Presentation on theme: "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery Dr. Sonia Anand McMaster University."— Presentation transcript:
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery Dr. Sonia Anand McMaster University
Epidemiology of Noncardiac Surgery Nearly 30 million patients have noncardiac surgical procedures annually in the United States Approximately 25% of these are major intra-abdominal, thoracic, vascular and orthopedic procedures
Pre-Op Risk Assessment =
Overview Guidelines- reflect evidence synthesis and consensus Evidence as of October 2007 Important Decision points: –Urgent vs Elective Surgery –High risk surgery vs intermediate vs low –Active Cardiac Condition vs non-active
The Search For High Risk
Methods for Assessing Risk Pre-Operatively Patient Based –High risk conditions –Functional Capacity Surgery Based –Vascular Surgery –Emergency surgery Intervention Based –Medications –Revascularization
Six Independent predictors of cardiac risk 1)ischemic heart disease 2)congestive heart failure 3) cerebrovascular disease 4) high risk surgery (AAA, orthopedic sx) 5) pre-operative insulin tx for diabetes 6) preoperative creatinine for creat > 2 mg/dL Lee et al
Active/Major Cardiac Conditions Unstable Coronary Conditions Decompensated CHF Significant arrhythmias (i.e. 3 HB, new Vtach) Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm )???????
Non-Active Cardiac Factors Intermediate Risk Hx of CHD History of prior CHF Hx of stroke Diabetes Renal insufficiency Minor Risk* Age > 70 Abnormal ECG Nonsinus rhythm Uncontrolled systolic BP * Not associated with cardiac risk
Functional Capacity Functional status has shown to be a reliable periop and long-term predictor of cardiac events Functional status determined based on ability to do ADLs MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest Periop risk is increased if person cannot > 4 METS
1 MET 4 MET 10 MET Eat, dress DO light house work i.e. Washing dishes Climb a flight of stairs Run a short distances Moderate recreational golf, dancing, baseball Strenuous sports swimming, basketball
The Trump Card: Functional Capacity Perioperative cardiac risk is increased in patients unable to exercise 4 METs Functional capacity can be estimated in the office –Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs –Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs –Swimming and singles tennis exceeds 10 METs
Surgery Risk Type TypeCardiac riskexamples High> 5%Aortic, peripheral vasc sx Intermediate risk1-5%Intraperitoneal Intrathoracic Carotid End Head and neck Orthopedic Sx Prostate Sx Low<1%Endoscopic procedures Superficial Cataract Sx Breast Sx Ambulatory Sx
Surgery-Specific Risk: High Risk* Major emergency surgery Vascular surgery including: aortic surgery, infra-inguinal bypass Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5%
Stepwise Approach Step 1: Determine urgency of surgery Step 2: Active cardiac condition?-test Step 3: Undergoing low-risk surgery? < 1%* Step 4: Good functional capacity? * Combined morbidity and mortality < 1% even in high risk patients
The Catheterization Questions to Ask Yourself Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now? Am I willing to send the patient to CABG? Am I doing this just to know the anatomy?
Is pre-op coronary revasc advantageous? If high risk surgery and patient has active cardiac issue Functional test and perfusion Imaging and if L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op CARP – if none of these – no advantage of revasc
Functional Test Exercise test with ECG If abnormal ECG, Rx perfusion imaging –Adenosine –Dipyridamole –Dobutamine –Dobutamine stress echo
Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry No CAD CAD: Medical Rx CAD: CABG (n=314) Periop MI Death *** * * Eagle et al. Circulation, 1997
Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes Post-Op MI30 Day Mortality 2.7 Year Mortality RevascularizationConservative Mgmt 510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized to Revasc (PCI 59%, CABG 41%) or conservative management. McFalls, E. CARP Trial;AHA 2004
Get Out of Jail Free Cards If the patient has been revascularized within 5 years (stent or CABG) and has no change in symptoms and no active major issues, they do not need any further testing or stratification. If the patient has had a coronary evaluation within 2 years and no change in symptoms, they are at acceptable risk for surgery.
High Risk Patients & Revascularization Pre-Op 101 pts with extensive ischemia randomly assigned to pre-op revascularization or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up. % Days since surgery Months since surgery Poldermans, D. JACC 2007; 49(17): VD in 12 (24%), 3VD in 33 (67%), Left main in 4 (8%).
The Effect of Percutaneous Revascularization Above Optimal Medical Therapy: COURAGE Years Survival Free of Death/MI 2287 Pts w/myocardial ischemia and CAD randomized to PCI with optimal medical therapy (PCI group) and 1138 to medical therapy alone. Boden, W. NEJM 2007; 356:1503 Medical therapy PCI + Medical therapy
STENTS If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after If received DES.... –1) postpone sx until > 12 months, –2) do sx on both asa+clop – 3) do sx on single ap tx
Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended
Medical tx 1) beta blockers-if on keep them if not.... 2) Statins continue, ? Start -need randomized trials
Statins Improve Survival After Vascular Surgery Durazzo, AES. JVS 2004:39(5): pts randomized 20 mg atorvastatin or placebo for 45 days. Vascular surgery ~ 30 days after randomization. F/U 6 months Primary Endpoint CV death + NFMI+ Ischemic stroke+ Unstable Angina
Statins Improve Long-Term Survival After Vascular Surgery Time (months) Survival Statin (+) Statin (-) Ward, RP. Int J Card 2005; 104(3):264 Retrospective review of 446 consecutive infrainguinal bypass surgeries p < 0.004
Statin Intensity & Operative Outcomes 359 vascular surgery pts, statin dose were recorded. Myocardial ischemia & HR variability were assessed by 72-h 12-lead ECG. TNT measured on day 1, 3, 7, and discharge. Cardiac events included cardiac death or NFMI at 30 days and follow-up mean 2.3 years Statin therapy % of Max Recommended
Other Issues DVT/PE prophylaxis Anesthetic technique-volatile agent with general anesthetic - troponin LV function >> propofol, midazolam, balanced anesthesia (Grade B) No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes Routine troponin monitoring not recommended
Surveillance for Perioperative Myocardial Infarction ECGs –All intermediate and high-risk patients should get a post-op ECG. –As need for signs or symptoms of ischemia Troponin / CK –In patients with signs or symptoms of ischemia –Do not do screening biomarkers
High Risk Features Severe obstructive or restrictive pulmonary disease Diabetes Renal impairment Anemia, polycythemia, thrombocytosis
PCI pre-op ST-elevation MI Unstable angina Non ST elevation MI
2007 ACC/AHA Perioperative Guidelines
Take Home Messages Unstable syndromes require management prior to surgery. Look for –Unstable angina –Signs of heart failure –Stenotic valve lesions –Ventricular arrhythmias Functional tolerance is the best single predictor of outcome Be very specific in your history (one step at at time, regular or slow pace, etc) If patient on beta blockers & statins continue them, more trials to mandate them PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.