Presentation on theme: "Dr. Sonia Anand McMaster University"— Presentation transcript:
1 Dr. Sonia Anand McMaster University ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgeryDr. Sonia AnandMcMaster University
2 Epidemiology of Noncardiac Surgery Nearly 30 million patients have noncardiac surgical procedures annually in the United StatesApproximately 25% of these are major intra-abdominal, thoracic, vascular and orthopedic procedures
4 Overview Guidelines- reflect evidence synthesis and consensus Evidence as of October 2007Important Decision points:Urgent vs Elective SurgeryHigh risk surgery vs intermediate vs lowActive Cardiac Condition vs non-active
7 Six Independent predictors of cardiac risk ischemic heart diseasecongestive heart failure3) cerebrovascular disease4) high risk surgery (AAA, orthopedic sx)5) pre-operative insulin tx for diabetes6) preoperative creatinine for creat > 2 mg/dLLee et al
8 Active/Major Cardiac Conditions Unstable Coronary ConditionsDecompensated CHFSignificant 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 RiskHx of CHDHistory of prior CHFHx of strokeDiabetesRenal insufficiencyMinor Risk*Age > 70Abnormal ECGNonsinus rhythmUncontrolled systolic BP* Not associated with cardiac risk
10 Functional CapacityFunctional status has shown to be a reliable periop and long-term predictor of cardiac eventsFunctional status determined based on ability to do ADL’sMET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at restPeriop 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 dishesStrenuous sports swimming, basketballClimb a flight of stairsRun a short distancesEat, dress10 MET1 MET4 MET
12 The Trump Card: Functional Capacity Perioperative cardiac risk is increased in patients unable to exercise 4 METsFunctional capacity can be estimated in the officeEnergy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METsClimbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METsSwimming and singles tennis exceeds 10 METs
13 Surgery Risk Type Type Cardiac risk examples High > 5% Aortic, peripheral vasc sxIntermediate risk1-5%IntraperitonealIntrathoracicCarotid EndHead and neckOrthopedic SxProstate SxLow<1%Endoscopic proceduresSuperficialCataract SxBreast SxAmbulatory Sx
14 Surgery-Specific Risk: High Risk* Major emergency surgeryVascular surgery including: aortic surgery, infra-inguinal bypassProlonged 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?-→testStep 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 issueFunctional test and perfusion Imaging and ifL main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-opCARP – if none of these – no advantage of revasc
18 Functional Test Exercise test with ECG If abnormal ECG, Rx perfusion imagingAdenosineDipyridamoleDobutamineDobutamine stress echo
19 Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry 246810No CADCAD:Medical RxCABG(n=314)Periop MIDeath3.08.52.80.61.1****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 electiveAAA repair (33%) or infrainguinal bypass (67%), randomized toRevasc (PCI 59%, CABG 41%) or conservative management.252015105Post-Op MI30 Day2.7 YearMortalityMortalityRevascularizationConservative MgmtMcFalls, 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 revascularizationor not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up.504030%202VD in 12 (24%),3VD in 33 (67%),Left main in 4 (8%).10714212836912Days since surgeryMonths since surgeryPoldermans, 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 withoptimal medical therapy (PCI group) and 1138 to medical therapy alone.1.00.90.80.70.60.51234567YearsSurvival Free of Death/MIMedical therapyPCI + Medical therapyBoden, W. NEJM 2007; 356:1503
24 STENTSIf upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx afterIf received DES....1) postpone sx until > 12 months,2) do sx on both asa+clop3) 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 monthsPrimary EndpointCV death +NFMI+Ischemic stroke+Unstable AnginaDurazzo, AES. JVS 2004:39(5):975
28 Statins Improve Long-Term Survival After Vascular Surgery Retrospective review of 446 consecutive infrainguinal bypass surgeries204060801001.00.75.50.25Time (months)SurvivalStatin (+)p < 0.004Statin (-)Ward, RP. Int J Card 2005; 104(3):264
29 Statin Intensity & Operative Outcomes 359 vascular surgery pts, statin dose were recorded. Myocardial ischemia & HRvariability were assessed by 72-h 12-lead ECG. TNT measured on day 1, 3, 7,and discharge. Cardiac events included cardiac death or NFMIat 30 days and follow-up mean 2.3 yearsStatin 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 outcomesRoutine troponin monitoring not recommended
31 Surveillance for Perioperative Myocardial Infarction ECGsAll intermediate and high-risk patients should get a post-op ECG.As need for signs or symptoms of ischemiaTroponin / CKIn patients with signs or symptoms of ischemiaDo not do screening biomarkers
32 High Risk Features Severe obstructive or restrictive pulmonary disease DiabetesRenal impairmentAnemia, polycythemia, thrombocytosis
33 PCI pre-opST-elevation MIUnstable anginaNon ST elevation MI
35 Take Home MessagesUnstable syndromes require management prior to surgery. Look forUnstable anginaSigns of heart failureStenotic valve lesionsVentricular arrhythmiasFunctional tolerance is the best single predictor of outcomeBe 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 themPCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.