Ross S. Pacini, M.D.

A Classic Example

71 y/o male with recent onset

hematochezia

Colonoscopy done showing a large, friable

upper rectal mass

Biopsy shows a moderately differentiated

invasive adenocarcinoma

Suspicious lymph node also noted

Possible liver mets (too small to be sure)

Invasion of the muscularis propria

A Classic Example

Cardiology consulted for pre-op

“clearance”

Pt is an active, asymptomatic retired

engineer

Jogs 2-3 times/week around a lake (0.5-1

mile)

Has “diet-controlled” HTN

No h/o CP or SOB

A Classic Example

A stress echo is ordered which shows evidence of ischemia in the distribution of the LAD (anterior wall defect)

Due to abnormal stress, he gets a cardiac cath

40% distal LM

95% prox LAD, 100% mLAD

75% OM 2 (LCx distribution)

95% prox RCA, 100% mRCA

EF=55%; no MR or AS

A Classic Example

Undergoes CABG x 5

Goes to cardiac rehab

Undergoes Surgery for Colon Cancer

~60 days after CABG

Subsequently undergoes chemotherapy

and does OK

….but was it all necessary?

History of Pre-Op Evalaution

Cardiac complications from surgery are

fairly common (between 2-7%

depending on the population studied)

Modern medicine and surgical

techniques have greatly reduced risk

compared to 20-30 years ago

Goal of evaluation is to help minimize

these risks; ultimate question is just how

much can these risks be modified?

History of Pre-Op Evaluation

Traditionally, it was felt that many

patients needed a full cardiac evaluation

before elective surgery

In the 90’s ACC/AHA started publishing

guidelines on how to perform risk

stratification

Guidelines were updated in 2002

Complex algorithms

History of Pre-Op Evaluation

Up through the 2002 guidelines, there

was no good published trial to actually

evaluate outcomes

Older data had suggested a clinical

benefit to pre-op revascularization, but

nothing had been done in the modern

era

History of Pre-Op Evaluation

In 2007, we got greatly simplified guidelines based on very good trial data (2 very important trials in particular: CARP and DECREASE V).

Radically changed our approach to evaluation Acceptance has been slow for a variety of

reasons.

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it” –Upton Sinclair [cynical view]

CARP Trial

During my externship at Emory, I was asked to do a pre-op evaluation on a cardiac patient

Desperately wanting to impress and suck up, I asked my attending, “Even if we prove he has significant CAD, can we lower his risk of complications by ‘fixing him’?”

He assigned me to read a trial (of course) and present it the next day

CARP Trial*

Randomized trial of 510 patients at VA’s.

Pt’s undergoing AAA repair or major LE

(fem-pop, etc) surgery [these are classically

the highest risk surgeries]

Pt’s had to have at least 70% stenosis of at

least one major coronary artery and be

suitable for revascularization (PCI or CABG)

Exclusion criteria: >49% LM disease,

LVEF<20%, or severe AS

*New England J of Med, 2004: 351 (2795-2804)

CARP Trial

Patients were then randomized to either

have revascularization (PCI or CABG) or

go straight to their surgery

Primary endpoint was mortality

Secondary endpoints were MI, CVA,

limb loss, and need for dialysis

CARP Trial: Results

Groups were well matched

Most patients underwent assigned treatments

No difference in death (3.1% vs. 3.4%), MI, CVA, Dialysis, days in ICU, or days in hospital between revascularization and no-revascularization

CARP Trial

CARP Trial: Results

There were 2 important differences in the group

In the revasc group, 10 patients died before they could have their vascular surgery vs. only 1 in the non-revasc group

Those in the revasc group waited an average of 54 days before getting their surgery vs. 18 days in the non-revasc group

Definitive trial that suggested pre-op revasc didn’t make a difference

CARP or CRAP

Critics have suggested that

study was was underpowered

(screened 5,859 pt’s to get

510 enrolled)

Most excluded for not having

severe enough CAD or needed

emergent surgery

More importantly, critics said,

“What about severe CAD (3v

CAD, LM disease)?”

