Pre-operative Cardiovascular Evaluation: Guidelines and More Eric A. Brody MD, FACC Medical Director, NA Cardiology and Medical Services Associate Professor of Clinical Medicine University of Arizona Medical Center

Objectives Review Algorithm for Pre-op risk assessment for current guidelines Define the roles of the cardiac/medical consultant for the non-cardiac surgery patient Discuss “clearance” Review the 10 commandments of the cardiac/medical consultant

Mechanisms of Perioperative MI Unique postoperative conditions lend themselves to AMI –Volume loss/Fluid Shifts –Anemia –Anxiety/Pain –Tachycardia –Temperature fluctuations –Coagulation cascade MVO 2 Shear Stresses Excess Catechols Platelet Activation

What Causes Perioperative MI? Surgery Patient Volume Shifts Anemia Medication withdrawal Temperature fluctuation Acidosis Underlying CAD Hypertension Tachycardia Anxiety/Pain Hemostasis Myocardial Infarction

Treatment of Peri-operative MI Medical Therapy Beta Blockers Ca+ Channel. Blockers ACE inhibitors/ARB Antithrombotic Therapy UFH/LMWH Anti-thrombins Thrombolysis Interventional Therapy PCI/Stent Antiplatelet Therapy ASA GP2b3a Thienopyridines

Role of the Medical Consultant Identify co-morbidities which may complicate surgery Airway/anaesthesia issues Functional status of the patient Clarify pre-op medications Peri-procedural cardiac risk

What is “Cleared”? Questions to answer. Patients condition is optimized prior to surgery?? Benefits outweigh risk of surgery?? OK to proceed?? Medical Legal considerations removed???

What is “Cleared”? My preference- one of 2 options –“Patient is considered ______________ (low, moderate or high) risk for peri-op cardiovascular complications based on current ACC/AHA guidelines” -” My recommendations for perioperative care include…..” -”Patient requires additional testing to better clarify perioperative cardiac risk.”

ACC/AHA Perioperative Guidelines Updates: October 2007 Last revision: 2002 Significant changes to previous guidelines Dramatic change in perioperative evaluation algorithm. JACC 2007: vol. 50 (17)

2007 Update

Perioperative Guidelines Algorithm Need for Emergency non- cardiac Surgery? Step 1 Operating Room Perioperative Surveillance and postop. Risk stratification. Risk Factor management Yes No Step 2

Perioperative Guidelines Algorithm Active Cardiac Conditions Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Yes

Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease Unstable or Severe Angina (class III or IV) or recent MI >7 days but < one month

Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Significant Arrhythmias High grade AV block Mobitz II AVB Third degree AVB Symptomatic Vent. Arrhythmias/Bradycardia SVT/Afib with uncontrolled rate (>100/min) Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease

Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Severe Valvular Heart disease Severe Aortic Stenosis Critical Mitral Stenosis Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease

Perioperative Guidelines Algorithm Active Cardiac Conditions Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Yes No Step 3

Perioperative Guidelines Algorithm Low Risk non- cardiac Surgery? Step 3 Proceed with planned surgery Yes Endoscopic Superficial Breast Most ambulatory surgeries Cataracts/ocular Low Risk Surgeries

Perioperative Guidelines Algorithm Low Risk non-cardiac Surgery? Step 3 Proceed with planned surgery No Step 4

Perioperative Guidelines Algorithm Good Functional Capacity without symptoms (>4 mets) Step 4 Proceed with planned surgery Yes

Assessing Functional Capacity 1 Met 4 mets ADL’s Eat, Dress or Toilet Walk Indoors Walk 1-2 blocks, level ground Light House Work

Assessing Functional Capacity 4 mets >10 mets Climb 1 flight stairs or walk uphill Walk 4 mph Run a short distance Heavy Housework Strenuous Sports Moderate sports

Assessing Functional Capacity

Another Way to look at This!! No Clinical Risk Factors and Low or intermediate risk surgeries with good functional capacity may proceed directly to the OR.

Perioperative Guidelines Algorithm Good Functional Capacity without symptoms (>4 mets) Step 4 Proceed with planned surgery Yes No or Unknown Step 5

Clinical Risk Factors Ischemic Heart Disease Compensated or Prior CHF DM (insulin requiring) Renal Insufficiency (creat. >2.0) Cerebrovascular Disease Step 5 Lee et al. Circulation. 1999;100: )

Revised Cardiac Risk Index Procedure Type Percent AAA Other Vascular Thoracic Abdominal Orthopedic Other

Perioperative Guidelines Algorithm No Clinical Risk Factors Step 5 Proceed with planned surgery

Perioperative Guidelines Algorithm 1 or 2 Clinical Risk Factors Step 5 Intermediate Risk Surgery Vascular Surgery Proceed to OR with HR control or Consider Non invasive testing Class IIa, LOE B Class IIb, LOE B

Cardiac Risk Stratification: High Risk Procedures Reported Cardiac Risk often >5% –Emergent major operations, particularly in elderly patients –Aortic and other major vascular –Peripheral vascular –Anticipated prolonged procedures with large fluid shifts or blood loss

Cardiac Risk Stratification: Intermediate Risk Procedures Reported cardiac risk generally <5% –Carotid endarterectomy –Major head and neck, especially for CA –Intraperitoneal and intrathoracic –Orthopedic, especially in elderly –Radical prostatectomy

Perioperative Guidelines Algorithm 3 or more Clinical Risk Factors Step 5 Intermediate Risk Surgery Vascular Surgery Proceed to OR with HR control or consider Non invasive testing Consider Non- invasive testing Class IIa, LOE B

TYPE of Surgery

On line tool to calculate patient and procedure specific risk for planned surgery

ACC/AHA Perioperative Guidelines Updates: October 2007 Miscellaneous

ACC/AHA Perioperative Guidelines Updates: October 2007 Who Needs an ECG?? Undergoing Vascular surgery (one or more clinical risk factors) Class I Undergoing Vascular Surgery (no risk factors) IIa Intermediate risk surgery with established CVD (CAD, PVD, Cerebrovascular disease) Class I Intermediate Risk surgery with one or more clinical risk factors

ACC/AHA Perioperative Guidelines Updates: October 2007 Who Needs an ECG?? –CLASS III- ECG not needed in asymptomatic patients undergoing low risk surgical procedures.

Recommendations for Statin Therapy ACC/AHA Perioperative Guidelines Updates: October 2007 Class I- (LOE B) –Patients taking statins should be continued on this therapy at time of non-cardiac surgery

Best Treatment of Perioperative MI

Conclusions: Ways to Avoid Cardiac Complications Know the Patient’s History –Prior MI or known CAD –Prior CHF and LVEF –Renal Failure/ baseline Creatinine –History of significant Valvular heart disease Stenosis > regurgitation

Conclusions: Ways to Avoid Cardiac Complications Know what your surgeons and anesthesiologists did –Speak with them directly to coordinate perioperative care. –Blood loss/serial hematocrits –Fluid resuscitation –Check the post op orders yourself

Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 Our own insecurities –Long history of “clearance” performed by cardiologists Changing the Culture –Surgeons –Anesthesiologists

Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 Getting the surgeons to listen to peri-operative recommendations –“ You lost me at ‘Cleared’…..” –Importance of continuing statin therapy and beta blocker therapy in those already taking these medications

Conclusions: Ways to Avoid Cardiac Complications Know the patients’ medications –Continue Beta Blockers if on these preoperatively –Prophylactic beta blockade is not indicated in all patients

Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 The “Business” of stress testing and preoperative evalutation Who’s going to pay?

Preoperative Evaluation Keep it simple!!