Presentation on theme: "Update on Perioperative Medicine"— Presentation transcript:
1 Update on Perioperative Medicine Hugo Quinny Cheng, MDDivision of Hospital MedicineUniversity of California, San Francisco
2 Update on Perioperative Medicine Who needs a preoperative cardiac stress test?What are the benefits and risks of -blockers?Can statins prevent postoperative MI?When can patients with stents go to the OR?How should chronic anticoagulation be managed?Should arthroscopy patients get DVT prophylaxis?Is preoperative smoking cessation beneficial?
3 Preoperative Stress Testing A 65 y.o. man with a history of coronary artery disease and long-standing diabetes will undergo radical prostatectomy. He had a myocardial infarction in 2003, but now has no cardiac symptoms.Meds: lovastatin, atenolol, glyburide, benazepril, ASAExam: BP=115 / 70 HR=60; normal heart & lung examECG: NSR, LVH, otherwise normal
4 65 y. o. man s/f radical prostatectomy 65 y.o. man s/f radical prostatectomy. History of remote MI and long-standing diabetes. He is currently asymptomatic.Stress test prior to surgeryNo stress test is neededMake him carry a copy of Harrison’s up a flight of stairs
5 “New Standard” Cardiac Risk Index Predictors:Higher risk operation*Ischemic heart diseaseCongestive heart failureDiabetes requiring insulinCreatinine > 2 mg/dLStroke or TIAPredictors Complications**%%2 4%3 or more 9%* Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery** Defined as MI, pulmonary edema, cardiac arrest, complete heart blockLee, et al. Circulation, 1999
6 Control HR & go to OR (IIa) 2007 ACC/AHA GuidelineGood Functional Capacity?Go to ORyes≥ 3 predictors1 or 2 predictorsno predictors*no or ?Go to ORControl HR & go to OR (IIa)Vascular surgery?Consider stress test if results will change management (IIa)noyesor(IIb)* CAD, CHF, DM, CKD, CVA/TIA
7 770 vascular patients with 1 or 2 of following: Age > 70, MI, angina, CHF, DM, stroke / TIA, Cr > 1.8No stress test (n = 384)Stress test (n = 386)34 with extensive ischemia (9%); 12 had PCI or CABG352 with no or limited ischemia1.8%30-day CV Death or MI2.3%1.1%15%Poldermans et al. JACC, 2006
8 Extensive Ischemia Predicts High Risk 101 patients undergoing vascular surgery, all with ≥ 3 risk predictors and stress test showing extensive ischemiaPoldermans, et al. JACC, 2007
9 Reducing Risk with Medical Management A 75 y.o. woman will undergo hemicolectomy next week. She has a history of diabetes and a remote stroke, but no current cardiovascular symptoms.Start a -blockerStart a statinStart both -blocker & statinNo new medications needed
10 Cardiac Mortality & Nonfatal MI (%) patients undergoing vascular surgery - All had ischemic potential on dobutamine echo - Randomized to beta-blocker or standard care40Cardiac Mortality & Nonfatal MI (%)7142128102030Days after SurgeryBisoprololStandard CarePoldermans, et al. NEJM, 1999
11 POISE: PeriOperative Ischemia Evaluation 8351 patients with s/f major noncardiac surgeryCAD, CHF, CVA/TIA, CKD, DM, or high-risk surgeryNot already taking -blockerMetoprolol XL (immediately preop until 30 days postop)PlaceboPatients followed for 30 days after surgery:1° Endpoint: cardiac mortality & nonfatal arrest or MIPoise Study Group. Lancet, 2008
12 Poise Study Group. Lancet, 2008 POISE: ResultsMetoprolol XL:Reduced cardiac events (mostly nonfatal MI)butIncreased risk of stroke & total mortalityPoise Study Group. Lancet, 2008
13 POISE: Treatment Protocol 2-4 hOR0-6 h12 h1st dose Metoprolol 100 mg XL*2nd dose Metoprolol 100 mg XL*3rd & daily dose Metoprolol 200 mg XL*^* Study drug held for SBP < 100 or HR < 50^ Daily dose reduced to 100 mg if persistent bradycardia or hypotension