DECREASE V*

Studied patients undergoing open AAA repair or infrainguinal arterial reconstruction

Enrolled patients had to have a large area of ischemia on stress testing (3/6 walls on nuc or 5/17 walls on stress echo)

Only patients with 3 or more risk factors actually had a stress test (those with 0-2 were excluded)

*J Amer Coll Cardiol 2007: 49 (1763-1769)

DECREASE V

Pt’s were then randomly assigned to

undergo cath and revascularization or

proceed straight to surgery

All patients got perioperative b-blockers

Primary outcome was death and MI that

occurred between randomization and 30

days post-op

DECREASE V

1,880 patients were screened. 1,779

were excluded for being too low risk

(1,450) or not having enough ischemia

(329). Eventually, 101 patients enrolled

Goal was to get the highest risk patients

going for the highest risk surgery

43% of the patients had an EF <35% (none

had severe AS)

DECREASE V

Of those enrolled for cath/revasc

24% had 2v CAD, 67% had 3v CAD, and 8% had LM disease

65% got PCI; 35% got CABG

CABG pt’s waited an average of 29 days for their vascular surgery; PCI patients waited 31 days

○ 2 CABG pt’s died while waiting for AAA surgery

○ 1 PCI pt had an MI before he could have vascular surgery

DECREASE V

Ultimate results

were no difference

between the two

groups

43% in the revasc

group vs. 33% in the

“straight to surgery”

group reached the

primary endpoint

(death or MI).

DECREASE V

Conclusion was that

pre-op revasc didn’t

help, even in high

risk patients

Criticized for small

sample size and

technically being

only a pilot study

Pre-Op Eval Guidelines*

Based on these trials and other

available data, ACC/AHA guidelines

were updated in 2007 and made much

simpler

Eval can be done in 5 easy steps

Vast majority of patients can proceed to

surgery

* J Amer Coll Cardiol 2007: 50 (e159-241)

Step 1

Step 2

Active cardiac conditions:

Unstable coronary syndromes

Decompensated CHF

Significant arrhythmias

Severe valvular disease (usually stenosis)

In short…most of these patients should be seeing cardiology anyway and

most are probably already hospitalized.

Step 3

Low risk surgeries:

Endoscopic Procedures

Superficial Procedures

Cataract Surgery

Breast Surgery

Ambulatory Surgery

Step 4

Examples of 4 MET’s or more Climbing a flight of stairs

Walking up a hill

Walking on level ground at 4 MPH

Scrubbing floors/move furniture

Housework like dishes, dusting, vacuuming

Golfing without a cart, bowling, dancing, doubles tennis

Step 5

This is the first and only step that

requires any real thinking

If functional capacity of <4 MET’s or

unknown (wheelchair, etc), then 2

important criteria must be established

Is it intermediate or high risk surgery?

How many risk factors does the patient

have?

Step 5: Type of surgery

High risk surgery includes:

Aortic surgery

Peripheral Vascular surgery

Intermediate risk surgery includes:

Carotid Endarterectoy

Percutaneous AAA repair

Head and Neck Surgery

Orthopedic Surgery

Intraperitoneal/Intrathoracic Surgery

Any surgery not low or high risk

Step 5: Risk Factors

Revised Cardiac Risk Index

History of ischemic heart disease

History of CHF

History of CVA

DM treated with insulin

Renal Insufficiency (Cr >1.9)

Step 5: Part 1

Part 5: Step 2

In Short, if you have a patient with a functional capacity of <4MET’s

AND they have 3 or more risk factors AND they are going for high risk

vascular surgery, you might consider doing a stress test. As we’ve

seen from previous data, though, this probably will not be helpful.

Super short cut (for the gutsy)

Is the patient having an active acute

coronary syndrome, decompensated

CHF, severe valve disease, or

uncontrolled arrhythmia?

