Transcript Preoperative Risk Stratification for Noncardiac Surgery

Cardiac Issues With
Noncardiac Surgery
Joseph F. Winget, MD FACC
Clinical Assistant Professor
University of Vermont Medical School
Champlain Valley Cardiovascular Associates, P.C.
Objectives
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Preoperative risk assessment
Anticoagulation and antithrombotic issues
Postoperative Management
Endocarditis prophylaxis
Disclosures
• None
Surgery or not?
• 87 year old white female
with known critical AS fall
and breaks her hip.
• No CHF, MI, syncope
• Stable and relatively
independent before the
fall.
• LVEF 65%
• 82 year old white male
with known CAD. Stable
angina pectoris.
• Catheterization shows
occluded LAD which was
fed by collaterals
• No CHF
• AODM and HTN
• Severe worsening spinal
stenosis and weakness
• LVEF 50%
Preoperative cardiac issues
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How healthy is the patient?
How active is the patient?
How risky in the planned surgery?
Is preoperative cardiac testing necessary?
What preventive measures can be taken
to reduce cardiac risk?
L’Italien JACC 1996;27:779
JACC 2002; 39:542
JACC 2002 39:542
Is testing predictive of outcomes?
Circ 1997; 95: 53
Cardiac event rates and
dobutamine echocardiography
JAMA 2001; 285:1865
Who to test?
• Intermediate risk patients undergoing
intermediate or high risk surgery
• Testing does not add additional
information in low risk or high risk patient
groups.
What test?
• Well validated
– Exercise or
pharmacologic
echocardiography
– Exercise or
pharmacologic
Cardiolite
• Not well validated
– CTA
– MRI
– Cardiac angiography*
Therapies to reduce perioperative
cardiac complications
• Revascularization
– Percutaneous revascularization
– CABG
• Medical therapy
Benefit of CABG
Circ 1997; 96: 1882
Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or
No Coronary-Artery Revascularization before Elective Major Vascular Surgery
McFalls E 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
McFalls E et al. N Engl J Med 2004;351:2795-2804
Medical therapy to lower risk
Lindenauer, PK JAMA. 2004 May 5; 291(17)2092
Beta blocker use?
NEJM 1996; 335:1713
Beta blocker use?
Recommendations
• Revascularization for appropriate clinical
indications
• Maximize adjuvant medical therapy
– Aspirin
– Statin
– Beta blocker
• Close perioperative follow-up
– Prolonged telemetry monitoring
Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical
conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of
age or greater
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Surgery or not?
• 87 year old white female
with known critical AS fall
and breaks her hip.
• No CHF, MI, syncope
• Stable and relatively
independent before the
fall.
• 82 year old white male
with known CAD. Stable
angina pectoris
• Catheterization shows
occluded LAD which was
fed by collaterals
• No CHF
• AODM
• Severe worsening spinal
stenosis and weakness
Cardiac Issues in noncardiac
surgery
• Establish patient risk
• Assign procedural risk
• Test intermediate risk patients undergoing
intermediate or high risk surgery
• Optimize medical therapy
• Revascularization when clinically indicated
• ACC/AHA Guidelines JACC 2007; 50:
1707-1732
Anticoagulation / Antiplatelet
Agents
• 55 year old male s/p
CABG in 2000. Drug
eluting stent placed to
native vessel in
August of 2008.
• Needs colonoscopy
• Can plavix and aspirin
be safely stopped?
• 70 year old white
female with chronic
AF needs shoulder
surgery
• History of CVA
• Warfarin 5 mg daily
• Does the patient need
some form of bridging
preoperatively?
Anticoagulation / Antithrombotic
Issues
• Anticoagulants – warfarin
– Atrial fibrillation
– Venous thrombosis
– Prosthetic heart valves
• Antithrombotic agents – clopidogrel
– Bare metal stents vs. drug eluting stents
Do you need to stop antiplatelet /
anticoagulation therapy?
• Procedural risk for bleeding
– Low risk for bleeding
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Athrocentesis
Cataract surgery
Dental cleaning / extraction
Cutaneous surgery
CHADS score - AF
Circulation 2004; 110:2287
JAMA 2001; 285:2864
Atrial fibrillation
• Bridge
– AF and prosthetic
valves
– AF and significant LV
dysfunction (EF<40%)
– AF and any prior
thrombotic event
(CVA, TIA, arterial
emboli)
– “high risk” patients
• No bridging
– Low risk patients
How to bridge
• Stop warfarin for 48 hours
• Start lovenox at 1mg/kg SQ BID for 6
doses
• Stop lovenox the morning before surgery
Prosthetic heart valves
• Bioprosthetic valves
– All, if in atrial fibrillation
• Mechanical valves
– All, regardless of rhythm
Venous thrombosis
• Deep venous thrombosis
• Pulmonary emboli
• Hypercoagulable states
– Factor V Leiden
– Protein C / S deficiencies
– Lupus anticoagulant
How to Bridge
• Stop warfarin
• Start replacement therapy once INR < 2.0
– IV heparin
– SQ low molecular weight heparin - lovenox
Coronary stents
Recommendations – stent patients
• Bare Metal Stents
– Delay elective
procedures for at least
1 month and
preferably 6 months
– Restart clopidogrel as
soon as possible
– Loading dose?
• Drug eluting stents
– Delay elective
procedures for 1 year
– Continue aspirin
– Restart clopidogrel as
soon possible
– Loading dose?
Proposed approach to the management of patients with previous percutaneous coronary
intervention (PCI) who require noncardiac surgery, based on expert opinion
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Improved cardiac care for
noncardiac surgery?
Yes, we can!
Perioperative Medication
Management
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Beta Blockers
Alpha agonists
Calcium blockers
ACE / ARB
• Statins
• Diuretics
continue
continue
continue prn
stop preoperatively
start when stable
continue
as needed
Endocarditis prophylaxis
• 70 year old female with rheumatic valvular
heart disease and Bjork-Shiley MVR in
1984 needs dental work.
• Are antibiotics required?
SBE prophylaxis
• Antibiotics
– All Prosthetic valves
– Prior bacterial
endocarditis
– Cyanotic congenital
heart disease (CHD)
– Any repair CHD with
prosthetic material *
Circ 2007; 115
• No Antibiotics
– Uncomplicated
valvular heart disease
– Pacemakers or
defibrillators
– Hypertrophic
cardiomyopathy