1. CCS 2016 Guideline: Perioperative Cardiac Risk Assessment and Management for Patients Undergoing Non-Cardiac Surgery
October 2016

2. Disclosures
All CCS guideline and position statement panel conflicts of interest can be found on the CCS website (

3. Scope of Problem
Worldwide >200,000,000 major noncardiac surgical procedures annually
1:20 suffer myocardial injury/infarction or cardiac arrest/death within 30 days
Perioperative cardiac complications account for 1/3 of perioperative deaths
Speaker: Joel Parlow

4. Scope of Problem
CCS and Canadian experts felt new guidelines needed for perioperative assessment and management in noncardiac surgery
Speaker: Joel Parlow

5. Primary Panel Co-chairs: PJ Devereaux (Cardiology)
Joel Parlow (Anesthesiology)
Primary Panel:
Emmanuelle Duceppe (GIM)
Paul MacDonald (Cardiology)
Kristen Lyons (Cardiology)
Michael McMullen (Anesthesiology)
Sadeesh Srinathan (Thoracic Surgery)
Michelle Graham (Cardiology)
Vikas Tandon (Cardiology)
Kim Styles (Cardiology)
Amal Bessissow (GIM)
Dan Sessler (Anesthesiology)
Greg Bryson (Anesthesiology)
Speaker: Joel Parlow

6. Secondary Panel Multidisciplinary- 22 members
8 general internists
4 cardiologists
6 anesthesiologists
1 general surgeon
1 vascular surgeon
1 orthopedic surgeon
1 academic nurse
Reviewed and provided feedback on draft guidelines
Speaker: Joel Parlow

7. Final Review / Approval
CCS Guidelines Committee
CCS Council
Editor of Canadian Journal of Cardiology
Speaker: Joel Parlow

8. Scope of Guidelines Four themes:
Preoperative cardiac risk assessment
Perioperative cardiac risk modification
Monitoring for perioperative cardiac events
Management of perioperative cardiac complications
Significant change from previous guidelines…
Shift of emphasis from preoperative noninvasive cardiac testing to increased use of biomarkers and postoperative monitoring of patients at risk and management of cardiac complication
Speaker: Joel Parlow

9. Scope of Guidelines Population:
adult patients undergoing major noncardiac surgery
defined as requiring at least overnight stay in hospital
Only cardiovascular outcomes considered
Focus on highest quality evidence in the literature
Speaker: Joel Parlow

10. Guideline Process Primary panel members each took lead of topics
Thorough discussion and voting of each topic by panel
Literature search, GRADE quality assessment
Excluded studies by Dr. Poldermans
Meta-analyses included if results consistent
Voting
Recommendation required 2/3 majority of non-conflicted primary panel members
2/3 felt evidence too weak: no recommendation
Good clinical practice statement required 2/3 majority to believe recommendation indicated based only on values and preferences
All votes documented in appendix
Speaker: Joel Parlow

11. Conflicts
Academic/intellectual or financial conflicts of interest declared
Conflicted members could participate in discussion but not voting
Table listing conflicts of interest of panel members for every topic
Speaker: Joel Parlow

12. Preoperative cardiac risk assessment
Speaker: Joel Parlow

13. Which patients should undergo cardiac risk assessment before noncardiac surgery?
≥45 years of age, or
18-44 years of age with known significant cardiovascular disease
coronary artery disease,
cerebral vascular disease,
peripheral arterial disease,
congestive heart failure,
severe pulmonary hypertension, or
severe obstructive intra-cardiac abnormality
e.g., aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy
Speaker: PJ Devereaux

14. Categories of Surgery Emergency surgery Urgent surgery
an acute life or limb threatening condition
Urgent surgery
e.g., surgery for an acute bowel obstruction, hip fracture
Semi-urgent surgery
e.g., surgery for cancer that has potential to metastasize
Elective surgery
Speaker: PJ Devereaux

15. Good Practice Statement
For patients requiring emergency surgery, we recommend against delaying surgery for preoperative cardiac risk assessment
Speaker: PJ Devereaux

16. Good Practice Statement
For patients requiring urgent or semi-urgent sx, we recommend undertaking preoperative cardiac risk assessment only if patient’s hx or P/E suggests potential undiagnosed severe obstructive intra-cardiac abnormality, severe pulmonary hypertension, or unstable cardiovascular condition
Speaker: PJ Devereaux

