus .Cardiovascular authority, like American College of Cardiology/American Heart Association.Anaesthesiology authority, like ASA.I am not a cardiologist, nor do I play one on TV. The point is to learn as much as possible, act responsibly based on your own knowledge and the knowledge of experts, and get assistance when you need it.
8 Objectives: How to approach cardiac Patients. Risk stratification. Modification of level of care.Discuss standard recommendation.
9 focused approach………We are not cardiologists, We simply need to recognize when a cardiac condition might affect the patient’s response to anaesthesia, and what to do about it. We need to be:Thorough enough to find all significant problems (sensitivity).Focused enough to consider only significant problems (specificity).
10 …and Stepwise Approach? Thorough, focused cardiac evaluationACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery (2007).Indicated cardiac testing and consultation.Optimization of cardiovascular function in relation to the demands of the surgery and the anaesthesia.
11 The courage is knowledge of how to fear what ought to be feared & how not to fear what ought not to be feared.
12 Applying Classification of Recommendations and Level of Evidence Class I Benefit >>> RiskProcedure/ Treatment SHOULD be performed/ administeredClass IIa Benefit >> Risk Additional studies with focused objectives neededIT IS REASONABLE to perform procedure/administer treatmentClass IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpfulProcedure/TreatmentMAY BE CONSIDEREDClass IIIRisk ≥ Benefit No additional studies neededProcedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFULLevel of Evidence:Level A: Data derived from multiple randomized clinical trials or meta-analysesMultiple populations evaluatedLevel B: Data derived from a single randomized trial or nonrandomized studiesLimited populations evaluatedLevel C: Only consensus of experts opinion, case studies, or standard of careVery limited populations evaluated
13 So, let’s start with …The Preop portion of the ACC/AHA Guidelines, which is based on your history and physical, plus indicated tests.
14 Guidelines : Stepwise approach Need for surgery:Emergent vs Urgent/Elective.Clinical Risk Predictors:(Major, Intermediate, Minor).Functional capacity (Exercise tolerance).
16 Major Clinical Risk Predictors Unstable Coronary Syndromes:Recent MI (> 7 and < 30 days).Unstable angina (Canadian Class III-IV).Decompensated CHF.Significant Dysrhythmias.High-grade AV block.Symptomatic ventricular dysrhythmias.Supraventricular dysrhythmias with uncontrolled ventricular rate.Severe Valve Disease.
17 Intermediate Clinical Risk Predictors Mild angina (Canadian Class I - II).Prior MI by history or pathological Q waves.Compensated or prior CHF.Diabetes, especially IDDM.Renal Insufficiency (creatinine > 2mg%).
18 Minor Clinical Risk Predictors Advanced age.Abnormal ECG (LVH, LBBB, ST-T abnl).Rhythm other than sinus (e.g. a-fib).Low functional capacity (< 4 METs).Hx CVA.Uncontrolled HTN (>180 / >110).So, at some point someone is going to ask, “What’s Canadian Class Angina?”
19 Cardiac Functional Classification: Canadian Cardiovascular Society No angina with ordinary physical activity . Angina with strenuous exertion.II. Slight limitation of ordinary activity.III. Marked limitation of ordinary activity.IV. Inability to carry on any physical activity without discomfort. Angina may be present at rest.
20 Functional Capacity = Exercise Tolerance Major clinical risk predictors are sufficient alone to trigger further testing or intervention before pt posted for Sx.Intermediate and minor clinical risk predictors are subject to a second step:Evaluation of cardiovascular functional capacity, i.e., exercise tolerance.
21 Exercise ToleranceAngina or anginal equivalents (DOE, palpitations, fatigue)= Ischemic threshold.Point where metabolic demand > supplyMetabolic equivalent (MET): MET = resting O2 consumption(VO2)= 3.5mL/kg/minFunctional capacity in METs:Poor: < 4Mod: 4-7: > 4 is the “tipping point”.Good:Excellent: > 10.
