the perioperative cardiovascular evaluation: what every resident should know

The PerioperativeCardiovascular Evaluation:

What Every ResidentShould Know

The “What Every ResidentShould Know” Lecture Series

• 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

• 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 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

Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.

Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924

Recommendations for Noninvasive Stress TestingAccording to the ACC/AHA Guidelines (2007)

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 (3.1% vs. 3.4%)• 2.7 years (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

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

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 1.8%– Pre-op stress test 2.3%– Odds Ratio 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.


• Primary endpoint = composite of cardiac death, nonfatal MI, & nonfatal cardiac arrest at 30 days post-op– Metoprolol 5.8%– Placebo 6.9%– Hazard ratio 0.84 (p = 0.04)



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


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

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 peri-

op 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 cost-effective 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


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 ST-segment 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


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


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.

http://content.onlinejacc.org/cgi/content/full/50/17/e159

http://content.onlinejacc.org/cgi/content/full/50/17/e159



Perioperative Cardiac Events

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…– 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



Prophylactic Coronary Revascularization



Heart Rate Control

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.

the perioperative cardiovascular evaluation: what every resident should know

Documents

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preop ekg

vascular surgery patients

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unselected patients

accaha guidelines

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n engl j med