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• List of the medical/cardiac problems, severity, and

degree of control. • List of medications.

Allergies.• Steps to achieve optimal pre-op status-

Tests (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 PERIOP. INHERENT SURGICAL

PREDICTORS IMPAIRMENT RISK RISK

High risk Very limited ADLs HIGH High risk >5%

e.g.,unstable or ++++ EST e.g., AAA or

cor syndrome - emergent abd.op.

Intermediate risk - INTER- Intermediate 1-5%

e.g., prior MI - MEDIATE e.g. TURP or

Low risk Vigorous ADLs ORIF

e.g., stable abn’l or (-) EST at LOW Low risk <1%

EKG hight workload. 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

AHAGuide-

lines

Up-to-date

S

I

C

C

I

C

S

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 APE- not 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 procedureChoice 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

McFalls et al., Coronary-Artery Revascularization before Elective Major Vascular Surgery. NEJM 2004;351:2795-804.

510 pts randomized.

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%

REVASCULARIZATION

Myoc. O2 Demand during Anesthesia and Surgery

.

RPP

10,000

Hosp. O.R. Induction I hr.into Transfer 24 hrs

Adm. Arrival of Anesth. Surgery to PACU later

Consent

On BBs

Frishman and Oka

.

Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Mangano et al, NEJM 1996; 335;1713-20

NEJM 1999;341:1789-94

112 pts., + DSE

Bisoprolol 5-10mg po vs P.

Begun av. 37 d. pre-op, to 30 d. post-op.

Cardiacdeath

3.4%vs 17%

Nonfatal MI

0% vs 17%

Cardiac death

3.4%vs 17%

Nonfatal MI

0% vs 17%

53 pts. on BBs previously -

Mortality 4.5%

B-Blockers and Reduction of Cardiac Events in Noncardiac Surgery. A.D.Auerbach, MD, MPH and Lee Goldman, MD

Boersma et al, JAMA 2001:285;1865-1873

PREDICTORS OF CARDIAC EVENTS AFTER MAJOR VASCULAR SURGERY

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.

• 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 riskCLINICAL FUNCTIONAL PERIOP. INHERENT SURGICAL

PREDICTORS IMPAIRMENT RISK RISK

High risk Very limited ADLs HIGH High risk >5%

e.g.,unstable or ++++ EST e.g., AAA or

cor syndrome - emergent abd.op.

Intermediate risk - INTER- Intermediate 1-5%

e.g., prior MI - MEDIATE e.g. TURP or

Low risk Vigorous ADLs ORIF

e.g., stable abn’l or (-) EST at LOW Low risk <1%

EKG hight workload. 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 intervention-chiefly 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.

• 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 orErythro. or Clinda.

• “Epi” is permitted.