22 Exercise Tolerance in METs 1 MET: Eat, dress, use the toilet.2 METs: Household ambulation.3 METs: Light housework Walk level ground 2-3 MPH.4 METs: Walk up one flight stairs. Walk level ground 4 MPH.4-10 METs: Run short distance. Scrub floors, move furniture. Moderate sports.>10 METs: Strenuous sports.
23 Surgical Risk Predictors High (> 5% Cardiac Death/MI). Emergent major operation, espec. in elderly, Aortic and other major vascular Sx Peripheral vascular,Prolonged procedure.Intermediate (< 5%) Carotid endarterectomy, Head & neck Intraperitoneal, Intrathoracic, Prostate, OrthoLow (< 1%) Endoscopic, Superficial, Cataract, Breast
28 Treatment for patients requiring PCI who need subsequent surgery
29 Procedure Details : CABG Time since procedure.Which arteries grafted & Type of conduit.Present medication.Symptoms benefits.Baseline ECG
30 Recommended stepwise approach How urgent noncardiac surgery is ?p/o risk stratification & assessment done.All these are Gr V cases.
31 Step 2 Has Pt undergone coronary revascularisation in past 5 yrs ? If yes & Pt has no s/s of cardiac problem – further detail cardiac testing not required.
32 Step 3If Pt has any coronary evaluation in past yrs – revealing no significant CAD ,if there is no aggravations of s/s –no further testing is needed.
33 Step 4 Does Pt have any major clinical predictors ? Delay noncardiac surgery until problem has identified & treated.
34 Step 5 If Pt have intermediate clinical predictors. Consider functional capacity & surgery specific risks.Decide accordingly weather further testing needed or not.
35 Step 6Pt with intermediate predictor & mod to excellent functional capacity can undergo intermediate Sx.Pt with 2 or more intermediate predictor & poor functional capacity OR mod functional capacity but high risk Sx – further testing & evaluation needed.
36 Step 7Noncardiac Sx safe in Pt with minor clinical predictor & mod to excellent functional capacity.Additional testing must for Pt with no clinical predictors but poor functional capacity & who are facing high risk Sx.
37 CASE 1 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTSTO BE POSTED FOR TURP
38 CASE 2 70 YR FEMALE ,HYPERTENSIVE & SEVERE OSTEOARTHRITIS. CABG DONE 2 YRS BACK ON ANTIPLATE, ANTI HT & STATINSTO BE POSTED FOR TKR
39 CASE 3 80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCE TO BE POSTED FOR CATARACT
48 Summary from ACC / AHAPerioperative evaluation and mgmt of high-risk cardiac patients for noncardiac surgery requires careful teamwork and communication between patient, surgeon, anesthesiologist, physian or cardiologist.Indications for cardiac testing and treatments are the same as in the non-operative setting, and should clearly affect patient management.Factors include the urgency of surgery, patient-specific risk factors, and surgery-specific considerations.
49 SummaryFor many patients, noncardiac surgery represents their first opportunity for assessment of short- and long-term cardiac risk. The consultant best serves the patient by making recommendations aimed at lowering the immediate perioperative cardiac risk, as well as assessing the need for postoperative risk stratification and interventions directed to modify cardic risk factors.Future research should be directed at determining the value of routine prophylactic medical therapy vs. more extensive diagnostic testing and interventions.
