Transcript preoperative assessment of cardiac patients for non

PREOPERATIVE ASSESSMENT
OF
CARDIAC PATIENTS FOR
NON CARDIAC SURGERY
Nabila Fahmy, MD
Ain shams university
2006
Goals of anesthesia for patients
with CVS diseases:
1.Cardiopulmonary : adequate oxygenation
and adequate balance of myocardial O2
supply to demand throughout. So, decrease
the risk of perioperative ischemia and
infarction.
2.Tissues : adequate CO and ABP to allow
adequate tissue and organ perfusion
especially cerebral, coronary, renal and
hepatic.
Purpose of Preoperative
Cardiac Evaluation
Define patient’s current cardiac status.
 Assess and project perioperative CV risk.
 Determine if preoperative testing is needed to
define cardiovascular status - recommended only
if it will change surgical care or perioperative
medical therapy.
 Initiate management to minimize cardiac risk
over the entire perioperative period, and
subsequently.

Preoperative management and
assessment




Patient.
Surgical procedures.
Cardio protective treatment.
Preoperative investigations.
General Approach to the
Patient - History


“Have you ever had any problem with your heart or arteries?”
“Do you exercise?” Typical responses …
– “I try to.”
Translation: “No.”
– “Not as much as I should.” Translation: “No.”
– “I’m active.”
Translation: “No.”