17. Good Practice Statement
For patients undergoing elective noncardiac surgery who are ≥45 years of age or years of age with known significant cardiovascular disease, we recommend preoperative cardiac risk assessment
Speaker: PJ Devereaux

18. Risk Communication
Ethical requirement to accurately apprise patients about benefits and risks of surgery
Survey of 104 general internists (Taher 2002)
marked variability in definitions of
low, moderate, and high perioperative cardiac risk
Systematic review of surgical and non-surgical RCTs (Trevena 2006)
patients have more accurate perception of risk presented as numbers rather than subjective words (low, moderate, or high-risk), probabilities, or effect measures (e.g., RRR)
Speaker: PJ Devereaux

19. Good Practice Statement
We recommend communicating to patients their perioperative cardiac risk
Speaker: PJ Devereaux

20. Recommendation
We recommend explicit communication of perioperative cardiac risk based on expected event rate among 100 patients or range of risk consistent with 95% confidence interval of risk estimate Strong recommendation, moderate-quality evidence
Speaker: PJ Devereaux

21. Method of preop cardiac risk assessment
Clinical risk indices
Revised Cardiac Risk Index (RCRI)
National Surgical Quality Improvement Program (NSQIP) risk scores
Speaker: Amal Bessissow

22. Clinical Risk Indices RCRI NSQIP risk scores
systematic review - 792,740 pts, 24 studies (Ford 2010)
RCRI had moderate discrimination to predict major perioperative cardiac complications
RCRI has undergone extensive external validation
NSQIP risk scores
NSQIP MICA (Gupta 2011), ACS NSQIP (Bilimoria 2013)
based on large datasets
suggest superior discrimination than RCRI
likely underestimate risks
no systematic monitoring of events
no external validation
Speaker: Amal Bessissow

23. Revised Cardiac Risk Index
Variables 
Pts
Hx of IHD  1
Hx of CHF
Hx of CVD
Insulin for diabetes 
Crt >177 mol/L
High-risk surgery 
Total RCRI
points
Risk of MI, cardiac arrest, or death 30 days after surgery
95% CI
3.9%
2.8%-5.4% 1
6.0%
4.9%-7.4% 2
10.1%
8.1%-12.6% ≥3
15.0%
11.1%-20.0%
* based on high-quality external validation studies
Speaker: Amal Bessissow

24. Recommendation
When evaluating cardiac risk, we suggest clinicians use RCRI over other available clinical risk prediction scores Conditional recommendation, low-quality evidence
Speaker: Amal Bessissow

25. Self-reported functional capacity
Reilly et al. (1999)
prospective cohort 600 pts undergoing major noncardiac sx
self-reported functional capacity did not predict CV events
aOR, 1.81 ; 95% CI,
Wiklund et al. (2000)
prospective cohort, 5939 pts having major noncardiac sx
METs not independently predictive of major cardiac events
data suggest observer bias in estimation of pts METS
Given limitations of evidence
primary panel decided not to make recommendation on how to use patient self-reported functional capacity to estimate perioperative cardiac risk
Speaker: Amal Bessissow

26. NT-proBNP/BNP Individual patient data meta-analysis (Rodseth 2014)
2179 patients – 18 studies
Preop NT-proBNP/BNP independently associated with death or nonfatal MI at 30 days
aOR 3.40 (95% CI, ) p<0.001
Threshold value associated with lowest p value for death and MI
NTproBNP ≥300 ng/l
BNP ≥92 mg/l
Speaker: Emmanuelle Duceppe

27. NT-proBNP/BNP
Risk of death or MI at 30 days after noncardiac surgery, based on patient’s preoperative NT-proBNP or BNP
Test result
Risk estimate
95% CI
NT-proBNP <300 ng/L or BNP <92 mg/L
4.9%
3.9% - 6.1%
NT-proBNP value ≥300 ng/L or BNP ≥92 mg/L
21.8%
19.0% %
compared to RCRI, preop NT-proBNP/BNP results improved risk classification in 155 patients in 1000 patient sample
based on risk categories <5%, 5-10%, >10-15%, >15%
Speaker: Emmanuelle Duceppe

28. Recommendation
We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients ≥65 years of age, 45 to 64 years of age with significant cardiovascular disease, or who have RCRI score ≥1 Strong recommendation, moderate-quality evidence
Speaker: Emmanuelle Duceppe

