1. Epidemiology of Noncardiac Surgery Dr. Mohammed Naser

2. Epidemiology of Noncardiac Surgery Cardiac patient undergoing non cardiac surgery can be at risk for major peri operative complication. Perioperative risk…increased sym+,pro inflammatory state hypercoagubility and ocasional post opetative hypoxia

4. Pre-Op Risk Assessment =

5. Overview Important Decision points: –Urgent vs Elective Surgery –High risk surgery vs intermediate vs low -Active Cardiac Condition vs non-active Functional capacity on basis of pt ablility To perform certain activities

6. The Search For High Risk

7. Methods for Assessing Risk Pre-Operatively Is the surgery emergency PROCEED and manage post operatively according to AHA& ACC guidelines

8. If the surgery emergency..??

9. Active/Major Cardiac Conditions Unstable Coronary Conditions Decompensated CHF Significant arrhythmias (i.e. 3 ⁰ HB, new Vtach) Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm ₂ )???????

10. 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

11. 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

12. Functional capacity

13. Functional Capacity Functional status has shown to be a reliable periop and long-term predictor of cardiac events MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest Periop risk is increased if person cannot > 4 METS

14. 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

15. 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

16. 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

17. 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%

18. 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

19. 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?

20. 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

21. 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

22. 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

23. Medical tx 1) beta blockers-if on keep them if not.... 2) Statins continue, ? Start -need randomized trials

24. 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

25. 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

26. High Risk Features Severe obstructive or restrictive pulmonary disease Diabetes Renal impairment Anemia, polycythemia, thrombocytosis

27. PCI pre-op ST-elevation MI Unstable angina Non ST elevation MI

28. 2007 ACC/AHA Perioperative Guidelines

29. Take Home Messages

30. 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.