1. The Perioperative Cardiovascular Evaluation: What Every Resident Should Know

2. The “What Every Resident Should Know” Lecture Series Hypertension Dyslipidemia Heart Failure Pericardial Disease Ventricular Arrhythmias Preoperative Cardiac Evaluation

3. Epidemiology There are 6 million noncardiac surgeries per year among patients ≥ 65 yo. –The prevalence of CV disease among elderly patients is 25-35%. The 30-day incidence of peri-op MI or cardiac death is… –2.5% among unselected patients > 40 yo –6.2% among vascular surgery patients 1 1 Mangano DT. Anesthesiology 1998; 88: 561-564.

4. Topics Pre-op clinic evaluation Pre-op stress test Pre-op revascularization Peri-op use of –Beta blockers –Statins –Aspirin & Clopidogrel Post-op surveillance

5. Case #1 A 64 yo FF with HTN, DLP, & OA s/p right THA in 2007 is awaiting a left TKA. She is asymptomatic except for knee pain. Her PCM performs an EKG, which demonstrates NSTWA in lead AVL. Does she need to see a cardiologist for a pre-op evaluation?

6. Goldman L, et al. N Engl J Med 1977; 297: 845-850.

7. Detsky AS, et al. J Gen Intern Med 1986; 1: 211-219.

8. Lee TH, et al. Circulation 1999; 100: 1043-1049.

9. ACC 2007 Guidelines Active Cardiac Conditions –Acute coronary syndromes –Decompensated heart failure –Significant arrhythmias –Severe valvular disease Clinical Risk Factors –Ischemic heart disease –Prior heart failure –Cerebrovascular disease –Diabetes mellitus –Renal insufficiency

10. Case #2 75 yo WM with CAD s/p PCI to LCX 11/06 & 9/07, normal LVSF on TTE 11/06, HTN, DLP, DM2, obesity, & CKD is awaiting AAA repair. Denies sx of UA & HF. Performs ADLs without limitation. Home meds include Aspirin, Plavix, Lopressor, Lasix, & Vytorin. Does he need a pre-op stress test?

11. ACC 2002 Guidelines

17. ACC 2007 Guidelines

18. Duke Activity Status Index

19. Sum of the values for all 12 questions –Range = 0 to 58.2 Estimated VO 2 max in ml/kg/min = (0.43 x DASI) + 9.6 Divide by 3.5 to get METs –Range = 2.7-9.9 METs Hlatky MA. Am J Cardio 1989; 64: 651-654.

20. ACC 2007 Guidelines

21. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Recommendations for Noninvasive Stress Testing According to the ACC/AHA Guidelines (2007)

22. Case #3 A FP from NHCP pages you & asks for your advice: –A 45 yo woman with no active cardiac conditions & no clinical risk factors is awaiting surgery for a recurrent menigioma. –A pre-op EKG demonstrated TWI. –A MPI study demonstrated a partially reversible defect of the anteroseptal wall. Can she proceed with her surgery?

23. Coronary Artery Revascularization Prophylaxis (CARP) Trial 5859 patients undergoing vascular surgery at 18 VAMCs between MAR 1999 & FEB 2003 510 patients (9%) were eligible –≥ 1 coronary artery with ≥ 70% stenosis –Excluded LMCA disease & LVEF < 20% Randomized to pre-op revascularization (258) or no revascularization (252) –Revascularization: PCI 59% & CABG 41% McFalls ED. N Engl J Med 2004; 352: 2795-2804.

24. Coronary Artery Revascularization Prophylaxis (CARP) Trial Revascularization… –Delayed surgery (54 days vs. 18 days) –Did not reduce mortality 30 days(3.1% vs. 3.4%) 2.7 years(22% vs. 23%) –Did not prevent peri-op MI (11.6% vs. 14.3%) McFalls ED. N Engl J Med 2004; 352: 2795-2804.

25. ACC 2007 Guidelines

27. Case #4 A 79 yo WM with distant hx of MI (but nonobstructive CAD on LHC 9/02), HTN, DLP, & PAD is awaiting surgical hemorrhoidectomy. Denies sx of UA or HF Rides stationary bike for daily exercise Home meds include Aspirin, Plavix, Adalat, Monopril, & Zocor What other type of medication could help lower his risk of peri-operative MACE?

28. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Perioperative Beta-Blocker Therapy

29. Lindenauer PK. N Engl J Med 2005; 353: 349-361. Retrospective study –782,969 patients undergoing major noncardiac surgery at 329 US hospitals between JAN 2000 & DEC 2001 –85% of patients had no contraindication to beta blocker therapy (BBT) –18% of eligible patients received BBT during first two days of hospitalization –2.0% of eligible patients died during hospitalization

30. Lindenauer PK. N Engl J Med 2005; 353: 349-361. RCRI ScoreIn-Hospital Mortality OR 01.36 11.09 20.88 30.71 ≥ 40.58

31. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo (DECREASE) Study 1476 patients undergoing major vascular surgery at 5 centers between 2000 & 2005 770 intermediate-risk patients (1-2 CRFs) randomized to pre-op stress test (386) or no pre-op stress test (384) All received peri-op beta blocker therapy with goal resting HR 60-65 bpm Poldermans D. J Am Coll Cardiol 2006; 48: 964-969.

32. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo (DECREASE) Study Primary endpoint = composite of cardiac death & nonfatal MI at 30 days post-op –No pre-op stress test1.8% –Pre-op stress test2.3% –Odds Ratio0.78 (p = 0.62) “Cardiac testing can safely be omitted in intermediate-risk patients, provided that beta blockers aiming at tight heart rate control are prescribed.” Poldermans D. J Am Coll Cardiol 2006; 48: 964-969.

33. PeriOperative ISchemic Evaluation (POISE) Trial 8351 patients undergoing noncardiac surgery at 190 centers in 23 countries between OCT 2002 & JUL 2007 Randomized to metoprolol succinate (Toprol XL) vs placebo –100 mg 2-4 hours before surgery if HR >50 & SBP >100 –100 mg within 6 hours after surgery –200 mg/day starting 12 hours after first post-op dose –Continued for 30 days post-op Devereaux PJ. Lancet 2008; 371: 1839-1847.

34. PeriOperative ISchemic Evaluation (POISE) Trial Primary endpoint = composite of cardiac death, nonfatal MI, & nonfatal cardiac arrest at 30 days post-op –Metoprolol5.8% –Placebo6.9% –Hazard ratio0.84 (p = 0.04) Devereaux PJ. Lancet 2008; 371: 1839-1847.

35. PeriOperative ISchemic Evaluation (POISE) Trial MetoprololPlaceboHRP value Composite5.8%6.9%0.840.04 MI4.2%5.7%0.730.002 Death3.1%2.3%1.330.03 Stroke1.0%0.5%2.170.005 Bradycardia6.6%2.4%2.74<0.001 Hypotension15.0%9.7%1.55<0.001 Devereaux PJ. Lancet 2008; 371: 1839-1847.

36. ACC 2007 Guidelines

37. Case #5 A 64 yo FM with CAD s/p PCI with BMS in 2001, DM, DLP, HTN, & CVA is awaiting surgery for a H&N cancer. He is asymptomatic & has a moderate functional capacity by self-report. His home medications include Aspirin, Plavix, Tenormin, Zestril, Lopid, & Glucovance. What other type of medication could help lower his risk of peri-operative MACE?

38. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Perioperative Statin Therapy

39. Lindenauer PK. JAMA 2004; 291: 2092-2099. Retrospective study –780,591 patients undergoing major noncardiac surgery at 329 US hospitals between JAN 2000 & DEC 2001 –9.9% received lipid-lowering therapy (LLT) during first two days of hospitalization –3.0% of patients died during hospitalization Treatment with LLT was associated with a lower rate of peri-op mortality (2.1% vs. 3.1%, p < 0.001)

40. Lindenauer PK. JAMA 2004; 291: 2092-2099. RCRI ScoreMortality (%)NNT 01.4186 12.6103 24.560 37.139 49.330

41. Durazzo AES. J Vasc Surg 2004; 39: 967-975. 100 patients undergoing vascular surgery at a single center between APR 1999 & AUG 2000 Randomized to Atorvastatin 20 mg/day vs. placebo –Surgery performed 30 days later –Follow up thru 6 months post-op Primary endpoint = composite of cardiac death, MI, UA, & stroke –Atorvastatin 8% vs Placebo 26% (p = 0.03)

42. Case #6 79 yo WM with CAD s/p PCI to PDA with PES in JUN 2008, AS s/p AVR in 2000, HTN, DLP, & CVA in 2004 is awaiting repair of a right inguinal hernia. Denies sx of UA & HF. Performs ADLs without difficulty. Home meds include Aspirin, Plavix, Lopressor, Monopril, & Zocor. When can he undergo hernia repair?