14 Poldermans et al. Presented at ESC, 2008 DECREASE III497 statin naive patients s/f vascular surgeryFluvastatin XL 80 mg/dayStarted > 1 month preopContinued > 1 mo postopPlaceboPatients followed for 30 days after surgery:Clinical Endpoint: cardiac death or nonfatal MIPoldermans et al. Presented at ESC, 2008
15 Poldermans et al. Presented at ESC, 2008 DECREASE III: ResultsFluvastatin XL:Reduced the composite outcome of cardiac death & nonfatal MINo difference in rates of LFT or CPK elevationPoldermans et al. Presented at ESC, 2008
16 DECREASE-IV1066 patients with estimated 1-6% risk of postoperatived cardiac complicationsRandomized to: BisoprololFluvastatin XLBisoprolol + FluvastatinDouble placeboDrugs started average 34 days prior to surgeryPrimary endpoint: 30-day CV death or nonfatal MI
17 DECREASE-IV ResultsBisoprolol-treated patients had fewer complicationsTrend towards benefit with statinsNo safety issues* P < .002**Dunkelgrun et al. Ann Surg, 2009
18 Perioperative -blockers in 2009 Strong indications:Already using -blocker to treat angina, HTN, arrhythmiaPatients with ischemic potential having vascular surgeryPossible indications:Patients with ischemic potential having high-risk nonvascular surgery (e.g., > 5 hours or > 500 cc blood loss)Multiple risk predictors* in vascular or other high-risk surgery(*Coronary disease, renal insufficiency, diabetes)Titrate dose up gradually (rarely start immediately preop)
19 Statins: 2007 ACC/AHA Guideline Definite indications (class I):Continue statin if already taking prior to surgeryProbable indications (class IIa):All vascular surgery patientsPossible indications (class IIb):At least one risk predictor* in any intermediate risk surgery*Coronary disease, renal insufficiency, diabetes, CVA/TIA
20 Delaying Surgery After Coronary Stent A woman falls and suffers a cervical spine fracture. One month ago, she received a sirulimus-eluting stent for stable angina. The neurosurgeon won’t operate unless aspirin and clopidogrel are held for her surgery. Non-operative management in a halo for next 2 months is offered as an alternative.What do you recommend to the patient & surgeon?
21 Patient with recently placed drug-eluting stent has a c-spine fracture Patient with recently placed drug-eluting stent has a c-spine fracture. Surgeon won’t operate unless aspirin & clopidogrel are held perioperatively.Hold ASA & clopidogrelHold ASA & clopidogrel but bridge with heparinKeep her in a halo for next 2 months
22 Does Heparin Bridge Prevent Stent-related Complications? Prospective study of 103 patients with coronary stent placed within 12 months having noncardiac surgeryAntiplatelet drugs continued or held < 3 daysAll patients received heparin drip or enoxaparin14% of patient stented within 35 days of surgery suffered cardiac death or MI, or needed re-do PCIConclusion: High rate of cardiac complications even when bridging anticoagulants usedVicenzi et al. Br J Anaesth, 2006
23 ACC/AHA Guidelines for PCI Avoid PCI unless patient has independent indicationsAvoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapyDelay elective surgery in patients with recent PCIBalloon angioplasty: weeksBare metal stent: 4 weeksDrug eluting stent: 12 monthsIf clopidogrel must be stopped, try to continue ASANo evidence for bridging with other agents
24 Managing Perioperative Anticoagulation Two patients who take coumadin underwent THA. One has atrial fibrillation due to HTN. The other has a mechanical AVR. Neither has a history of stroke or any other comorbidity.Heparin bridge for AVR onlyHeparin bridge for AF onlyHeparin bridge for bothHeparin bridge for neither