29. Values and Preferences
Considering cost – NT-proBNP/BNP testing restricted to patient groups with baseline clinical risk estimate >5%
RCRI score 1 has >5% risk of MI, cardiac arrest, or death 30 days after surgery
VISION Study data – 30 day risk of CV death or MI
patients ≥65 years of age, years of age with known CV disease have >5% risk
patients without these characteristics have 2.0% risk
Compared to cardiac imaging and non-invasive cardiac stress testing
NT-proBNP/BNP inexpensive and avoids need for return visits
Speaker: Emmanuelle Duceppe

30. Practical Tip
Hospitals without NT-proBNP/BNP available at core lab can obtain point-of-care instrument to measure NT-proBNP in preop clinic
Speaker: Emmanuelle Duceppe

31. Resting Echocardiography
3 studies including 2832 pts
inconsistent association between TTE findings and perioperative ischemic events
Park 2011
1923 pts prospective cohort
TTE within 2 weeks before sx
Several TTE measurements predictors of major CV events
all TTE parameters inferior to NT-proBNP for predicting major CV events (p<0.001)
Speaker: Kim Styles

32. Recommendation
We recommend against performing preoperative resting echocardiography to enhance perioperative cardiac risk estimation Strong recommendation low-quality evidence
Speaker: Kim Styles

33. Practical Tips
If patient requires urgent/semi-urgent or elective surgery and clinical exam suggests undiagnosed severe obstructive intra-cardiac abnormality or severe pulmonary HTN, obtain urgent echocardiography before surgery to inform anesthesiologist, surgeon, and medical team of type and degree of disease
If clinical assessment suggests patient may have undiagnosed cardiomyopathy then echocardiogram should be obtained to facilitate optimization of long-term cardiac health, physicians should consider urgency of surgery when deciding whether to obtain echocardiogram before or after surgery
Speaker: Kim Styles

34. Coronary CT Angiography
Coronary CTA VISION (Sheth 2015)
Prospective cohort patients
Results blinded unless left main disease identified
Preop CCTA predicted CV death and nonfatal MI beyond RCRI
extensive disease: aHR 3.76 (95% CI, )
CCTA overestimated risk amongst patients who did not suffer primary outcome
compared to RCRI, preop CCTA results in inappropriate risk classification in 81 patients in 1000 patient sample
based on risk categories of <5%, 5-15%, >15%
Speaker: PJ Devereaux

35. Recommendation
We recommend against performing preoperative coronary CT angiography to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence
Speaker: PJ Devereaux

36. Exercise Stress Testing
Limited data - 4 studies (508 patients)
only 2 studies performed risk adjusted analysis
Carliner 1985 – treadmill exercise
200 pts prospective cohort
no significant association between ECG exercise change and death or MI
Sgura 2000 – supine bicycle
149 pts prospective cohort, vascular surgery
no significant association between exercise induced ST depression and death or MI
Speaker: Vikas Tandon

37. Recommendation
We recommend against performing preoperative exercise stress testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence
Speaker: Vikas Tandon

38. Cardiopulmonary Exercise Testing
Colson 2012
1725 patients undergoing major elective abdominal or thoracic surgery
CPET weak independent predictor of mortality at 5 yrs
3 studies looked at CPET association with 30 day outcomes
706 patients
inconsistent results across studies
no study evaluated if CPET improved risk reclassification in addition to clinical evaluation
Speaker: Vikas Tandon

39. Recommendation
We recommend against performing preoperative cardiopulmonary exercise testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence
Speaker: Vikas Tandon

40. Pharmacological stress echocardiography and radionuclide imaging
Several studies, mostly small sample size and small number of events
Low quality of evidence
most retrospective, few reported risk adjusted associations
No study adequately assessed incremental value of stress tests over well-established perioperative cardiac risk factors (e.g., RCRI)
Speaker: Vikas Tandon

41. Recommendations
We recommend against performing preoperative pharmacological stress echocardiography Strong recommendation, low-quality evidence and
Speaker: Vikas Tandon

42. Recommendations
We recommend against performing preoperative radionuclide imaging to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence, respectively
Speaker: Vikas Tandon

