Segment 1 Perioperative Risk Assessment

Need Advice – How Low is Low Dear Consult Sages ; I need your help and guidance to provide better service to my referring surgeons and their patients. I’ve attended your Consult Guys presentation at the annual meeting of the ACP for years. You have helped me abandon the use of the term “Cleared for surgery” and to instead really hone in on the patient’s perioperative risk as well as approaches to reduce that risk. I recently saw a patient who I assesed to be at Low cardiac risk.The surgeon wanted me to be more precise in risk determination. Here is the case and I’d appreciate your sage advice.

Case The patient is a 60 year old man for resection of a pulmonary nodule. Hx: hypertension, hypercholesterolemia Smokes 2ppd many years. Does not exercise but climbs 1 flight stairs daily without difficulty Bp 120/70 HR 60 Exam unremarkable. ECG: Normal sinus rhythm. Within normal limits By current guideline his risk is low but help me be more precise

ACC / AHA Guideline 2002 Philosophy “… the concept of “medical clearance” for surgery is short sighted. Goals of the preoperative consult: –Evaluate current medical status –Advise on disease management in the periop period. –At times recommend preventive measures for future. –Define your role in care (Co-manager?, subspecialty consultant?, etc)

“Clearance 2007”

ACC / AHA Guideline 2007 Anesthesia for the Consultant: Summary

October 23, new articles reviewed since 2002 guideline

1.Emergency surgery 2.Active cardiac conditions 3.Low risk surgery 4.Functional capacity 5.Clinical risk factors 6.Will testing – preop intervention change management ? Key Elements of Risk Stratification

Step 1 Need for emergency noncardiac surgery? Operating room Perioperative surveillance and postoperative risk stratification YES NO Step 2 Step 1

Step 2 Active cardiac conditions Consider operating room Evaluate and treat per ACC/AHA guidelines YES NO Step 3 Active Cardiac Conditions Unstable coronary syndromes Unstable coronary syndromes Unstable or severe angina Unstable or severe angina Recent MI Recent MI Decompensated HF Decompensated HF Significant arrhythmias Significant arrhythmias Severe valvular disease Severe valvular disease

Step 3 Low risk surgery Proceed with planned surgery YES NO Step 4 Low Risk Surgery Endoscopic procedures Endoscopic procedures Superficial procedures Superficial procedures Cataract surgery Cataract surgery Breast surgery Breast surgery

Step 4 Good functional capacity (METS > 4) without symptoms YES Proceed with planned surgery No or Unknown Step 5

Clinical Risk Factors History of ischemic heart disease History of ischemic heart disease History of compensated or prior HF History of compensated or prior HF History of cerebrovascular disease History of cerebrovascular disease Diabetes Diabetes Renal insufficiency Renal insufficiency

Step 5 Clinical Risk Factors (Isch HD, CHF hx, Cereb vasc dx, DM, Cr >2 3 or more Vascular surgery Consider testing if it will change management Intermediate Risk surgery Proceed with planned surgery with HR control or consider Noninvasive testing if it will change management 1 or 2 Vascular or intermediate risk surgery None Proceed with planned surgery

Revised Cardiac Risk Index Lee, Circulation patients, > 50 years old Major elective noncardiac surgery Six independent risk factors –High risk surgery AAA, vascular,thoracic, abdominal, ortho –History ischemic heart disease –History CHF –History cerebrovascular disease –Preoperative insulin use –Preoperative serum Cr > 2.0 mg/dl

= patients

National Surgical Quality Improvement Database >250 hospitals >200,000 pts/year Predictors of perioperative (up to 30 day) MI, Arrest ASA Class Functional status Age Serum Cr Type of surgery

Problems - Limitations MI (one or more of the following) –STEMI; new LBBB, new Q waves –Tn > 3 times top normal

Gupta vs ACC/AHA

= 5737 patients

= patients

State Farm Arena, Hidalgo Texas Seating 5500

Yankee Stadium, Bronx NY Seating 50,082

State Farm Arena, Hidalgo Texas

Problems - Limitations Outcomes dominated by 30 day death NSQIP does not record all cardiac complications –Pulmonary edema –Preop stress test –Echo –Arrhythmia history / occurrence –Aortic valve disease –Beta blocker use –Remote history of CAD (except prior PTCA or CABG) Most perioperative MI’s NSTEMI Revised Cardiac Risk Index still helpful in predicting cardiac complications

Guys’ Replies Gupta cardiac risk assessment – 30 day MI, Cardiac arrest MI: STEMI, Tn 3X elevation Not all cardiac arrests due to periop MI – NSQIP database does not include Pulmonary edema NSTEMI – Robust data base Data on procedure not previously known – Bedside calcualtion