1. Perioperative Cardiovascular Evaluation SooJoong Kim, MD, PhD. Department of Cardiology, Internal Medicine, Kyunghee University Medical Center

2. 30 million pt. with surgery : 30 million pt. with surgery : CAD or risk factors in 1/3 CAD or risk factors in 1/3 One million op. complicated by adverse C-V events One million op. complicated by adverse C-V events high risk populations(vascular op.) : periop. MI in 34% high risk populations(vascular op.) : periop. MI in 34% ( mortality rate 25%) Perioperative cardiac evaluation Perioperative cardiac evaluation What is the risk of cardiac complications during & after surgery? What is the risk of cardiac complications during & after surgery? How can that risk be reduced or eliminated ? How can that risk be reduced or eliminated ?

3. Role of Medical Consultant Preoperative assessment Preoperative assessment Identification of modifiable risk factors Identification of modifiable risk factors Optimization of the condition of pt. for op. Optimization of the condition of pt. for op. Prompt, Precise, & Thorough Prompt, Precise, & Thorough Written recommendation – overlooked Written recommendation – overlooked Communication & timely follow-up Communication & timely follow-up

4. Accurate Clinical criteria : significant predictors of adverse cardiac outcomes Clinical criteria : significant predictors of adverse cardiac outcomesEfficient Each clinical variable adds independent & useful information to overall risk assessment Each clinical variable adds independent & useful information to overall risk assessmentTimely So as not to unnecessary delays in decision to perform or postpone the planned surgery So as not to unnecessary delays in decision to perform or postpone the planned surgery  Accurate stratification of patients into lower and higher risk groups

5. Risk evaluation Risk evaluation Are there interventions to reduce risk ? Are there interventions to reduce risk ? Do these interventions expose the patient to potential harm or cause unnecessary delays in surgery ? Do these interventions expose the patient to potential harm or cause unnecessary delays in surgery ? Does the benefit of the intervention justify the risks ? Does the benefit of the intervention justify the risks ? Availability of effective interventions Availability of effective interventions

6. Ix. for further cardiac testing & tx. : Same as in non-op. setting timing is dependent on the urgency of noncardiac surgery the patient’s risk factors Specific surgical considerations. Preoperative testing should be limited to circumstances in which the results will affect treatment and outcomes.

7. Perioperative evaluation Patient-specific Patient-specific Procedure-oriented Procedure-oriented Time-focused Time-focused

8. Cardiovascular risk assessment Preop. evaluation : focus on C-V system Preop. evaluation : focus on C-V system Cardiac events : primary cause of death after op. Cardiac events : primary cause of death after op. Thorough examination for occult CAD Thorough examination for occult CAD Optimization of existing CAD Optimization of existing CAD Op. performed safely, even in significant cardiac disease Op. performed safely, even in significant cardiac disease

9. Significant postop. cardiac events Significant postop. cardiac events Unstable angina Unstable angina MI MI Pulmonary edema Pulmonary edema Serious arrhythmias (VT, VF) Serious arrhythmias (VT, VF) Cardiovascular risk assessment

10. Goldman & colleagues Goldman & colleagues Nine risk factor index (Hx, P/Ex, ECG, activity level, Lab, type of op.) Nine risk factor index (Hx, P/Ex, ECG, activity level, Lab, type of op.) Mangano & Goldman Mangano & Goldman Five independent preop. clinical predictors of postop. myocardial ischemia Five independent preop. clinical predictors of postop. myocardial ischemia HTN, ECG-LVH, DM, CAD, digoxin use HTN, ECG-LVH, DM, CAD, digoxin use Jeffrey & colleagues / Zeldin Jeffrey & colleagues / Zeldin Underestimation of risk of C-V events in major abdominal aortic op. Underestimation of risk of C-V events in major abdominal aortic op. Overestimation of cardiac Cx. in high risk pt. Overestimation of cardiac Cx. in high risk pt. Cardiovascular risk assessment

