Transcript Perioperative Cardiovascular Evaluation

Perioperative
Cardiovascular Evaluation
SooJoong Kim, MD, PhD.
Department of Cardiology, Internal Medicine,
Kyunghee University Medical Center
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30 million pt. with surgery :
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CAD or risk factors in 1/3
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One million op. complicated by adverse C-V events
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high risk populations(vascular op.) : periop. MI in 34%
(mortality rate 25%)
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Perioperative cardiac evaluation
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What is the risk of cardiac complications during & after surgery?
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How can that risk be reduced or eliminated ?
Role of Medical Consultant
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Preoperative assessment
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Identification of modifiable risk factors
Optimization of the condition of pt. for op.
Prompt, Precise, & Thorough
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Written recommendation – overlooked
Communication & timely follow-up
Accurate
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Clinical criteria : significant predictors of adverse cardiac
outcomes
Efficient
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Each clinical variable adds independent & useful
information to overall risk assessment
Timely
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So as not to unnecessary delays in decision to perform or
postpone the planned surgery
 Accurate stratification of patients into lower and
higher risk groups
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Risk evaluation
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Are there interventions to reduce risk ?
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Do these interventions expose the patient to
potential harm or cause unnecessary delays in
surgery ?
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Does the benefit of the intervention justify the
risks ?
Availability of effective interventions
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Ix. for further cardiac testing & tx.
: Same as in non-op. setting
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timing is dependent on
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the urgency of noncardiac surgery
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the patient’s risk factors
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Specific surgical considerations.
Preoperative testing should be limited to circumstances in
which the results will affect treatment and outcomes.
Perioperative evaluation
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Patient-specific
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Procedure-oriented
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Time-focused
Cardiovascular risk assessment
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Preop. evaluation : focus on C-V system
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Cardiac events : primary cause of death after op.
Thorough examination for occult CAD
Optimization of existing CAD
Op. performed safely, even in significant
cardiac disease
Cardiovascular risk assessment
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Significant postop. cardiac events
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Unstable angina
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MI
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Pulmonary edema
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Serious arrhythmias (VT, VF)
Cardiovascular risk assessment
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Goldman & colleagues
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Nine risk factor index (Hx, P/Ex, ECG, activity
level, Lab, type of op.)
Mangano & Goldman
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Five independent preop. clinical predictors of
postop. myocardial ischemia
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HTN, ECG-LVH, DM, CAD, digoxin use
Jeffrey & colleagues / Zeldin
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Underestimation of risk of C-V events in major
abdominal aortic op.
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Overestimation of cardiac Cx. in high risk pt.
Cardiovascular risk assessment
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Six independent predictors of cardiac complications
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high-risk surgery (procedures with a 5% or higher risk of
cardiac complications, such as vascular and prolonged
intraperitoneal or intrathoracic operations)
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history of ischemic heart disease
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history of congestive heart failure
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history of cerebrovascular disease
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preoperative treatment with insulin
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preoperative serum creatinine > 2.0 mg/dL.
rates of major cardiac complications
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0, 1, 2, or 3+ criteria  0.5%, 1.3%, 4%, and 9%,
Lee TH, et al. Circulation 1999;100:1043 – 1049.
Cardiovascular risk assessment
ACC/AHA Consensus
1. Clinical markers or predictors (pt.-specific)
Angina, previous MI, CHF, DM
major, intermediate, minor groups
2. Level of functional capacity
4 MET
poor functional capacity : a/w cardiac event after op.
3. Surgery specific risks
Cardiovascular risk assessment
Clinical predictors of periop. C-V risk
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Major clinical predictors
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Unstable coronary syndromes
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Acute (< 7D) or recent(7~30) myocardial infarction with evidence of
important ischemic risk by clinical symptoms or noninvasive study
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Unstable or severe angina (Canadian class III or IV)
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Decompensated heart failure
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Significant arrhythmias
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High-grade atrioventricular block
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Symptomatic ventricular arrhythmias in the presence of underlying
heart disease
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Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
Cardiovascular risk assessment
Clinical predictors of periop. C-V risk
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Intermediate clinical predictors
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Mild angina pectoris (Canadian class I or II)
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Previous myocardial infarction by history or pathological
Q waves (>1M)
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Compensated or prior heart failure
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Diabetes mellitus (particularly insulin-dependent)
5.
Renal insufficiency (> 2mg/dL)
Cardiovascular risk assessment
Clinical predictors of periop. C-V risk
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Minor clinical predictors
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Advanced age
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Abnormal ECG (LVH, LBBB, ST-T abnormalities)
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Rhythm other than sinus (e.g., atrial fibrillation)
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Low functional capacity (e.g., inability to climb one flight
of stairs with a bag of groceries)
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History of stroke
6.
