Cardioprotective Cardioprotective Agents in the Total Agents in the Total Joint Arthroplasty Joint Arthroplasty Patient: Are We Patient: Are We Doing Enough?Doing Enough?

Eric Schwenk MD*, Kishor Gandhi MD MPH*, Javad Eric Schwenk MD*, Kishor Gandhi MD MPH*, Javad Parvizi MD^, Eugene Viscusi MD*Parvizi MD^, Eugene Viscusi MD*

*Department of Anesthesiology,*Department of Anesthesiology,Thomas Jefferson University HospitalThomas Jefferson University Hospital^Rothman Institute for Orthopedics,^Rothman Institute for Orthopedics,Thomas Jefferson University HospitalThomas Jefferson University Hospital

IntroductionIntroduction For patients undergoing noncardiac surgery, cardiovascular For patients undergoing noncardiac surgery, cardiovascular

complications represent one of the biggest risks in the perioperative complications represent one of the biggest risks in the perioperative period.period.

The Revised Cardiac Risk Index (RCRI) is a simple way to assess The Revised Cardiac Risk Index (RCRI) is a simple way to assess cardiac risk for patients undergoing noncardiac surgery. cardiac risk for patients undergoing noncardiac surgery. 11

RCRI Predictors of Cardiovascular Complications RCRI Predictors of Cardiovascular Complications High Risk SurgeryHigh Risk Surgery 1 point1 point Coronary Artery DiseaseCoronary Artery Disease 1 point1 point Congestive Heart FailureCongestive Heart Failure 1 point1 point Cerebrovascular DiseaseCerebrovascular Disease 1 point1 point DM on InsulinDM on Insulin 1 point1 point Serum Cr > 2.0 mg/dlSerum Cr > 2.0 mg/dl 1 point1 point

The risk of major cardiac events during the perioperative period as The risk of major cardiac events during the perioperative period as predicted by RCRI:predicted by RCRI: No point = Low risk (0.4% complications)No point = Low risk (0.4% complications) 1 point = Low risk (0.9% complications)1 point = Low risk (0.9% complications) 2 point = Intermediate risk (6.6% complications)2 point = Intermediate risk (6.6% complications) More than 2 points = High risk (11.0% complications)More than 2 points = High risk (11.0% complications)

1. Lee TH et al. 1. Lee TH et al. CirculationCirculation 1999;100:1043. 1999;100:1043.

IntroductionIntroduction The use of cardioprotective agents for the prevention of The use of cardioprotective agents for the prevention of

CV complications in noncardiac surgery is controversial, CV complications in noncardiac surgery is controversial, particularly with beta blockers.particularly with beta blockers.

The 2006 ACC/AHA guidelines update on perioperative The 2006 ACC/AHA guidelines update on perioperative beta blocker use described major limitations in prior beta blocker use described major limitations in prior studies, including inadequate power, lack of titration to a studies, including inadequate power, lack of titration to a target heart rate, omission of low- and intermediate-risk target heart rate, omission of low- and intermediate-risk patients, and lack of evidence on which beta blocker to patients, and lack of evidence on which beta blocker to choose.choose.22

The POISE trial, a large, prospective, randomized The POISE trial, a large, prospective, randomized controlled trial, addressed some of these concerns and controlled trial, addressed some of these concerns and found that beta blockers reduced the risk of postop MI found that beta blockers reduced the risk of postop MI but increased the risk of stroke and overall mortality. but increased the risk of stroke and overall mortality. However, BBs were not titrated to a target heart rate However, BBs were not titrated to a target heart rate and, in addition, a high dose of the BB was given. This and, in addition, a high dose of the BB was given. This could account for some of the strokes that were could account for some of the strokes that were observed.observed.33

IntroductionIntroduction The risk of perioperative myocardial ischemia during noncardiac The risk of perioperative myocardial ischemia during noncardiac

vascular surgery is reduced in patients whose heart rates are tightly vascular surgery is reduced in patients whose heart rates are tightly controlled (HR < 65 bpm).controlled (HR < 65 bpm).44

A 2008 meta-analysis suggested that beta blockers are A 2008 meta-analysis suggested that beta blockers are cardioprotective if the patients’ maximal heart rate is <100 bpm. It cardioprotective if the patients’ maximal heart rate is <100 bpm. It also found that calcium channel blockers combined with beta also found that calcium channel blockers combined with beta blockers result in more effective control of heart rate.blockers result in more effective control of heart rate.55