43. Values and Preferences
Panel believed that cost and potential delays associated with stress tests should be taken into account given absence of evidence of overall absolute net improvement in risk reclass
Speaker: Vikas Tandon

44. Perioperative cardiac risk modification

45. Perioperative Risk Modification
Smoking cessation
Meta-analysis smoking cessation RCTs (Thomson 2014)
CV events after surgery
4 trials – 653 patients
no impact of preoperative smoking cessation on major CV events
RR 0.58 (95% CI, )
only 16 events
Speaker: Paul MacDonald

46. Smoking Cessation Meta-analysis smoking cessation RCTs (Thomson 2014)
Smoking cessation at time of surgery
12 trials – 1867 patients
Brief intervention: RR 1.30 (95% CI, )
Intensive intervention: RR (95% CI, )
Smoking cessation at 12 month
5 trials – 836 patients
Brief intervention: RR 1.09 (95% CI, )
Intensive intervention: RR 2.96 (95% CI, )
Speaker: Paul MacDonald

47. Recommendation
We recommend discussing and facilitating smoking cessation before noncardiac surgery Strong recommendation low-quality evidence
Speaker: Paul MacDonald

48. Values and Preferences
Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk
Speaker: Paul MacDonald

49. Values and Preferences
Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk
Speaker: Paul MacDonald

50. ASA Initiation / Continuation
POISE 2 (2014) – RCT 10,010 noncardiac Sx patients
with known vascular disease or risk factors
Initiation stratum (5628 pts)
ASA 200 mg vs placebo preop and ASA 100 mg daily vs placebo x 30 days postop
Continuation stratum (4382 pts)
ASA 200 mg vs placebo preop and ASA 100 mg daily vs placebo x 7 days postop
ASA had to be stopped ≥3 days preop (median 7 days)
Systematic monitoring troponin postop
Speaker: Paul MacDonald

51. POISE-2 Results Death or nonfatal MI at 30 days All-cause mortality
HR 0.99 (95% CI, 0.86–1.15) p=0.92
All-cause mortality
HR 1.05 (95% CI, 0.74–1.49) p=0.78
Cardiac death
HR 1.00 (95% CI, 0.63–1.60) p=0.99 MI
HR 0.98 (95% CI, 0.84–1.15) p=0.85
Major bleeding
HR 1.23 (95% CI, 1.01–1.49) p=0.04
Speaker: Paul MacDonald

52. Recommendations
We recommend against initiation of ASA for prevention of perioperative cardiac events Strong recommendation, high-quality evidence We recommend against continuation of ASA to prevent perioperative cardiac events, except in patients with a recent coronary artery stent and patients undergoing carotid endarterectomy
Speaker: Paul MacDonald

53. Practical Tips
Discontinue ASA at least 3 days before noncardiac surgery to reduce risk of major bleeding
Perioperative ASA continuation may be reasonable for some surgical interventions to prevent local thrombosis
e.g., free flap, acute limb ischemia
In patients with indication for chronic ASA, restart ASA when bleeding risk related to surgery has passed
i.e., 8 days after major noncardiac surgery
When patient suffers myocardial injury or thrombotic event after surgery in absence of bleeding, there may be net value to re-starting ASA sooner after surgery than 8-10 days
Speaker: Paul MacDonald

54. β-blocker Initiation Systematic review 2014
All cause mortality (14 trials, n=10,785)
β-blocker 3.0%, no β-B 2.3%, RR 1.30 ( )
Cardiac mortality (12 trials, n=10,648)
β-blocker 1.7%, no β-B 1.3%, RR 1.25 ( )
Myocardial infarction (14 trials, n=10,785)
β-blocker 3.4%, no β-B 4.7%, RR 0.72 ( )
Stroke (9 trials, n=10,545)
β-blocker 0.8%, no β-B 0.4%, RR 1.86 ( )
Results consistent without inclusion of POISE
Speaker: Joel Parlow

55. β-blocker Initiation POISE 8,351 patients MI Mortality Stroke
- Noncardiac surgery, long-acting metoprolol vs placebo MI
β-blocker 4.2% vs no β-B 5.7%, p=0.002
Mortality
β-blocker 3.1% vs no β-B 2.3%, p=0.03
Stroke
β-blocker 1.0% vs no β-B 0.5%, p=0.005
Unclear if earlier initiation or preoperative dose titration would be practical or safer
Speaker: Joel Parlow

