Transcript cardiac periop evaluation 7-03

Clearance of the Cardiac Patient
for Non-cardiac Surgery
Evaluation and
Management
PRE-OP CLEARANCE
• Not truly “Clearance” – but assurance that the
pt.’s condition is optimal for the proposed
surgery in the planned time frame.
• A focused assessment, addressing a particular
issue specified by the parties: Cardiac risk?
Atr. Fib? CHF? Pulmonary risk? General
medical status?
What is consultant’s role here?
• A calculation of the relative risk and estimation
of the Risk/Benefit. Controversial issues best
communicated verbally.
PRE-OP CLEARNCE –II
THE NOTE
•
•
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List of the medical/cardiac problems, severity, and
degree of control.
List of medications.
Allergies.
Steps to achieve optimal pre-op statusTests (minimal) and treatments,
e.g., A/C Rx, CHF, BB’s.
Peri-op precautions, e.g., prophylactic Abx, volume
guidelines. Post-op monitoring steps.
One page! Concise! LEGIBLE! Clearly signed,
with Tel./Beeper No.
COMPOSITE
QUALITATIVE ESTIMATION OF OPERATIVE RISK
CLINICAL
FUNCTIONAL
PREDICTORS
IMPAIRMENT
High risk
Very limited ADLs
e.g.,unstable
e.g., prior MI
Low risk
e.g., stable abn’l
EKG
RISK
HIGH
or ++++ EST
cor syndrome
Intermediate risk
PERIOP.
High risk >5%
emergent abd.op.
-
INTER-
-
MEDIATE
Vigorous ADLs
hight workload.
RISK
e.g., AAA or
-
or (-) EST at
INHERENT SURGICAL
Intermediate 1-5%
e.g. TURP or
ORIF
LOW
Low risk <1%
e.g., cataract op.
Energy Requirements –
Can Patient Perform 4 Mets?
CARDIAC
RISK
INDICES
(I)
The Goldman
Index
RISK OF
MAJORCARDIAC
COMPLICATIONS
Class I 0-5 pts.
Class II 6-12 pts.
Class III 13-25 pts.
Class IV =,> 26 pts.
Mangano, Goldman et al.
(II)
ACC
AHA
Guidelines
S
S
I
C
C
I
C
Up-to-date
S
I
C
C
I
C
(III)
Indications for pre-op stress testing
• EXCLUSIONS: Pts. with likely CAD who will not
consent to revascularization procedures.
Pts. whose non-cardiac surgery cannot be deferred
for 4-6 weeks.
• Pts. with recent ACS- MI, Unst.AP, ischemic APEnot revascularized, now asymptomatic, for
intermediate or high risk surgery.
• Pts. for intermediate or high risk surgery with limited
exertional capacity, plus additional clinical risk factors
such as CHF, cerebrovascular disease, diabetes, CRI.
Risk Reduction for the Cardiac
Patient for Non-cardiac Surgery
Choice of procedure
Choice of surgeon and hospital
Choice of pre-op interventions and meds.
Optimization of status in time allotted(?)
Expected post-revascularization delays
• CABS-1-3 months convalescence for
physical and emotional rehab.
• DES- at least 3 months clopidigrel,to reduce
instent-thrombosis risk.
• BMS- 4-6 weeks clopidigrel.
• POBA- one month, for hypercoagulable
intima.
8/56= 14% MACE- IF WITHIN 6 WEEKS OF PCI.
Am. J. Cardiol. 2005; 95:755
510 pts
randomized.
REVASCULARIZATION
For expanding
AAA or PVD of
legs.
At incr. clinical risk
or ischemia on EST.
All had coronary
angios with
stenosis>70% in
one or more major
cor. arts.
Exclusions:
Need for urgent or
emergency surgery.
LMCAD > 50%
LVEF < 20%
Severe AS.
30-day mortality: Revasc-3.1% No Revasc- 3.4%
Post-op MI(incr. Trop.)- 12% vs 14%
McFalls et al., Coronary-Artery Revascularization before
Elective Major Vascular Surgery. NEJM 2004;351:2795-804.
Myoc. O2 Demand during Anesthesia and Surgery
.
RPP
Con
sent
10,000
On BBs
Hosp. O.R.
Induction
I hr.into Transfer
Adm. Arrival of Anesth. Surgery
to PACU
Frishman and Oka
24 hrs
later
Effect of atenolol on mortality and cardiovascular morbidity
after noncardiac surgery. Mangano et al, NEJM 1996; 335;1713-20
.
112 pts., + DSE
Bisoprolol 5-10mg po
vs P.
Begun av. 37 d. preop, to 30 d. post-op.
Cardiac death
Cardiacdeath
3.4%vs 17%
3.4%vs 17%
Nonfatal MI
Nonfatal MI
0% vs 17%
0% vs 17%
53 pts. on BBs
previously Mortality 4.5%
NEJM 1999;341:1789-94
B-Blockers and Reduction of Cardiac Events in Noncardiac
Surgery. A.D.Auerbach, MD, MPH and Lee Goldman, MD
PREDICTORS OF CARDIAC EVENTS AFTER MAJOR VASCULAR SURGERY
Boersma et al, JAMA 2001:285;1865-1873
Case control study. 2816 pts.- vasc. Surgery- 160 died - each
compared to 2 survivors matched by year and surgery.
