1. What is Cardiology Clearance? Sheilah Bernard, MD, FACC Director, Cardiac Amb Services Sheilah Bernard, MD, FACC Director, Cardiac Amb Services 9:30-10:00am 2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future 2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Boston University School of Medicine May 19, 2006 Boston University School of Medicine May 19, 2006

2. Eight Steps to Best Possible Outcome Assess the patient’s clinical features Evaluate functional status Consider the patient’s surgery-specific risk Decide if further noninvasive evaluation is needed Decide when to recommend invasive evaluation Optimize medical therapy Perform appropriate perioperative surveillance Design maximal long-term therapy Assess the patient’s clinical features Evaluate functional status Consider the patient’s surgery-specific risk Decide if further noninvasive evaluation is needed Decide when to recommend invasive evaluation Optimize medical therapy Perform appropriate perioperative surveillance Design maximal long-term therapy

3. 2002, Eagle K et al. www.acc.org or www.americanheart.org www.acc.org www.americanheart.org AHA/ACC Practice Guidelines Perioperative CV Evaluation for Noncardiac Surgery

4. Fleisher: N Engl J Med, Volume 345(23).December 6, 2001.1677-1682

5. Implementing Guidelines Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI) –Resources: ETT 88%  47%; Cath 24%  11%; revascularization 25%  2% –Costs: $1087  $171 Effect was sustained 2 years after guideline implementation Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI) –Resources: ETT 88%  47%; Cath 24%  11%; revascularization 25%  2% –Costs: $1087  $171 Effect was sustained 2 years after guideline implementation Froelich JB, J Vasc Surgery 2002 36L758-63

6. B&W Preadmission Testing Center (PATC) and last minute Cardiology consults for: Dudley JC et al, AM HEART J 1996;131:245-9.

7. Sources of “last-minute” cardiology consults

8. Improved survival with atenolol after noncardiac surgery

9. Lindenauer, P. K. et al. N Engl J Med 2005;353:349-361 Adjusted Odds Ratio for In-Hospital Death Associated with Perioperative Beta-Blocker Therapy among Patients Undergoing Major Noncardiac Surgery, According to the RCRI Score and the Presence of Other Risk Factors in the Propensity-Matched Cohort and the Entire Study Cohort

10. Beta blocker guidelines

11. Limitations in the perioperative beta blocker literature Most trials inadequately powered Few randomized trials of medical therapy have been performed Few randomized trials have examined titration to effect (e.g. target heart rate) Few randomized trials have examined the role of perioperative beta blocker therapy Studies to determine role in intermediate and low risk populations are lacking. Optimal beta blocker No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom) Most trials inadequately powered Few randomized trials of medical therapy have been performed Few randomized trials have examined titration to effect (e.g. target heart rate) Few randomized trials have examined the role of perioperative beta blocker therapy Studies to determine role in intermediate and low risk populations are lacking. Optimal beta blocker No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom)

12. McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804 Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery

13. McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804 Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization

14. ?CABG/PCI before major elective vascular surgery? NO In conclusion, this multicenter, randomized trial shows that coronary-artery revascularization before elective vascular surgery does not alter long-term survival. Although the study was not powered to detect a beneficial effect in the short term, there also appears to have been no reduction in the number of postoperative myocardial infarctions, deaths, or days in the hospital. On the basis of these data, coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended. In conclusion, this multicenter, randomized trial shows that coronary-artery revascularization before elective vascular surgery does not alter long-term survival. Although the study was not powered to detect a beneficial effect in the short term, there also appears to have been no reduction in the number of postoperative myocardial infarctions, deaths, or days in the hospital. On the basis of these data, coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

15. Kaplan-Meier Survival Curves to One Year Sandham, J. et al. N Engl J Med 2003;348:5-14

16. The Statins for Risk Reduction in Surgery (StaRRS) study Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization –157 complications occurred 9.9% statin vs 16.5% non-statin Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization –157 complications occurred 9.9% statin vs 16.5% non-statin O’Neil-Callahan et al JACC 2005; 336-42

17. The Statins for Risk Reduction in Surgery (StaRRS) study

18. Optimization before the OR Pacing/ICD “Electrical” issues –Turn off ICD/magnet for VVI pacing Valvular “Coagulation” issues –Reverse, hold or bridge warfarin –SBE prophylaxis Myocardial “CHF” issues –PA catheter/CHF management Coronary “ischemia” issues –Per AHA/ACC algorithm Pacing/ICD “Electrical” issues –Turn off ICD/magnet for VVI pacing Valvular “Coagulation” issues –Reverse, hold or bridge warfarin –SBE prophylaxis Myocardial “CHF” issues –PA catheter/CHF management Coronary “ischemia” issues –Per AHA/ACC algorithm

19. Is patient high CV risk (>5%)? Unstable coronary syndromes –Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing –Unstable or severe angina CC III or IV Decompensated heart failure Significant arrhythmia –High degree AV block –Symptomatic ventricular arrhythmias in the presence of underlying heart disease –Supraventricular arrhythmia with uncontrolled ventricular rate Severe valvular disease Unstable coronary syndromes –Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing –Unstable or severe angina CC III or IV Decompensated heart failure Significant arrhythmia –High degree AV block –Symptomatic ventricular arrhythmias in the presence of underlying heart disease –Supraventricular arrhythmia with uncontrolled ventricular rate Severe valvular disease

20. Special “surgeries”….

21. Hemodynamic changes with labor Uterine contractions cause up to 500 cc autotransfusion C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR) Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change HR, volume, CO normalize by 5-6 weeks postpartum Uterine contractions cause up to 500 cc autotransfusion C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR) Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change HR, volume, CO normalize by 5-6 weeks postpartum

22. Hemodynamic changes with pregnancy

23. Classification of Valvular Heart Lesions according to Maternal, Fetal, & Neonatal Risk*

24. Areas in further need of research Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness Cost-effectiveness of the various methods of noninvasive testing Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients Establishment of optimal guidelines for selected patient subgroups, especially elderly Establishment of monitoring guidelines in treatment decisions and outcomes Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness Cost-effectiveness of the various methods of noninvasive testing Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients Establishment of optimal guidelines for selected patient subgroups, especially elderly Establishment of monitoring guidelines in treatment decisions and outcomes

25. Aortic Stenosis

26. What is cardiology clearance? Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management Interdisciplinary management Considerations in delivering the pregnant cardiac patient Future operational strategies Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management Interdisciplinary management Considerations in delivering the pregnant cardiac patient Future operational strategies