56. Recommendation
We recommend against β-blocker initiation within 24 hours before noncardiac surgery Strong recommendation, high-quality evidence
Speaker: Joel Parlow

57. β-blocker Continuation
Very low quality evidence regarding risk or benefit of continuing chronic β-blocker
Wallace, 2010 ( , n=12,105)
retrospective observational study in noncardiac surgery, with highly variable dosing
all cause 30-day mortality:
continuation: aOR 0.74 (95% CI, ) p=0.09
withdrawal: aOR 3.57 (95% CI, ) p<0.0001
Speaker: Joel Parlow

58. Conditional recommendation,
Among patients taking β-blocker chronically, we suggest continuing β-blocker during the perioperative period
Conditional recommendation,
low-quality evidence
Practical Tip
If patient’s systolic blood pressure is low before surgery, physicians should consider decreasing or holding dose of β-blocker before surgery
Speaker: Joel Parlow

59. α2-Agonist Initiation
POISE-2, 2014: n=10,010 noncardiac surgery with known vascular disease or risk factors
30-day mortality: clonidine 1.3% vs placebo 1.3%
HR 1.01 (95% CI, 0.72–1.44, p=0.94)
Nonfatal MI: clonidine 6.6% vs placebo 5.9%
HR 1.11 (95% CI, , p=0.18)
Hypotension: clonidine 47.6% vs placebo 37.1%
HR 1.32 (95% CI , p<0.001)
Bradycardia: clonidine 12.0% vs placebo 8.1%
HR 1.49 (95% CI, 1.32–1.69, p<0.001)
Nonfatal cardiac arrest: clonidine 0.3% vs placebo 0.1%, HR 3.20 (95% CI, 1.17–8.73, p=0.02)
Speaker: Joel Parlow

60. Recommendation
We recommend against preoperative initiation of α2-agonist for prevention of perioperative cardiovascular events Strong recommendation, high-quality evidence
Speaker: Joel Parlow

61. Calcium Channel Blocker Initiation
Systematic review of RCTs (Wijeysundera 2003)
5 trials (692 patients)
Death and MI: RR 0.35 (95% CI, )
Death: RR 0.40 (95% CI, )
Only 17 events
MI: RR 0.25 (95% CI, )
Only 5 events
Very low quality of evidence
only half studies blinded, only one with allocation concealment
possible publication bias
implausible treatment effects and large CI
Speaker: Sadeesh Srinathan

62. Recommendation
We suggest against initiation of calcium channel blockers for prevention of perioperative cardiovascular events Conditional recommendation, low-quality evidence
Speaker: Sadeesh Srinathan

63. ACEI / ARBs Continuation
Only three small RCTs
total 188 patients
ACEI/ARB continuation associated with increase intraoperative hypotension
pooled RR 2.53 (95% CI, )
Only one trial reported on CV events
too few events to draw conclusion
Other perioperative trials showed association between hypotension and postoperative risk of death, MI and stroke
Speaker: Sadeesh Srinathan

64. Recommendation
We recommend withholding ACEI/ARB starting 24 hours before noncardiac surgery in patients treated chronically with ACEI/ARB Strong recommendation, low-quality evidence
Speaker: Sadeesh Srinathan

65. Values and Preferences
Weight was accorded to absence of demonstrated benefit and substantial increase in risk of intraoperative hypotension associated with perioperative continuation of ACEI/ARB
Speaker: Sadeesh Srinathan

66. Practical Tip
Since risk of hypotension is greatest within 24 hours of surgery, physicians should consider restarting ACEI/ARB on day 2 after surgery in patients on chronic ACEI/ARB therapy, if patient is hemodynamically stable
Speaker: Sadeesh Srinathan

67. Statin Initiation Meta-analysis of RCTs (Sanders 2013)
3 trials – 178 patients
All-cause mortality
RR 0.73 (95% CI, )
Nonfatal MI
RR 0.47 (95% CI, )
Very few events
Speaker: Sadeesh Srinathan

68. Statin Initiation
Panel members felt evidence was too weak to support a recommendation
Speaker: Sadeesh Srinathan

69. Statin Continuation Xia 2015 Single RCT
550 patients undergoing noncardiac surgery with stable CAD
Rosuvastatin 20 mg or placebo 2h preop
MI at 30 days
Statin: 10/275 (3.6%)
Placebo: 22/275 (8.0%)
RR 0.45 (95% CI, ) p=0.03
Speaker: Sadeesh Srinathan