43. ACC 2007 Science Advisory “Elective procedures for which there is significant risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate course of thienopyridine therapy.” “For patients with DES who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued it at all possible and the thienopyridine restarted as soon as possible after the procedure.” Grines CL. Circulation 2007; 115: 813-818.

44. ACC 2007 Guidelines

45. Case #7 A 70 yo WM with 2V CAD (only the LAD is patent) but no prior revascularization & severe COPD undergoes a hemicolectomy for colon cancer. He has intermittent tachycardia & hypotension post-op. An EKG on POD #3 demonstrates sinus tachycardia with diffuse, deep, horizontal ST segment depression. The first set of cardiac markers is significantly elevated. Upon transfer to the ICU, he has PEA arrest. Prolonged ACLS is unsuccessful. What steps could have been taken to diagnosis his peri- op MI sooner?

46. Surveillance for Perioperative MI “In patients with high or intermediate clinical risk who have known or suspected CAD and who are undergoing high- or intermediate-risk surgical procedures, the procurement of ECGs at baseline, immediately after the surgical procedure, and daily on the first two days after surgery appears to be the most cost- effective strategy.” ACC/AHA 2007 Perioperative Guidelines

47. ST-Segment Monitoring Class IIa –Can be useful to monitor patients with known CAD or those undergoing vascular surgery Class IIb –May be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery ACC/AHA 2007 Perioperative Guidelines

48. ST-Segment Monitoring Computerized ST-segment trending is superior to visual interpretation Most studies examining the predictive value of ST-segment changes have used ambulatory ECG monitors No studies have examined the effect on outcome when therapy is based on ST- segment changes

49. Troponin Class I –Troponin measurement is recommended in patients with ECG changes or chest pain typical of ACS Class IIb –Use of troponin measurement is not well established in patients who have undergone vascular or intermediate-risk surgery but are clinically stable ACC/AHA 2007 Perioperative Guidelines

50. Troponin Measurement of troponin (rather than CK or CK-MB) detects much smaller amounts of myocardial injury Troponin elevation (unlike ST-segment changes) is not associated consistently with adverse CV outcomes No studies have examined the effect on outcome when therapy is based on results of troponin elevation

51. PA Catheter Class IIb –May be reasonable in patients at risk for major hemodynamic disturbances that are easily detected by a PAC –Decision must be based on 1) patient, 2) surgical procedure, and 3) practice setting ACC/AHA 2007 Perioperative Guidelines

52. References ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. http://content.onlinejacc.org/cgi/content/full /50/17/e159. http://content.onlinejacc.org/cgi/content/full /50/17/e159 Poldermans D, Hocks SE, Feringa HH. “Pre-Operative Risk Assessment and Risk Reduction Before Surgery.” J Am Coll Cardiol 2008; 51: 1913-1924.

53. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Perioperative Cardiac Events

54. Postoperative MI

55. Management Recent surgery is… –an absolute contraindication to fibrinolytic therapy –a relative contraindication to PCI Emergent or urgent revascularization should not be performed in cases of MI secondary to… –Tachycardia –Hypertension –Anemia –Pulmonary embolism

56. Management Standard medical therapy is beneficial –Aspirin –Beta blocker –ACE inhibitor –Statin Noninvasive testing should be performed for risk stratification before discharge –TTE –MPI study

57. Anticoagulation

58. ACCP 2008 Guidelines

59. 2006 ACC VHD Guidelines

60. 2006 ACC AF Guidelines

61. Pacemakers / ICDs

62. ACC 2007 Guidelines

64. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Prophylactic Coronary Revascularization

65. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924 Heart Rate Control

66. Poldermans D. Circulation 2003; 107: 1848-1851. Case-control study –2816 patients undergoing vascular surgery at a single center between 1991 & 2000 –160 patients (5.8%) died during hospitalization Statin therapy was less common in cases than in controls (8% vs. 25%, p < 0.001) Adjusted OR for peri-op mortality for statin use vs. nonuse = 0.22

67. StaRRS Study: Statins for Risk Reduction in Surgery Retrospective study –1,163 patients undergoing vascular surgery at a single center between JAN 1999 & DEC 2000 –45.2% received statins Peri-op cardiac complications (death, MI, ischemia, CHF, or VA) –13.5% overall –9.9% among statin users –16.5% among statin nonusers –Adjusted OR = 0.52 (p = 0.001) O’Neil-Callahan K. J Am Coll Cardiol 2005; 45: 336-342.