If the answer is no, go to surgery with

optimal medical therapy

Peri-Operative B-blockade

This has been an interesting evolution

Originally, quite controversial

Then, became fairly mainstream for almost

all patients

In 2008, however, we finally got a very large

trial on the matter

POISE

Inclusion criteria

>44 years old

Had a h/o CAD, PVD, CVA, h/o hospitalized

for CHF; or undergoing vascular surgery; or

3/7 risk factors (intrathoracic/intraperitoneal

surgery, h/o CHF, h/o TIA, DM, CKD, age

>70, or undergoing emergent surgery)

POISE

Exclusion criteria

HR <50 bmp, high grade (2nd or 3rd degree)

AV block, asthma, already on b-blocker,

CABG within 5 years and no evidence of

recent ischemia, low-risk surgery, on

verapamil, or allergy to b-blocker

POISE

Pt’s were randomized to receive a b-

blocker or placebo

B-blocker was metoprolol succinate (Toprol

XL®).

Pt’s got 100 mg 2-4 hours before surgery.

They then got another 100 mg within 6

hours of surgery. Pt’s then continued with

200 mg daily for a total of 30 days starting

12 hours after the first post-operative dose

Side note: That’s A LOT of b-blockade

POISE

Primary outcome was a composite of

death, MI, and non-fatal cardiac arrest

30 days after randomization

A total of 8,351 patients were

randomized

POISE

For the primary endpoint, 5.8% in

metoprolol group vs. 6.9% in placebo

group had composite death, MI, cardiac

arrest (HR 0.84; p=0.0399)

But, there was more to the story…

POISE

There were more deaths (3.1% vs. 2.3% p=0.0317) and more strokes (1.0% vs. 0.5% p=0.0123) in the metoprolol group

The primary outcome was driven solely by a lower incidence of MI in the metoprolol group (3.6% vs. 5.1% p=0.0008)

There was also more clinically significant hypotension and bradycardia with metoprolol (Duh!).

Primary

Outcome

Non-fatal

MI

Stroke Death

POISE

Conclusion was suddenly that b-

blockers are bad and are killing people,

but was that really the correct

conclusion?

Massive doses of b-blockers in b-

blocker naïve patients.

No titration at all

ACC/AHA Guidelines*

Because of this trial, in 2009, we got an

update to our previous guidelines

Authors took a more critical look at b-

blockade in the peri-operative setting

and made some very reasonable

recommendations based on POISE as

well as previous literature

*J Amer Coll Cardiol 2009: 54 (2102-2128)

Key Points to B-blockers

If pt is already on a b-blocker for a good

reason, continue it (Class I rec)

Reasonable (IIa) to give b-blockers to

pt’s with CAD undergoing high or

intermediate risk surgery

Reasonable to give b-blockers to pt’s

undergoing high or intermediate risk

surgery who have more than 1 risk

factor (CAD, CHF, CKD, CVA, DM)

Key Points to B-blockers

In pt’s with only 1 risk factor that is not

CAD undergoing intermediate risk

surgery, the utility of b-blockers is

questionable (IIb)

In pt’s with no risk factors undergoing

high risk surgery, the utility of b-blockers

is questionable

Key Points to B-blockers

Titration is critical

Start days-weeks before surgery and titrate

to a goal HR of 50-60 bmp

Routine use of b-blockers, especially

when not titrated, may be harmful

Statin Therapy

My take: It can’t hurt

Evidence is limited, but most points to

benefit

Guidelines suggest the following:

Continue pt’s who are already on a statin

Probably helpful in all vascular surgery pt’s

Can be considered for pt’s with at least 1

risk factor undergoing intermediate risk

surgery

A brief word on anti-platelets

Please never tell a cardiac patient to stop ASA+Plavix without talking to the cardiologist

Very dangerous; seen it more times than I care to admit

Pt’s with BMS need DAPT for at least 1 month; those with DES for 1 year

Most cardiac pt’s should be continued on ASA if possible

My cardiac surgeons do it…so can you

Summary

Virtually no ambulatory patients require

stress testing prior to non-cardiac

surgery

If folks are acutely ill with cardiac

issues, by all means, fix that before

elective surgery

Peri-operative b-blockers are useful in

carefully selected patients

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