70. Recommendation
We recommend continuing statin therapy perioperatively in patients who are on chronic statin therapy Strong recommendation, moderate-quality evidence
Speaker: Sadeesh Srinathan

71. Coronary artery revascularization before noncardiac surgery
Illuminati 2015
RCT (n=426)
CEA with no apparent evidence of CAD
Pre-op cath/revasc vs no cath
All-cause mortality at 30 days
intervention 0% vs control 1.0%, p=0.24
MI at 30 days
intervention 0% vs control 4.3%, p=0.01
Few events, large effect sizes
Speaker: Michelle Graham

72. Coronary artery revascularization before noncardiac surgery
CARP trial (McFalls 2004)
510 patients undergoing vascular surgery
Randomized to revascularization vs medical Tx
left main disease ≥50% excluded
Mortality at median of 2.7 yrs
coronary revascularization group 22%
no-revascularization group 23%
RR, 0.98; 95% CI, 0.70 to 1.37; P=0.92
Surgery delayed 54 days vs 18 days
Speaker: Michelle Graham

73. Recommendation
For patients with stable coronary artery disease undergoing noncardiac surgery, we recommend against preoperative prophylactic coronary revascularization Strong recommendation, low-quality evidence
Speaker: Michelle Graham

74. Values and preferences
Absence of clearly demonstrated benefit
inconsistent results between trials
Surgical delays
Increase in costs
Risk of bleeding with dual antiplatelet therapy
Speaker: Michelle Graham

75. Practical tips CCS Class III-IV or unstable angina
Coronary revascularization preop seems prudent
individual risk-benefit assessment required in patients who require urgent/semi-urgent noncardiac surgery
Patients undergoing PCI should have noncardiac surgery delayed until risk of stopping dual antiplatelet therapy outweighed by risk of delaying noncardiac surgery
Speaker: Michelle Graham

76. Monitoring for perioperative cardiac events

77. Pulmonary artery catheters
Systematic review of 8 trials (2667 patients)
(Shah 2005)
All-cause mortality
PAC: 92/1389 (6.6%)
No PAC: 101/1318 (7.7%)
Pooled OR 0.84 (95%CI, )
One trial showed increased risk pulmonary embolus
PAC: 8/997 (0.8%)
No PAC: 0/997 (0%)
p=0.004
Speaker: Michelle Graham

78. Recommendation
We recommend against using pulmonary artery catheters in patients undergoing noncardiac surgery Strong recommendation, moderate-quality evidence
Speaker: Michelle Graham

79. Troponin Monitoring POISE Trial (8351 patients)
65% of patients suffering a perioperative MI do not experience ischemic symptoms
2/3 of perioperative MIs would go unrecognized without periop troponin monitoring
Presence or absence of signs/symptoms does not change risk 30-day mortality
symptomatic MI: aOR 4.76 (95% CI, )
asymptomatic MI: aOR 4.00 (95% CI, )
Speaker: Emmanuelle Duceppe

80. VISION Study (Botto 2014) Prospective international cohort study
15,065 noncardiac surgery patients with at least overnight stay in hospital,
TnT measured postop days 1,2,3
MINS Criteria = peak TnT  0.03 ng/ml due to myocardial ischemia
MINS: 9.8% death at 30 days
No MINS: 1.1% death at 30 days
Speaker: Emmanuelle Duceppe

81. VISION Study (Botto 2014) 84% MINS asymptomatic
undetected without troponin monitoring
Asymptomatic perioperative TnT elevations adjudicated as myocardial injuries due to ischemia – that did not fulfill Universal Definition of MI – were also associated with increased risk of 30-day mortality
aHR, 3.30; 95% CI, 2.26–4.81
Speaker: Emmanuelle Duceppe

82. Troponin Monitoring Meta-analysis of postop troponin (Levy 2011)
14 studies – 3,318 patients
Postop troponin elevation associated with all-cause mortality at 12 months
aOR 6.7 (95% CI, )
Speaker: Emmanuelle Duceppe