50 Proposed Approach to the Management of Patients with Previous PCI Who Require Noncardiac Surgery BalloonBare-metalDrug-elutingangioplastystentstent<365 days> days< days>365 daysTime since PCI<14 days>14 daysDelay for elective orProceed to theDelay for elective orProceed to thenonurgentsurgeryoperation roomnonurgentsurgeryoperating roomwith aspirinwith aspirinPCI, percutaneous coronary intervention
51 Proposed Treatment for Patients Requiring PCI Who Need Subsequent Surgery Acute MI, H risk ACS, orH risk cardiac anatomyStent & continue dual antiplatelet therapyBleeding risk of surgerylowNot lowTiming of surgery14-29 daysdays>365 daysBare-metalstentBalloonangioplastyDrug-elutingstent
52 Recommendations for Perioperative Beta-Blocker Therapy SurgeryNo Clinical Risk FactorsCAD or High Risk (1 or more clinical risk factors)Patients Currently Taking Beta BlockersVascularClass llb, Level of Evidence: BClass lla, Level of Evidence: BClass 1, Level of Evidence: CIntermediate risk…Low risk
53 Recommendations for Statin Therapy For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued.For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable.For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures,statins may be considered.IIIaIIbIIIB
58 Aims on evaluation Delay case for treatment of unstable symptoms. Modification of intraoperative or postoperative (e.g. ICU) monitoring.
59 Aims on evaluation Modification of perioperative medical therapy. Coronary or valve procedure before noncardiac surgery.Modification of location of care
60 Rest ECG: IndicationsClass I:Recent angina with intermed-high risk clinical predictors for intermed-high risk procedure.Class IIa: Asymptomatic diabetics.Class IIb: Prior coronary revascularization or cardiac hospital admission. Asymptomatic males > 45 or females > 55 with 2 CAD risk factors.Class III: Asymptomatic pts. For low-risk procedures
61 Rest ECG: Significant Findings Path.Q waves (> 0.4s wide, or > 25% of R, in 2 contiguous leads): Size and extent predict LVEF, long term mortality.Horizontal or downsloping ST depression > 0.5mm, LVH with strain pattern (ST depression + TWI in I, II, III, AVL or AVF, V5, V6), LBBB with CAD predict increased perioperative risk and long term mortality.Significant dysrhythmias: High-grade AV block, symptomatic ventricular dysrhythmias, supraventricular dysrhythmias with uncontrolled rate.
62 Echocardiogram: Indications Asymptomatic murmurs :Class I: Diastolic, continuous, holosystolic, mid & late systolic, III/VI murmurs.Class IIa: Murmur assoc with abnl cardiac palpation or auscultation, abnl ECG or CXR.Class III: II/VI midsystolic innocent murmur. Dx of “silent” AR or MR without murmur, to recommend endocarditis prophylaxis.
64 Stress Testing: ECG or Echo Normal rest ECG → ECG stress, Abnl ECG → EchoClass I: Dx of intermediate probability CAD, Prognosis of CAD or s/p ACS, Eval of med tx. Proof of ischemia before revascularization.Class IIa: Evaluate exercise tolerance in unreliable historian.Class IIb: Dx of high or low probability CAD, Resting ST depression < 1mm, On digoxin, LVH by ECG, Dx of restenosis in high-risk asymptomatic .Class III: Resting pre-excitation or ST depression > 1mm, Routine screening. 28
65 Recommendations for CAG in Preop Evaluation Class I: Patients With Suspected or Known CADEvidence for high risk of adverse outcome based on noninvasive test results.Angina unresponsive to adequate medical therapy.Unstable angina, particularly when facing intermediate-risk* or high-risk* noncardiac surgery.Equivocal noninvasive test results in patients at high clinical risk undergoing high-risk* surgery.Class IIaMultiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first).Moderate to large ischemia on noninvasive testing but without high-risk features and lower left ventricular ejection fraction.Nondiagnostic noninvasive test results in patients at intermediate clinical risk undergoing high-risk* noncardiac surgery.Urgent noncardiac surgery while convalescing from acute MI.
66 Recommendations for CAG in Preop Evaluation Class IIbPerioperative MI.Medically stabilized class III or IV angina and planned low-risk or minor* surgery.Class IIILow-risk* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).Mild stable angina with good left ventricular function and no high-risk noninvasive test results.Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., left ventricular ejection fraction less than 0.20), or refusal to consider revascularization.Candidate for liver, lung, or renal transplant less than 40 years old, as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.