Statin use - in Deaths: 8%. - in Survivors: 25%
OR for periop. mortality among statin users vs. nonusers:
0.22 (0.10-0.47)
Grayburn, P.A. and Hillis, L.D., Annals Int. Med. 2003; 138:506-511
IN CONCLUSION…..
• Who need B-Blockers?
Pts. for intermediate or high
risk surgery, with confirmed or likely CAD, or coronary
risk factors (without asthma or bradys.)
• Who need stress testing?* Pts. with (probable) CAD, for
elective intermediate or high risk surgery, with limited
exertional capacity, plus additional clinical risk factors
such as CHF, CVA/TIA, diabetes, CRI.
• Who need coronary angios?* Pts. with recent ACS for
intermediate or high risk op.
Pts. with extensive ischemia on EST.
Pts. with hair-trigger angina despite Rx.
* if urgency of surgery permits.
1. 76 M. for TURP. Had IWMI 5 yrs. ago, with occasional
exertional angina since. Is on Imdur.
•
•
•
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Inherent surgical risk – 1-3%.
Pt.’s clinical risk - Intermediate.
Exercise tolerance – very good. Condition is stable.
Overall peri-op risk – 2-3 % for peri-op Mortality,
M.I., CHF.
• Steps to reduce risk:
Add B-blocker pre-op.
?Add statins - proper run-in time?
Maintain HCT > 30%
Add ASA soon post-op.
Qualitative assessment of operative risk
CLINICAL
FUNCTIONAL
PREDICTORS
IMPAIRMENT
High risk
Very limited ADLs
e.g.,unstable
e.g., prior MI
Low risk
e.g., stable abn’l
EKG
RISK
HIGH
or ++++ EST
cor syndrome
Intermediate risk
PERIOP.
High risk >5%
emergent abd.op.
-
INTER-
-
MEDIATE
Vigorous ADLs
hight workload.
RISK
e.g., AAA or
-
or (-) EST at
INHERENT SURGICAL
Intermediate 1-5%
e.g. TURP or
ORIF
LOW
Low risk <1%
e.g., cataract op.
2. 72 yo W. –acute NSTEMI 2 wks. ago.
Has 2 cm. left breast nodule.
• Clinical risk intermediate or high, depending on ease of
precipitating ischemia.
• Surgical risk- low for biopsy
- intermediate for mastectomy.
• Moderate time pressures for interventionchiefly emotional:
PCI and Plavix x 6 weeks to 3-6 months?
CABS and rehab x two months?
EST and BB’s in one-two weeks?
3. 73 yo M. has ischemic rest pain.
Also HTN, LVH and angina on Rx.
Fem-pop bypass proposed.
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Surgical risk- intermediate –to - high.
Clinical risk- Intermediate.
Exercise tolerance – limited by claudication.
Time factor - < 30 days- no gangrene yet.
Options? - BB’s
-EST stratification
- PCI
- CABS
• If 2-block claudication w/o rest pain?
Med. management or possibly iliac stent.
Future CAD risk stratifiction.
4. 54 yo W. needs hysterectomy, has anemia.
Has HTN and NSSTTC.
• Surgical risk is intermediate; low if laparoscopic.
• Clinical risk low (hypertension)
- or intermediate ( if NSSTTC are significant and new.)
• Exercise tolerance very good.
• Time factor – not urgent.
• Steps: Obtain old EKGs.
Start HTN Rx- BB’s, diuretics, ACE-inhibs.
Consider EST if duration of STTC is unknown.
5. 80 yo W., left hip IT fracture x5wks, history of
HTN, and atrial fibrillation.
• Heart rate control- BB’s, CCB’s, digoxin.
• Heart disease assessment – Px, 2DE.
Stress testing and revascularization are
precluded by the fracture.
• Anticoagulation Rx- indicated but not urgent.
Long term use will depend on reliability and
communication issues.
• Orthopedic time frame – elective at this point.
6. 28 yo W., with click and MVP, requires dental
work.
• Dx- Mitral valve prolapse, with (perhaps) MR.
No arrhythmias or chest pain.
• Meds- e.g., Fiorinal PRN, OCPs.
Not on A/C Rx.
• Allergies- NKDA
• Recs: Premedicate with Amoxicillin 2 gms po.
Use “EPI” if preferable.
7. 72 yo M. for TKR, with NIDDM and
asymptomatic left carotid stenosis.
• Time frame is elective.
• Estimate surgical risk as low intermediate.
• Exercise tolerance is unknown and CAD likely,
but he has no CHF, prior MI,CVA/TIA, insulin
use or CRI. DSE or Persantine MIBI are
probably not indicated.
• Plan for CEA, in view of ACAS data if
institutional surgical risk is <5%.
• With DM and carotid vasc. disease, consider
coronary risk equivalent to that of prior MI
with respect to statin, BB, and ASA use
8. 55. yo W. has mechanical MVR, Atr. Fib, on
A/C RX, and needs dental extractions.
• Hold Warfarin for 3 nights, check INR and
proceed, then immediately resume RX.
• Or- Hold A/C RX for 4 nights. Check INR on
3rd day, and cover with LMWH pre-op and
immediately post-op, while resuming
warfarin.
• Remember SBE prophylaxis- Amox or
Erythro. or Clinda.
• “Epi” is permitted.