83. Recommendation
We recommend obtaining daily troponin measurements for 48 to 72 hours after noncardiac surgery in patients with baseline risk >5%* for cardiovascular death or nonfatal MI at 30 days after surgery Strong recommendation, moderate-quality evidence
* Patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥1, age 45 to 64 years with significant cardiovascular disease, or age ≥65 years
Speaker: Emmanuelle Duceppe

84. Postoperative ECG Prospective cohort study (Rinfret 2004)
3564 patients, age ≥50 years old, major noncardiac surgery
ECG done in recovery room and on day 1, 3 and 5 postop
New ischemic findings independent predictor of subsequent major cardiac events
aOR 2.19 (95% CI, 1.22–3.93) p=0.009
Speaker: Kim Styles

85. * elevated preop NT-proBNP/BNP measurement or,
Recommendation
We suggest performing postoperative ECG in post-anesthetic care unit in patients with baseline risk >5%* for CV death or nonfatal MI Conditional recommendation, low-quality evidence
* elevated preop NT-proBNP/BNP measurement or,
if there is no preop NT-proBNP/BNP measurement, in those who have RCRI score ≥1, age 45 to 64 years with significant CV disease, or age ≥65 years
Speaker: Kim Styles

86. Postoperative Telemetry
3 prospective cohort studies (740 patients)
Ischemia defined as
≥1mm of horizontal or down-sloping ST depression or ≥2mm ST elevation for ≥60 seconds
Longer duration more predictive of postop adverse outcomes
In vascular surgery pts and pts with or at risk of CAD,
ischemic changes predicted postop cardiac events
Speaker: Kim Styles

87. Postoperative Telemetry
With troponin screening, additional benefit of postoperative telemetry monitoring has not been established
Telemetry is associated with substantial resources and costs
Panel members felt evidence was too weak to support recommendation regarding postop telemetry monitoring
Speaker: Kim Styles

88. Postoperative Shared-Care Management
Meta-analysis RCTs or observational studies (Grigoryan 2013)
18 studies – 9096 patients with hip fracture
Intervention:
inpatient systematic multidisciplinary approach to hip fracture management involving orthopedic surgeon and geriatrician
Shared-care models reduced in-hospital and long-term mortality
In-hospital: RR 0.60 (95% CI, )
Long-term mortality: RR 0.83 (95% CI, )
Speaker: PJ Devereaux

89. *elevated preop NT-proBNP/BNP measurement,
Recommendation
We suggest shared-care management of patients with baseline risk >5%* for CV death or nonfatal MI Conditional recommendation, low-quality evidence
*elevated preop NT-proBNP/BNP measurement,
or if there is no preop NT-proBNP/BNP measurement, in those who have RCRI score ≥1, age 45 to 64 years with significant CV, or age ≥65 years
Speaker: PJ Devereaux

90. Management of perioperative cardiac complications

91. Postoperative Management of Complications
ASA and statin in patients suffering myocardial injury after noncardiac surgery
Prospective cohort study (Devereaux 2011)
415 noncardiac surgery patients who suffered postop MI
ASA and statin at discharge reduced 30-day mortality
ASA : aOR 0.54 (95% CI, )
Statin: aOR 0.26 (95% CI, )
Speaker: PJ Devereaux

92. Retrospective propensity matched cohort study (Foucrier 2014)
66 MINS patients and 132 matched non-MINS patients (controls)
among MINS patients
43 received therapeutic intensification of ≥1 of 4 cardiac medications (ASA, statin, beta-blocker, ACE-I)
23 patients did not receive therapeutic intensification after MINS
MINS patients not receiving therapeutic intensification had
HR, 1.77; 95% CI,
MINS patients receiving therapeutic intensification had
HR, 0.63; 95% CI,
Speaker: PJ Devereaux

93. Recommendation
We recommend initiation of long-term ASA and statin in patients who suffer myocardial injury or myocardial infarction after noncardiac surgery Strong recommendation, moderate-quality evidence
Speaker: PJ Devereaux

94. x
Speaker: Joel Parlow

95. Conclusions
New Canadian Guidelines provide evidence-based recommendations on perioperative cardiac assessment and management for patients undergoing noncardiac surgery
Significant changes from prior guidelines
Shift of emphasis from preoperative noninvasive cardiac testing to increased use of biomarkers and postoperative monitoring of patients at risk and management of cardiac complication

96. Questions?
This could stay – leave for now and we’ll decide later