11. Six independent predictors of cardiac complications Six independent predictors of cardiac complications high-risk surgery (procedures with a 5% or higher risk of cardiac complications, such as vascular and prolonged intraperitoneal or intrathoracic operations) high-risk surgery (procedures with a 5% or higher risk of cardiac complications, such as vascular and prolonged intraperitoneal or intrathoracic operations) history of ischemic heart disease history of ischemic heart disease history of congestive heart failure history of congestive heart failure history of cerebrovascular disease history of cerebrovascular disease preoperative treatment with insulin preoperative treatment with insulin preoperative serum creatinine > 2.0 mg/dL. preoperative serum creatinine > 2.0 mg/dL. rates of major cardiac complications rates of major cardiac complications 0, 1, 2, or 3+ criteria  0.5%, 1.3%, 4%, and 9%, 0, 1, 2, or 3+ criteria  0.5%, 1.3%, 4%, and 9%, Cardiovascular risk assessment Lee TH, et al. Circulation 1999;100:1043 – 1049.

12. Cardiovascular risk assessment 1. Clinical markers or predictors (pt.-specific) Angina, previous MI, CHF, DM major, intermediate, minor groups 2. Level of functional capacity 4 MET poor functional capacity : a/w cardiac event after op. 3. Surgery specific risks ACC/AHA Consensus

13. Major clinical predictors 1. 1. Unstable coronary syndromes Acute (< 7D) or recent(7~30) myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina (Canadian class III or IV) 2. 2. Decompensated heart failure 3. 3. Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate 4. 4. Severe valvular disease Cardiovascular risk assessment Clinical predictors of periop. C-V risk

14. Intermediate clinical predictors Intermediate clinical predictors 1. 1. Mild angina pectoris (Canadian class I or II) 2. 2. Previous myocardial infarction by history or pathological Q waves (>1M) 3. 3. Compensated or prior heart failure 4. 4. Diabetes mellitus (particularly insulin-dependent) 5. 5. Renal insufficiency (> 2mg/dL) Cardiovascular risk assessment Clinical predictors of periop. C-V risk

15. Minor clinical predictors Minor clinical predictors 1. 1. Advanced age 2. 2. Abnormal ECG (LVH, LBBB, ST-T abnormalities) 3. 3. Rhythm other than sinus (e.g., atrial fibrillation) 4. 4. Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) 5. 5. History of stroke 6. 6. Uncontrolled systemic hypertension Cardiovascular risk assessment Clinical predictors of periop. C-V risk

16. Cardiovascular risk assessment 4 MET 4 MET Level of functional capacity Perioperative cardiac and long-term risks increased in patients < 4-MET

17. Surgery specific risks Cardiovascular risk assessment Cardiac risk > 5% Cardiac risk < 1% Cardiac risk 1~5%

18. Surgery specific risks Cardiovascular risk assessment

19. ACC/AHA Guidelines (<2 yr)

20. ACC/AHA Guidelines

23. Hx. taking & physical examination Hx. taking & physical examination Lab. & specialized testing Lab. & specialized testing ECG : arrhythmia, high-degree AVB, LVH ECG : arrhythmia, high-degree AVB, LVH  a/w adverse outcome Recent MI (<1M) Recent MI (<1M) Unstable angina Unstable angina CHF or S3  aggressive preoperative medical tx. CHF or S3  aggressive preoperative medical tx. (pul. edema risk : x5) Severe valvular disease (AS) Severe valvular disease (AS)  stroke, MI, arrhythmia, acute HF Preoperative evaluation

24. Duration & severity of DM & HTN, stroke Hx.  adverse perioperative cardiac events Duration & severity of DM & HTN, stroke Hx.  adverse perioperative cardiac events DBP > 100 mmHg  should be controlled before op. DBP > 100 mmHg  should be controlled before op. Advanced age : indirect marker of surgical cardiac risk Advanced age : indirect marker of surgical cardiac risk Preoperative evaluation