Uncontrolled systemic hypertension
Cardiovascular risk assessment
Level of functional capacity
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4 MET
Perioperative cardiac and
long-term risks increased in
patients < 4-MET
Cardiovascular risk assessment
Surgery specific risks
Cardiac risk > 5%
Cardiac risk 1~5%
Cardiac risk < 1%
Cardiovascular risk assessment
Surgery specific risks
ACC/AHA Guidelines
(<2 yr)
ACC/AHA Guidelines
ACC/AHA Guidelines
ACC/AHA Guidelines
Preoperative evaluation
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Hx. taking & physical examination
Lab. & specialized testing
ECG : arrhythmia, high-degree AVB, LVH
 a/w adverse outcome
Recent MI (<1M)
Unstable angina
CHF or S3  aggressive preoperative medical tx.
(pul. edema risk : x5)
Severe valvular disease (AS)
 stroke, MI, arrhythmia, acute HF
Preoperative evaluation
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Duration & severity of DM & HTN, stroke Hx.
 adverse perioperative cardiac events
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DBP > 100 mmHg  should be controlled before op.
Advanced age : indirect marker of surgical
cardiac risk
Role of specialized testing
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Ambulatory ECG : assess of silent ischemia
: assess of arrhythmia
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Echocardiography : assess of LV resting fx.
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Performed when HF suspected
: assessment of valvular heart dis.
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Exercise or pharmacologic stress testing with imaging
: detection of occult CAD
: estimate of functional capacity
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Expensive, subjective(interpreter-dependent)
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Stress ECG with imaging  reliable tool for CAD & functional
capacity evaluation
Role of specialized testing
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Stress testing
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False (+) : female, >50 yrs & in LVH cases
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False (-) : taking BB or CCB
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201-Tl : specific & good (-) predictive value
Coronary angiography
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Reserved for pt at high risk & should be done only if
angioplasty or CABG is considered
Perioperative management
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HTN
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Valvular heart disease
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Myocardial disease
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Arrhythmia
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ICD
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Medical tx
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Beta blocker
Alpha agonist
Calcium antagonist
Nitrate
Statin
CABG or PCI
Postoperative management
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Myocardial ischemia
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Arrhythmia
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CHF
Postoperative management
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Myocardial ischemia
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Silent, non-Q infarction
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Peak incidence at POD #2~ #3
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ECG at baseline, postop(immediate), POD #3 in
high risk pts.
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Cardiac marker if clinically suspected or
abnormal ECG
Postoperative management
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Postop. Arrhythmia
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Usually transitory
VPC : tx only if sustained or hemodynamically
significant
Postoperative management
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CHF
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Excessive vol. administration, HTN,
exacerbation of preexisting ventricular
dysfunction
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Unexplained pul. edema  suspicion of silent
MI
Postoperative management
Cardiovascular drugs
Aspirin
Discontinue 7 days before operation; restart 2 days after operation
Beta blockers
Continue, to prevent withdrawal; useful for postoperative adrenergic
hyperactivity
Clonidine HCl
Continue, to avoid rebound hypertension
Warfarin sodium,
except when used
for artificial valves
Discontinue 3-5 days before operation; restart when patient resumes oral intake
Warfarin therapy for
prosthetic valves
Thrombosis risk is higher in patient with mitral valve than with aortic valve.
ACCP gives three options for perioperative anticoagulation:
· Stop warfarin several days preoperatively and proceed to surgery once INR is
at a safe level for operation; restart shortly after operation
· Decrease dosing to keep INR low during procedure
· Stop warfarin and start heparin preoperatively; stop heparin 2-4 hr
preoperatively; proceed to surgery once INR is safe for operation; restart
heparin postoperatively when safe; restart warfarin postoperatively when safe
Postoperative management
Prophylaxis for infective endocarditis
For dental, respiratory, gastrointestinal, or
genitourinary tract procedures or other situations
when bacteremia is a risk
Pacemaker management (consult technical
consultant of pacemaker manufacturer, if
needed)
Temporarily program pacemaker to fixed-rate
mode to avoid temporary pacemaker inhibition by
electrocautery-induced electromagnetic
interference; limit length and frequency of use of
electrocautery, particularly near pacemaker site
Safeguard with automatic implantable
cardioverter-defibrillator
Best to switch off temporarily during surgery;
electrocautery may interfere with function
Drug use in patient with transplanted heart
(due to denervation, resting heart rate is
increased but response to stress is blunted)
Supersensitivity to adenosine (Adenocard),
normally responds to beta blockers and calcium
channel blockers, does not respond to atropine
sulfate or digoxin (Lanoxicaps, Lanoxin)