Short-term statin use has been shown to reduce cardiac events in Short-term statin use has been shown to reduce cardiac events in patients undergoing vascular surgery.patients undergoing vascular surgery.66 They may also be They may also be cardioprotective in other noncardiac surgeries.cardioprotective in other noncardiac surgeries.77

44 Poldermans D et al. Poldermans D et al. J Am Coll Cardiol J Am Coll Cardiol 2006;48(5):964-9. 2006;48(5):964-9. 5 5 Beattie WS et al. Beattie WS et al. Anes Analg Anes Analg 2008;106(4):1039-48. 2008;106(4):1039-48. 66 Durazzo AE et al. Durazzo AE et al. J Vasc Surg J Vasc Surg 2004;39(5):967-75. 2004;39(5):967-75. 77 Lindenauer PK et al. Lindenauer PK et al. JAMA JAMA 2004; 291(17):2092-9.2004; 291(17):2092-9.

ObjectivesObjectives

To assess the percentage of total joint To assess the percentage of total joint arthroplasty patients experiencing arthroplasty patients experiencing postop CV complications who took postop CV complications who took preoperative beta blockers, calcium preoperative beta blockers, calcium channel blockers, and statins. channel blockers, and statins.

To determine if beta blockers and To determine if beta blockers and calcium channel blockers are being calcium channel blockers are being titrated to a target heart rate.titrated to a target heart rate.

MethodsMethods Retrospective cohort study of 3529 patients who underwent total Retrospective cohort study of 3529 patients who underwent total

joint arthroplasty (hip or knee replacement) at a large, urban joint arthroplasty (hip or knee replacement) at a large, urban teaching hospital. teaching hospital.

Postoperative complications were recorded into a database by a Postoperative complications were recorded into a database by a team of researchers and linked to a database containing team of researchers and linked to a database containing patients’ past medical history, medication history, preoperative patients’ past medical history, medication history, preoperative medications, and preoperative vital signs.medications, and preoperative vital signs.

Postoperative cardiovascular complications were defined as: Postoperative cardiovascular complications were defined as: angina, myocardial infarction, atrial fibrillation, tachycardia, angina, myocardial infarction, atrial fibrillation, tachycardia, supraventricular tachycardia, miscellaneous arrythmias, supraventricular tachycardia, miscellaneous arrythmias, pulmonary edema, acute congestive heart failure, hypotension, pulmonary edema, acute congestive heart failure, hypotension, and bradycardia.and bradycardia.

Bivariate analysis was conducted on RCRI risk stratification. Bivariate analysis was conducted on RCRI risk stratification. Analysis was based on Pearson’s Chi Square analysis with alpha Analysis was based on Pearson’s Chi Square analysis with alpha = 0.05 and was conducted with use of SPSS software (version = 0.05 and was conducted with use of SPSS software (version 11.0, Chicago, Illinois).11.0, Chicago, Illinois).

ResultsResults

Cardiovascular Cardiovascular Complications (n=188)Complications (n=188)

Low Risk Low Risk (n=129, (n=129, 68.6%)68.6%)

Intermediate Risk Intermediate Risk (n=56, 29.8%)(n=56, 29.8%)

High Risk High Risk (n=3, 1.6%)(n=3, 1.6%)

Age>60 (n=131)Age>60 (n=131) 84 (64.1%)*84 (64.1%)* 44 (33.6%)*44 (33.6%)* 3 (2.3%)3 (2.3%)

Angina/MI (n=49)Angina/MI (n=49) 23 (46.9%)*23 (46.9%)* 25 (51.0%)*25 (51.0%)* 1 (2.0%)1 (2.0%)

Tachycardia/ArrhythmiasTachycardia/Arrhythmias

(n=65)(n=65)

47 (72.3%)47 (72.3%) 17 (26.2%)17 (26.2%) 1 (1.5%)1 (1.5%)

Pulmonary Edema/CHF Pulmonary Edema/CHF (n=14)(n=14)

8 (57.10%)8 (57.10%) 5 (35.7%)5 (35.7%) 1 (7.10%)1 (7.10%)

Hypotension (n=47)Hypotension (n=47) 40 (85.1%)*40 (85.1%)* 7 (14.9%)*7 (14.9%)* 0 (0%)0 (0%)