“What exercise do you do? Tell me the most physically strenuous thing
you did in the last 2 weeks.”
Is there real (exertional) angina, recent or past MI, HF, documented
arrhythmia, pacemaker or ICD?
Any history or other indicators of atherosclerotic vascular disease?
CAD risk factors and “doses of risk factors”
Preoperative risk scoring and
predictors of cardiac morbidity and
mortality
MULTIFACTORIAL INDEX OF CARDIAC RISK
,GOLDMAN,1977
RISK FACTOR
NO OF POINTS
 S3 GALLOP, INCREASED JVP .
 PREVIOUS MI ( LESS THAN 6 MONTHS ).
 PVE (MORE THAN 5 / MIN ).
 ATRIAL DYSRHYTHMIAS, OTHER THAN SINUS.
 AGE GREATER THAN 70 Y.
 EMERGENCY OPERATION.
 SEVERE AORTIC STENOSIS.
 POOR GENERAL CONDITION.
 INTRAPERITONEAL OR INTRATHORACIC OPER.
• > 26 ONLY LIFE-SAVING OPERATION CONTEMPLATED.
•
•
•
13 -25 CARDIAC CONSULTATION IS ESSENTIAL.
5 - 13 Varying degrees of cardiac risks (0.7-5%).
0 - 5 (0.3 - 3% risk)
11
10
7
7
7
5
3
3
3
MODIFIED MULTIFACTORIAL INDEX (DETSKY
ET AL,1986) for vascular surgery
 MI WITHIN 6 MONTHS.
 MI MORE THAN 6 MONTHS.
CANADIAN CV SOCIETY ANGINA
 CLASS 3.
 CLASS 4.
 UNSTABLE ANGINA WITHIN 3 MON.
ALVEOLAR PULMONARY EDEMA
 WITHIN 1 WEEK.
 EVER.
 VALVULAR DISEASE (CRITICAL AS).
 SINUS ATRIAL PREMATURE BEATS.
 MORE THAN 5 PREMATURE VENTRICULAR BEATS.
 AGE OVER 70 YEARS.
 EMERGENCY OPERATION.
 POOR GENERAL PHYISICAL STATUS.
10
5
10
20
10
10
5
20
5
5
5
10
5
> 30 ( High risk ) / 20-30 (intermediate risk) / 0 – 20 ( low risk)
Patient-specific Clinical Predictors of Increased Perioperative
Cardiovascular Risk (ACC/AHA Guidelines)
Major predictors
Unstable coronary syndromes.
-Recent myocardial infarction
with evidence of important
ischemic risk or clinical symptoms
or noninvasive study.
-Unstable or severe †angina
(Canadian class III or IV).
Decompensated congestive heart
failure.
Significant arrhythmias.
-High-grade atrioventicular
block
-Symptomatic ventricular
arrhythmias in the presence of
underlying heart disease.
-Supraventicular Arrhythmias
with uncontrolled ventricular rate.
Severe valvular disease.
Intermediate
 Mild
angina
predictors
(Canadian class I or
II)
 Previous MI by
history or
pathological Q waves.
 DM especially
insulin dependent.
 Renal insufficiency.
Minor
Advanced
age.
Abnormal
electrocardiogram (left
ventricular hypertrophy, left
bundle branch block, ST-T
abnormalities)
Rhythm other than sinus
(e.g. atrial fibrillation)
Low functional capacity
(e.g. inability to climb one
flight of stairs with a bag of
groceries)
History of stroke
Uncontrolled systemic
hypertension.
The Functional status of the patient.
Estimated Energy Requirements for Various activities
1 MET
-Can you take care of 4 METs
yourself?
Eat, dress, or use the toilet?
-Walk indoors around the
house?
Walk a block or two on
ground level at 2 or 3 mph
or 3.2 to 4.8 km/h?
-Do light work around the
house like dusting or
washing
dishes?
-Climb a flight of stairs or walk
up a hill?
-Walk on level ground at 4mph
or 6.4 km/h?
-Do heavy work around the
house like scrubbing floors or
lifting or moving heavy
furniture?
-Participate
in
moderate
recreational activities like golf,
bowling,
dancing
doubles
tennis, or throwing a baseball or
football
>10 METs -Participate in strenuous sports
like swimming, single tennis,
football, basketball or skiing?
Exercise capacity integrates the
physiologic effects of all the patient’s
combined cardiac abnormalities.
If history reveals
GOOD EXERCISE CAPACITY,
then the patient’s operative risk is low.
General Approach to the Patient  Physical Examination –
general
appearance, bruits, rales, elevated JVP,
heart rate & rhythm, murmurs of
severe AS or MS
 Comorbidity: renal impairment,
diabetes, pulmonary disease
Q: Which cardiac conditions worry me
most?
A:
Severe stenotic (flow-limiting) lesions:
 coronary - disease severity and extent
 AS > MS
 severe pulmonary hypertension
 Regurgitant valvular lesions are rarely a problem
perioperatively.
 I am less concerned about CHF or arrhythmia in the
absence of ischemia. Both are readily treated and usually
without permanent sequelae, unlike MI and death.
 AF is, however, a potentially costly (in money and
morbidity) nuisance. Avoid it.
Preoperative management and
assessment
 Patient.
 Surgical procedures.
 Preoperative investigations.
 Cardio protective treatment.
Surgical procedures.
Type and site of surgery
Duration of surgery >3 hrs
Type and site of
Consider to be a risk factor
surgery
High risk
Intermediate
risk
Low risk
Cardiac Risk Stratification for
Different Types of Surgical
Procedures (Eagle et al,2002)
High risk
> 5 % chance of death or non-fatal myocardial Infarction
 Emergency surgery especially in the elderly.
 Procedures with massive blood loss or fluid shifts.
 Major vascular surgery.
Peripheral vascular surgery .
Intermediate risk
1- 5% chance of death or non-fatal myocardial Infarction
 Carotid artery surgery.
 Elective intra-abdominal or intra-thoracic surgery.
 Prostatic surgery.
 Major head and neck surgery.
 Orthopedic surgery.
Low risk
< 1% chance of death or non-fatal myocardial Infarction
 Endoscopic surgery.
 Ocular surgery.
 Peripheral surgery.
 Breast surgery.