25 Two patients who take coumadin underwent THA. One has AF due to HTN Two patients who take coumadin underwent THA. One has AF due to HTN. The other has a mechanical AVR. Neither has a history of stroke any other comorbidity.Heparin bridge for AVR onlyHeparin bridge for AF onlyHeparin bridge for bothHeparin bridge for neither
26 Thromboembolic Risks with Non-rheumatic Atrial Fibrillation CHADS-2 Score:1 point for CHF, HTN, Age > 75, DM2 points for Stroke/TIAScore 0 - 2: < 5% annual stroke risk Score 3 - 4: 5-10%Score 5 - 6: > 10%Annual Stroke RiskAlbers et al. Chest, 2001
27 Thromboembolic Risks with Mechanical Valves Annual IncidenceCannegieter, et al. Circulation, 1994
28 Effect of Mechanical Valve Location & Design on Thromboembolic Risk Aortic RR = 1.0Mitral RR = 1.8Valve Design:Caged Ball RR = 1.0Tilting Disk RR = 0.7Bi-leaflet RR = 0.6Cannegieter, et al. Circulation, 1994
29 Perioperative Anticoagulation: 2008 ACCP Guidelines Atrial FibrillationMechanical ValveRecommendCHADS2 = 5-6, recent CVA, or rheumatic AFAny MVR; older (caged-ball or tilting disc) AVR; recent CVAFull dose heparin bridgeCHADS2 = 3-4Bileaflet AVR plus one additional stroke risk factorFull or low dose heparinCHADS2 = 0-2Bileaflet AVR without AF or other stroke risk factorLow dose or no heparinFull dose = therapeutic dose of heparin IV or LMWH SCLow dose = DVT prophylaxis dose of heparin SC or LMWH SC
30 DVT Prophylaxis Which DVTs matter? Symptomatic versus asymptomaticProximal versus distal2008 American College of Chest Physicians:Weights DVT risk greater than bleeding riskTreats asymptomatic DVT as important
31 RCT of LMWH in Knee Arthroscopy Background: ACCP guidelines recommend LMWH if additional risk factors for DVT are present.Study Design: ~1300 patients randomized to compression hose or LMWH x 7 days after knee arthroscopy. All patients underwent screening ultrasound.Results: Combined incidence of death or any clot reduced in patients receiving LMWH (0.9% vs 3.2%). Almost all clots were either asymptomatic or distal. Non-significant trend for increased bleeding.Conclusions: LMWH superior to compression hose after knee arthroscopy (NNT = 43). Impact on symptomatic DVT small.Camporese et al. Ann Intern Med, 2008.
32 Preoperative Smoking Cessation A middle-aged man will undergo repair of a ventral hernia in 1 month. He currently smokes one pack of cigarettes per day. How do you counsel him?Quit smoking now to prevent postoperative complications.It’s always good to quit, but it’s too late to affect your risk of complications.Don’t stop smoking! You will actually increase your surgical risk by quitting!
33 Effect of Smoking Cessation Time since quittingp < .001Complication Rate (%)Warner, Anesthesiology 1984
34 Preoperative Smoking Cessation Counseling RCTs of Preoperative Smoking Cessation Counseling:120 patients undergoing arthroplasty in 6-8 weeks117 patients undergoing various operations in 4 weeks60 patients undergoing colorectal resection in 2-3 weeksIntervention: Smoking cessation counseling at weekly meetings (or by telephone) & offer free nicotine replacement productsOutcomes: Postop complications, especically wound related (e.g., dehiscence, infection, hematoma)
35 Smoking Cessation 6-8 Weeks Before TKA or THA Moller et al. Lancet, 2002
36 Smoking Cessation 4 Weeks Before Surgery Lindstrom et al. Ann Surg, 2008.
37 Smoking Cessation 2-3 Weeks Before Colorectal Surgery Sorensen, et al. Colorectal Dis, 2003
38 Take Home Points Reserve stress testing for higher risk patients -- Limited ischemia ok, but extensive ischemia = high riskStart -blocker cautiously & only in high risk patientsDelay surgery in patients with recent stent placementIndividualize thrombotic risk assessment when managing perioperative anticoagulationConsider LMWH for knee arthroplasty patientsSmoking cessation for ≥ 4 weeks may be beneficial