Bradycardia (n=13)Bradycardia (n=13) 11 (84.6%) 11 (84.6%) 2 (15.40%) 2 (15.40%) 0 (0%)0 (0%)

Table 1: Postoperative Cardiovascular Complications by Risk Table 1: Postoperative Cardiovascular Complications by Risk StratificationStratification

N (%)* p<0.05

ResultsResultsFigure 1: Preoperative Cardioprotective Figure 1: Preoperative Cardioprotective

AgentsAgents

ResultsResultsTable 2: Tight Rate Control (<65 bpm)Table 2: Tight Rate Control (<65 bpm)

Rate Control AgentRate Control Agent Percentage of Percentage of Patients with Tight Patients with Tight

Rate ControlRate Control

NoneNone 32.0% (n=58)32.0% (n=58)

Long-term BBLong-term BB 33.3% (n=19)33.3% (n=19)

BB on day of surgeryBB on day of surgery 32.1% (n=18)32.1% (n=18)

Long-term CCBLong-term CCB 45.7% (n=16) 45.7% (n=16)

CCB on day of CCB on day of surgerysurgery

37.5% (n=12) 37.5% (n=12)

Long-term BB and Long-term BB and CCBCCB

40.0% (n=2) 40.0% (n=2)

BB and CCB on day BB and CCB on day of surgeryof surgery

33.3% (n=3) 33.3% (n=3)

ResultsResultsFigure 2: Tight Rate Control by ComplicationFigure 2: Tight Rate Control by Complication

DiscussionDiscussion The majority of patients who experienced The majority of patients who experienced

cardiovascular complications were not taking cardiovascular complications were not taking beta blockers, calcium channel blockers, or beta blockers, calcium channel blockers, or statins before surgery. Most of these patients statins before surgery. Most of these patients were low- or intermediate-risk, emphasizing were low- or intermediate-risk, emphasizing the importance of including these patients in the importance of including these patients in future studies. future studies.

Our results suggest that adequate rate control Our results suggest that adequate rate control is not being achieved in the majority of is not being achieved in the majority of patients taking beta blockers or calcium patients taking beta blockers or calcium channel blockers before total joint channel blockers before total joint arthroplasty. Combining the two agents might arthroplasty. Combining the two agents might lead to better rate control, but a prospective lead to better rate control, but a prospective trial is needed to confirm this.trial is needed to confirm this.

DiscussionDiscussion For patients For patients in whom a beta blocker or in whom a beta blocker or

calcium channel blocker is deemed calcium channel blocker is deemed appropriateappropriate, adequate rate control may , adequate rate control may need to be achieved by more aggressive need to be achieved by more aggressive titration in the perioperative period, titration in the perioperative period, combining the agents as appropriate to combining the agents as appropriate to avoid bradycardia and hypotension. avoid bradycardia and hypotension.

The use of short-term statins in The use of short-term statins in noncardiac surgery may be noncardiac surgery may be cardioprotectivecardioprotective8,98,9 and some of the and some of the patients who experienced cardiovascular patients who experienced cardiovascular complications may benefit from a statin. complications may benefit from a statin.

8. Durazzo AE et al. 8. Durazzo AE et al. J Vasc Surg J Vasc Surg 2004;39(5):967-75 2004;39(5):967-75 9. Lindenauer PK et al. 9. Lindenauer PK et al. JAMA JAMA 2004; 291(17):2092-9.2004; 291(17):2092-9.

Thank YouThank You

Dr. Kishor Gandhi – Regional Anesthesia Dr. Kishor Gandhi – Regional Anesthesia Fellow; St. Luke’s Hospital, New York, NY Fellow; St. Luke’s Hospital, New York, NY

Dr. Eugene Viscusi – Director, Acute Pain Dr. Eugene Viscusi – Director, Acute Pain Management Service; Thomas Jefferson Management Service; Thomas Jefferson University Hospital, Philadelphia, PAUniversity Hospital, Philadelphia, PA

Dr. Zvi Grunwald – Chair, Department of Dr. Zvi Grunwald – Chair, Department of Anesthesiology; Thomas Jefferson Anesthesiology; Thomas Jefferson University Hospital, Philadelphia, PAUniversity Hospital, Philadelphia, PA