preoperative cardiac assessment
Stepwise approach to preoperative cardiac Assessment.
yes
Step 1
Emergency surgery
OR
No
Step 2
yes
CC for
further investigation
How can we collect
preoperative
No
data
in a guideline?
Coronary
revascularization
within the last 5 years yes
OR
Step 3
Major Clinical predictors
Without significant change in the symptoms
No
Favorable cardiac evaluation in 2 years
Step 4
Step 5
No
low
Risk of surgery
yes
OR
high
intermediate
OR
Step 7
Step 6
For intermediate risk surgery
Step 6
One intermediate
Clinical predictor
And
Poor functional status
NO
OR
yes
Consider CC for
Further investigation
For High risk surgery
Step 7
Intermediate clinical predictor
OR
Poor functional status
Yes
Consider C C for
Further investigation
NO
OR
Preoperative management and
assessment
 Patient.
 Surgical procedures.
 Preoperative investigations.
 Cardio protective treatment.
Preoperative investigations
shows;
•
1.ECG
Pathologic Q wave ( > 1 mm wide ) indicates infarction.
- Anterior wall: L1 and aVL +
V & V2
Anteroseptal (occlusion of left anterior descending artery).
V3 & V4
Strictly anterior (occlusion of left anterior descending artery).
V5 & V6
anterolateral (occlusion of left anterior descending artery or
1
left circumflex artery or a branch of the right coronary artery ).
- Inferior wall : L II,III and aVF
(occlusion of right coronary artery)
• Poor R wave progression.
• The ST segment shows one of the following;
- A transient depression indicates subendocardial ischemia
(classic angina).
- A Persistent depression indicates subendocardial infarction.
- A transient elevation indicates transmural ischemia (Variant
angina ).
- Non-specific changes.
• T wave changes.
• Long QT interval.
• Dysrhythmias or heart block.
2.Chest X ray:
to exclude cardiomegaly and pulmonary
vascular congestion.
3.Holter (Continuous Ambulatory) ECG
monitor
to evaluate ;
• Severity and frequency of ischemic
episodes.
• Silent ischemia.
• Dysrhythmias and anti-arrhythmic drugs.
4.Exercise ECG:
•
It has a sensitivity of 65-80% and specificity of 90% A
normal test does not necessarily exclude coronary artery
disease, but can indicate severe multi-vessel disease by;
- > 2 mm horizontal or down sloping ST depression.
- Persistence of ST depression after exercise for 5 min or
longer.
- Sustained decrease in systolic BP >15 mm Hg for 10 min
or longer after exercise.
- Failure to reach a maximum heart rate of > 70 % of
the predicted.
- Frequent or complex ventricular Dysrhythmias at a low
heart rate.
5.Cardiac Enzymes:
Cardiac Enzymes
Onset
Peak Duration
S. creatine kinase
(MB isoenzyme)
3
hrs
12
hrs
36
hrs
Lactate dehydrogenase
(type 1 )
2
days
6
days
12
days
Cardiac troponin I
3.8
hrs
18
hrs
7 – 10
days
Cardiac troponin T
3-12
hrs
24
hrs
10 – 14
days
N.B; In unstable angina, CK-MB is not elevated, but troponin I
and T may be elevated indicating the presence of
micro-infarction.
Thallium Imaging (Scintigraphy) :
6.
•
Presence of a cold spot (i.e. does not take thallium) during
Stress only indicates ischemia, but a constant cold spot
indicates infarction.
•
Stress can be induced by either;
-
Exercise.
OR
- Pharmacologically: which is indicated in:
Intolerance to exercise e.g. peripheral vascular
disease.
o Aortic aneurysm as exercise may cause its rupture.
o
By: a - Drugs producing coronary VD as;
Adenosine
-
Dipyridamole
b - Drugs increasing myocardial O2 demand as;
Dobutamine
7.
-
Isopreternol
Radionuclide Angiography:
- It has a 90% specificity and sensitivity.
- It detects new abnormal wall motion
and the ejection fraction.
8.
Two Dimensional Echocardiography:
- It detects abnormal wall motion
abnormalities and evaluates cardiac
function.
- Stress echocardiography can be done after
dobutamine injection.
9. Coronary Angiography and
Cardiac Catheterization:
• It is the gold standard for evaluation of
Coronary artery disease.
• It detects sites of obstruction and evaluates
ventricular and valve functions.
• It is done to assess the patient’s benefit before;
- Percutaneous transluminal coronary
angioplasty.
Or
- Coronary artery bypass grafting.
Summary of American College and American Heart Association
guidelines for cardiac evaluation before nonemergent,
noncardiac surgery
DoMajor
WeClinical
Have
To Do All These Tests?
Predictors
A stepwise algorithm to determine the need for testing
proposed by the ACC/AHA task force is based on available
evidence and expert opinion, and integrates clinical history,
surgery specific risk, and exercise tolerance.
Endoscopic procedure
Ocular surgery
Preoperative non-invasive testing in
known or suspected CAD - Which
patient?
 poor or unknown functional capacity: can’t exercise,
don’t exercise
 known or suspected CAD: angina, prior MI based on
history or pathological Q waves, CAD-equivalent
(peripheral vascular disease), risk factor profile
 known or suspected significant AS, MS, pulmonary
HTN
 high surgical risk procedure: aortic or peripheral
vascular, BIG SURGERY
Preoperative non-invasive testing
in known or suspected CAD - Which
test?
rest echocardiography: but little insight into CAD
 simple treadmill: exercise capacity
 stress or dobutamine echo