25. Ambulatory ECG : assess of silent ischemia Ambulatory ECG : assess of silent ischemia : assess of arrhythmia : assess of arrhythmia Echocardiography : assess of LV resting fx. Echocardiography : assess of LV resting fx. Performed when HF suspected Performed when HF suspected : assessment of valvular heart dis. : assessment of valvular heart dis. Exercise or pharmacologic stress testing with imaging Exercise or pharmacologic stress testing with imaging : detection of occult CAD : estimate of functional capacity Expensive, subjective(interpreter-dependent) Expensive, subjective(interpreter-dependent) Stress ECG with imaging  reliable tool for CAD & functional capacity evaluation Stress ECG with imaging  reliable tool for CAD & functional capacity evaluation Role of specialized testing

26. Stress testing Stress testing False (+) : female, >50 yrs & in LVH cases False (+) : female, >50 yrs & in LVH cases False (-) : taking BB or CCB False (-) : taking BB or CCB 201-Tl : specific & good (-) predictive value 201-Tl : specific & good (-) predictive value Coronary angiography Coronary angiography Reserved for pt at high risk & should be done only if angioplasty or CABG is considered Reserved for pt at high risk & should be done only if angioplasty or CABG is considered Role of specialized testing

27. Perioperative management HTN HTN Valvular heart disease Valvular heart disease Myocardial disease Myocardial disease Arrhythmia Arrhythmia ICD ICD

28. Medical tx Medical tx Beta blocker Beta blocker Alpha agonist Alpha agonist Calcium antagonist Calcium antagonist Nitrate Nitrate Statin Statin CABG or PCI CABG or PCI

29. Myocardial ischemia Myocardial ischemia Arrhythmia Arrhythmia CHF CHF Postoperative management

30. Myocardial ischemia Myocardial ischemia Silent, non-Q infarction Silent, non-Q infarction Peak incidence at POD #2~ #3 Peak incidence at POD #2~ #3 ECG at baseline, postop(immediate), POD #3 in high risk pts. ECG at baseline, postop(immediate), POD #3 in high risk pts. Cardiac marker if clinically suspected or abnormal ECG Cardiac marker if clinically suspected or abnormal ECG Postoperative management

31. Postop. Arrhythmia Postop. Arrhythmia Usually transitory Usually transitory VPC : tx only if sustained or hemodynamically significant VPC : tx only if sustained or hemodynamically significant Postoperative management

32. CHF CHF Excessive vol. administration, HTN, exacerbation of preexisting ventricular dysfunction Excessive vol. administration, HTN, exacerbation of preexisting ventricular dysfunction Unexplained pul. edema  suspicion of silent MI Unexplained pul. edema  suspicion of silent MI Postoperative management

33. Cardiovascular drugs Aspirin Discontinue 7 days before operation; restart 2 days after operation Beta blockers Continue, to prevent withdrawal; useful for postoperative adrenergic hyperactivity Clonidine HCl Continue, to avoid rebound hypertension Warfarin sodium, except when used for artificial valves Discontinue 3-5 days before operation; restart when patient resumes oral intake Warfarin therapy for prosthetic valves Thrombosis risk is higher in patient with mitral valve than with aortic valve. ACCP gives three options for perioperative anticoagulation: · Stop warfarin several days preoperatively and proceed to surgery once INR is at a safe level for operation; restart shortly after operation · Decrease dosing to keep INR low during procedure · Stop warfarin and start heparin preoperatively; stop heparin 2-4 hr preoperatively; proceed to surgery once INR is safe for operation; restart heparin postoperatively when safe; restart warfarin postoperatively when safe

34. Postoperative management Prophylaxis for infective endocarditisFor dental, respiratory, gastrointestinal, or genitourinary tract procedures or other situations when bacteremia is a risk Pacemaker management (consult technical consultant of pacemaker manufacturer, if needed) Temporarily program pacemaker to fixed-rate mode to avoid temporary pacemaker inhibition by electrocautery-induced electromagnetic interference; limit length and frequency of use of electrocautery, particularly near pacemaker site Safeguard with automatic implantable cardioverter-defibrillator Best to switch off temporarily during surgery; electrocautery may interfere with function Drug use in patient with transplanted heart (due to denervation, resting heart rate is increased but response to stress is blunted) Supersensitivity to adenosine (Adenocard), normally responds to beta blockers and calcium channel blockers, does not respond to atropine sulfate or digoxin (Lanoxicaps, Lanoxin)