Transcript Peri-Op_Eval

The Perioperative
Cardiovascular Evaluation:
What Every Resident
Should Know
The “What Every Resident
Should Know” Lecture Series
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Hypertension
Dyslipidemia
Heart Failure
Pericardial Disease
Ventricular Arrhythmias
Preoperative Cardiac Evaluation
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 patients1
1Mangano
DT. Anesthesiology 1998; 88: 561-564.
Topics
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Pre-op clinic evaluation
Pre-op stress test
Pre-op revascularization
Peri-op use of
– Beta blockers
– Statins
– Aspirin & Clopidogrel
• Post-op surveillance
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?
Goldman L, et al. N Engl J Med 1977; 297: 845-850.
Detsky AS, et al. J Gen Intern Med 1986; 1: 211-219.
Lee TH, et al. Circulation 1999; 100: 1043-1049.
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
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?
ACC 2002 Guidelines
ACC 2002 Guidelines
ACC 2002 Guidelines
ACC 2002 Guidelines
ACC 2002 Guidelines
ACC 2002 Guidelines
ACC 2007 Guidelines
Duke Activity Status Index
Duke Activity Status Index
• Sum of the values for all 12 questions
– Range = 0 to 58.2
• Estimated VO2max 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.
ACC 2007 Guidelines
Recommendations for Noninvasive Stress Testing
According to the ACC/AHA Guidelines (2007)
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
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?
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.
Coronary Artery Revascularization
Prophylaxis (CARP) Trial
• Revascularization…
– Delayed surgery (54 days vs. 18 days)
– Did not reduce mortality
• 30 days
• 2.7 years
(3.1% vs. 3.4%)
(22% vs. 23%)
– Did not prevent peri-op MI (11.6% vs. 14.3%)
McFalls ED. N Engl J Med 2004; 352: 2795-2804.
ACC 2007 Guidelines
ACC 2007 Guidelines
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?
Perioperative Beta-Blocker Therapy
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
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
Lindenauer PK.
N Engl J Med 2005; 353: 349-361.
RCRI Score
In-Hospital Mortality OR
0
1.36
1
1.09
2
0.88
3
0.71
≥4
0.58
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.
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 test
– Pre-op stress test
– Odds Ratio
1.8%
2.3%
0.78 (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.
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.
PeriOperative ISchemic Evaluation
(POISE) Trial
• Primary endpoint = composite of cardiac
death, nonfatal MI, & nonfatal cardiac
arrest at 30 days post-op
– Metoprolol
– Placebo
– Hazard ratio
5.8%
6.9%
0.84 (p = 0.04)
Devereaux PJ. Lancet 2008; 371: 1839-1847.
PeriOperative ISchemic Evaluation
(POISE) Trial
Metoprolol
Placebo
HR
P value
Composite
5.8%
6.9%
0.84
0.04
MI
4.2%
5.7%
0.73
0.002
Death
3.1%
2.3%
1.33
0.03
Stroke
1.0%
0.5%
2.17
0.005
Bradycardia
6.6%
2.4%
2.74
<0.001
Hypotension
15.0%
9.7%
1.55
<0.001
Devereaux PJ. Lancet 2008; 371: 1839-1847.
ACC 2007 Guidelines
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?
Perioperative Statin Therapy
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
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)
Lindenauer PK.
JAMA 2004; 291: 2092-2099.
RCRI Score
Mortality (%)
NNT
0
1.4
186
1
2.6
103
2
4.5
60
3
7.1
39
4
9.3
30
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)
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?
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.
ACC 2007 Guidelines
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 periop MI sooner?
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 costeffective strategy.”
ACC/AHA 2007 Perioperative Guidelines
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
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 STsegment changes
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
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
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
References
• ACC/AHA 2007 Guidelines on
Perioperative Cardiovascular Evaluation
and Care for Noncardiac Surgery.
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.
Perioperative Cardiac Events
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Postoperative MI
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…
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–
–
–
Tachycardia
Hypertension
Anemia
Pulmonary embolism
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
Anticoagulation
ACCP 2008 Guidelines
2006 ACC VHD Guidelines
2006 ACC AF Guidelines
Pacemakers / ICDs
ACC 2007 Guidelines
ACC 2007 Guidelines
Prophylactic Coronary Revascularization
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Heart Rate Control
Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
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
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.