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Dr. Sonia Anand McMaster University

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1 Dr. Sonia Anand McMaster University
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery Dr. Sonia Anand McMaster University

2 Epidemiology of Noncardiac Surgery
Nearly 30 million patients have noncardiac surgical procedures annually in the United States Approximately 25% of these are major intra-abdominal, thoracic, vascular and orthopedic procedures

3 Pre-Op Risk Assessment =

4 Overview Guidelines- reflect evidence synthesis and consensus
Evidence as of October 2007 Important Decision points: Urgent vs Elective Surgery High risk surgery vs intermediate vs low Active Cardiac Condition vs non-active

5 The Search For High Risk

6 Methods for Assessing Risk Pre-Operatively
Patient Based High risk conditions Functional Capacity Surgery Based Vascular Surgery Emergency surgery Intervention Based Medications Revascularization

7 Six Independent predictors of cardiac risk
ischemic heart disease congestive heart failure 3) cerebrovascular disease 4) high risk surgery (AAA, orthopedic sx) 5) pre-operative insulin tx for diabetes 6) preoperative creatinine for creat > 2 mg/dL Lee et al

8 Active/Major Cardiac Conditions
Unstable Coronary Conditions Decompensated CHF Significant arrhythmias (i.e. 3⁰HB, new Vtach) Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????

9 Non-Active Cardiac Factors
Intermediate Risk Hx of CHD History of prior CHF Hx of stroke Diabetes Renal insufficiency Minor Risk* Age > 70 Abnormal ECG Nonsinus rhythm Uncontrolled systolic BP * Not associated with cardiac risk

10 Functional Capacity Functional status has shown to be a reliable periop and long-term predictor of cardiac events Functional status determined based on ability to do ADL’s MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest Periop risk is increased if person cannot > 4 METS

11 10 MET 1 MET 4 MET Moderate recreational golf, dancing, baseball
DO light house work i.e. Washing dishes Strenuous sports swimming, basketball Climb a flight of stairs Run a short distances Eat, dress 10 MET 1 MET 4 MET

12 The Trump Card: Functional Capacity
Perioperative cardiac risk is increased in patients unable to exercise 4 METs Functional capacity can be estimated in the office Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs Swimming and singles tennis exceeds 10 METs

13 Surgery Risk Type Type Cardiac risk examples High > 5%
Aortic, peripheral vasc sx Intermediate risk 1-5% Intraperitoneal Intrathoracic Carotid End Head and neck Orthopedic Sx Prostate Sx Low <1% Endoscopic procedures Superficial Cataract Sx Breast Sx Ambulatory Sx

14 Surgery-Specific Risk: High Risk*
Major emergency surgery Vascular surgery including: aortic surgery, infra-inguinal bypass Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5%

15 Stepwise Approach Step 1: Determine urgency of surgery
Step 2: Active cardiac condition?-→test Step 3: Undergoing low-risk surgery? < 1%* Step 4: Good functional capacity? * Combined morbidity and mortality < 1% even in high risk patients

16 The Catheterization Questions to Ask Yourself
Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now? Am I willing to send the patient to CABG? Am I doing this just to know the anatomy?

17 Is pre-op coronary revasc advantageous?
If high risk surgery and patient has active cardiac issue Functional test and perfusion Imaging and if L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op CARP – if none of these – no advantage of revasc

18 Functional Test Exercise test with ECG
If abnormal ECG, Rx perfusion imaging Adenosine Dipyridamole Dobutamine Dobutamine stress echo

19 Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry
2 4 6 8 10 No CAD CAD: Medical Rx CABG (n=314) Periop MI Death 3.0 8.5 2.8 0.6 1.1 *** * Eagle et al. Circulation, 1997

20 Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes
510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized to Revasc (PCI 59%, CABG 41%) or conservative management. 25 20 15 10 5 Post-Op MI 30 Day 2.7 Year Mortality Mortality Revascularization Conservative Mgmt McFalls, E. CARP Trial;AHA 2004

21 Get Out of Jail Free Cards
If the patient has been revascularized within 5 years (stent or CABG) and has no change in symptoms and no active major issues, they do not need any further testing or stratification. If the patient has had a coronary evaluation within 2 years and no change in symptoms, they are at acceptable risk for surgery.

22 High Risk Patients & Revascularization Pre-Op
101 pts with extensive ischemia randomly assigned to pre-op revascularization or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up. 50 40 30 % 20 2VD in 12 (24%), 3VD in 33 (67%), Left main in 4 (8%). 10 7 14 21 28 3 6 9 12 Days since surgery Months since surgery Poldermans, D. JACC 2007; 49(17): 1763

23 The Effect of Percutaneous Revascularization Above Optimal Medical Therapy: COURAGE
2287 Pts w/myocardial ischemia and CAD randomized to PCI with optimal medical therapy (PCI group) and 1138 to medical therapy alone. 1.0 0.9 0.8 0.7 0.6 0.5 1 2 3 4 5 6 7 Years Survival Free of Death/MI Medical therapy PCI + Medical therapy Boden, W. NEJM 2007; 356:1503

24 STENTS If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after If received DES.... 1) postpone sx until > 12 months, 2) do sx on both asa+clop 3) do sx on single ap tx

25 Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended

26 Medical tx 1) beta blockers-if on keep them if not....
2) Statins continue, ? Start -need randomized trials

27 Statins Improve Survival After Vascular Surgery
100 pts randomized 20 mg atorvastatin or placebo for 45 days. Vascular surgery ~ 30 days after randomization. F/U 6 months Primary Endpoint CV death + NFMI+ Ischemic stroke+ Unstable Angina Durazzo, AES. JVS 2004:39(5):975

28 Statins Improve Long-Term Survival After Vascular Surgery
Retrospective review of 446 consecutive infrainguinal bypass surgeries 20 40 60 80 100 1.00 .75 .50 .25 Time (months) Survival Statin (+) p < 0.004 Statin (-) Ward, RP. Int J Card 2005; 104(3):264

29 Statin Intensity & Operative Outcomes
359 vascular surgery pts, statin dose were recorded. Myocardial ischemia & HR variability were assessed by 72-h 12-lead ECG. TNT measured on day 1, 3, 7, and discharge. Cardiac events included cardiac death or NFMI at 30 days and follow-up mean 2.3 years Statin therapy % of Max Recommended

30 Other Issues DVT/PE prophylaxis
Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B) No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes Routine troponin monitoring not recommended

31 Surveillance for Perioperative Myocardial Infarction
ECGs All intermediate and high-risk patients should get a post-op ECG. As need for signs or symptoms of ischemia Troponin / CK In patients with signs or symptoms of ischemia Do not do screening biomarkers

32 High Risk Features Severe obstructive or restrictive pulmonary disease
Diabetes Renal impairment Anemia, polycythemia, thrombocytosis

33 PCI pre-op ST-elevation MI Unstable angina Non ST elevation MI

34 2007 ACC/AHA Perioperative Guidelines

35 Take Home Messages Unstable syndromes require management prior to surgery. Look for Unstable angina Signs of heart failure Stenotic valve lesions Ventricular arrhythmias Functional tolerance is the best single predictor of outcome Be very specific in your history (one step at at time, regular or slow pace, etc) If patient on beta blockers & statins continue them, more trials to mandate them PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.

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