•

but dobutamine in aortic aneurysm ???
myocardial perfusion imaging - exercise or dipyridamole
EXERCISE WHENEVER POSSIBLE.
Preoperative management and
assessment

Patient.
 Surgical procedures.
 Preoperative investigations.
 Cardio protective treatment.
C: Cardio protective treatment.
Medications
 Sedatives.
Alternative
strategies
 Nitroglycerin.
 Calcium Channel Blockers.
 Beta-Adrenergic Blockers.
Anti platelet drugs ( aspirin – clopidogrel ).
 α-2 agonists.
B-Blockers
 B-blockers protect against early adverse cardiac
outcome after surgery.
 This protective effect can continue long.
 Their administration did reduce mortality by

almost 55% over 2 years after surgery .
(Mangano et al, 1996 - Poldermans, 2001).
How often are B-blockers
used or underused?
Survey of Canadian Anesthesiologists
(VabDenKerkhof, 2003)
93% of anesthesiologists agreed that B
blockers are beneficial in patients with
known CAD.
Only 57% reported B-blockers’ use in these
patients.
Only 34% of those regular users continue B
blockers beyond early postoperative period.
What are the starting time, hemodynamic
targets, and duration of perioperative
B-blockers use?
 Start as soon as the high-risk is confirmed i.e.
days or weeks before surgery to achieve a
resting HR of 60 beats/min.
 Additional noninvasive dobutamine stress
echocardiography testing could be useful in
titration of B blockers in relation to HR at
which myocardial ischemia is induced.
 Continue in the postoperative period.
Cautious enthusiasm for the use of
perioperative B-Blockers.
 Severe LV dysfunction.
 Exacerbation of reactive airway disease.
 Insulin dependent diabetes. (?)
 Major atrioventricular nodal conduction
disease without pacemaker.
C: Cardio protective treatment.
Medications
Alternative
strategies
Alternative cardio protective
treatment strategies

CABG.

Percutaneous transluminal angioplasty
with coronary stenting.

Hydroxymethylglutaryl coenzyme A
reductase inhibitors (statins).
HMG COA–reductase inhibitors
(Statins)

Attenuates cardiac risk from anesthesia and
surgery.

It has direct anti-inflammatory effects and
reverses endothelial dysfunction by increasing
NO production and scavenging O2 free
radicals.

It did reduce perioperative mortality by 4.5%
folds (poldermans et al, 2003).
Recommendations for Coronary Angiography in
Perioperative Evaluation (ACC/AHA Guidelines)
Patients with suspected or known CAD
Evidence for high risk of adverse outcome based on
noninvasive test results
 Angina unresponsive to adequate medical therapy
 Unstable angina, particularly when facing
intermediate-risk or high-risk noncardiac surgery
 Equivocal noninvasive test results in patients at highclinical risk undergoing high-risk surgery

Q. When is revascularization (PCI, CABG)
recommended ? (ACC/AHA Guidelines)
A. Generally only when justified
by the usual clinical
factors, apart from planned non-cardiac surgery.
 No randomized trials document decreased perioperative cardiac
events.
 The decision to perform revascularization on a patient before
noncardiac surgery to “get them through” the noncardiac procedure is
appropriate only in a small subset of very-high-risk patients
 Lt Main Stenosis
 3 vessels with left ventricle dysfunction
 2-vessel disease involving severe proximal left anterior descending
artery obstruction, and intractable coronary ischemia despite
maximal medical therapy
 No prospective studies have determined optimal period of delay
after PCI before noncardiac surgery.
 Delay of 2-4 weeks after PCI with stent placement is supported
by observational study.
Q: Would you recommend that the surgery be
postponed for a certain period of time?
A1: In patients with previous MI without coronary
revascularization
 In the past there was general recommendation to delay
surgery 6 months after MI.
 However according to 2002 ACC/AHA practice guideline
recent MI defined as (MI less than 1 month).
 So it appears reasonable to wait 4 -6 weeks after MI to
perform elective surgery.
A2:In patients with valvular heart disease
–
–
–
If the aortic stenosis is severe and symptomatic,
elective noncardiac surgery should generally be
postponed or canceled.
Significant mitral stenosis increases the risk of HF.
However, preoperative surgical correction of mitral
valve disease is not indicated before noncardiac
surgery
When mitral stenosis is severe, the patient may
benefit from balloon mitral valvuloplasty or open
surgical repair before high-risk surgery
ACC/AHA guideline update for perioperative cardiovascular
evaluation for noncardiac surgery Anesth Analg 2002;94:1052
Conclusions (ACC/AHA Guidelines)
 Insure good communication between surgeon, anesthesiologist,
primary care physician, and consultant.
 Further cardiac testing and treatment generally are the
same as in the non-operative setting, considering:
 the urgency of the noncardiac surgery
 patient-specific risk factors
 surgery-specific factors
 Preoperative testing:
 when surgical risk is high.
 when patient-specific and surgery-specific risks are intermediate.
 when results will affect patient management.
Questions you should always ask yourself
 Is there CAD?
 If there is,
 how severe?
 how extensive?
 how “active”?
 How “big” is the
surgery?
 Is there severe …
 AS, MS
 pulmonary hypertension