Preoperative Evaluation and Management of Cardiac Patients

Preoperative Evaluation and Management of Cardiac Patients

PERIOPERATIVE EVALUATION AND MANAGEMENT OF CARDIAC PATIENTS FOR NONCARDIAC SURGERY David W Kabel MD, FACC Preoperative EvaluationParadigm Change Shift of emphasis From preoperative risk stratification and testing To perioperative management of risk Prevention of major adverse cardiac events (MACE)

Challenge to previous guidelines Stress testing Revascularization Beta blocker therapy Scope of the Problem

30 million+ non-cardiac surgeries in the US annually One third have known CAD or cardiac risk factors 500,000 considered high risk for cardiac complications Operative mortality is declining Better preop risk stratification Better perioperative management Less invasive procedures Mortality is declining for high risk procedures as well

Purpose of Preoperative Evaluation Assessment of perioperative risk to guide the decision to proceed with or the choice of surgery Determination of the need for changes in management Identification of cardiovascular conditions that warrant long term management Perioperative Team Approach

Shared decision making Patient preferences and goals PCP Surgeon Anesthesiologist Specialists as needed Requires considerable advanced planning in high risk patients with multi-system disease

Definition of Risk Previously determined as low medium or high risk Now only 2 categories Low risk-<1% Cataracts Dermatologic and minor cosmetic

Require no preop evaluation High risk-1% or greater Further workup depends on type of operation and patient characteristics Revised Cardiac Risk Index

One point for each risk factor Known ischemic heart disease Heart failure (current or past history) History of CVA or TIA Insulin dependent diabetes Creatinine> 2.0 High risk surgery-Suprainguinal vascular, intraperitoneal, or intrathoracic surgery RCRI-Scoring

Points 0 1 Cardiac complications 0.4% 0.9%

2 7% 3+ 11% 10 2 %

American College of Surgeons Risk Calculator Data from 525 hospitals and 1 million patients to develop this Considers type of surgery by CPT code Multiple patient factors are considered Type of Surgery-Low Risk(<1%) These surgeries usually require no additional preoperative cardiac evaluation Breast Dental Endocrine Eye Gynecology Reconstructive

Minor orthopedic(arthroscopy) Minor urologic(cystoscopy) Type of Surgery- High Risk(>5%) Aortic surgery-(Open procedures) Major peripheral vascular

Not high risk because of the nature of the procedure Almost all patients have multiple risk factors Perioperative EvaluationHistorical Points Known CAD Previous revascularization

Bypass PCI-When and what was done?-Bare metal vs DES Exertional symptoms Previous cardiac evaluation When, and what did it show?

Exercise tolerance Most important predictor of perioperative outcome Determines ability to increase O2 delivery perioperatively Risk and Exercise Tolerance Assessing Functional Status Exercise Tolerance and Risk

Functional Capacity of 4 METS confers low risk status Cant be evaluated in patients with mobility problems Orthopedic procedures, especially joint replacement COPD PAD with claudication Very high risk population Known vascular disease AAA repair represents highest risk

Preoperative EvaluationPhysical Exam Signs of heart failure

Rales JVD Edema S3 Tachycardia-Is patient in atrial fibrillation? Bradycardia-Heart block, SSS Murmur of aortic stenosis Pulmonary findings-Wheezes Any of these findings necessitate further workup Major Predictors of Increased CV Risk

Unstable coronary syndromes Decompensated heart failure Arrhythmias Ventricular tachycardia AV block and sick sinus Uncontrolled atrial fibrillation or flutter Severe valvular disease

Especially aortic stenosis These patients need further evaluation prior to noncardiac surgery Unstable Coronary Syndromes Class III or IV symptoms

Poor exercise tolerance Indications for stress testing or cath are same as for those not undergoing noncardiac surgery Patients with chronic stable angina (Class II) do not require preoperative stress testing Heart Failure

Greater perioperative risk than ischemia Should have EF measured BNP may have prognostic significance if normal Optimize therapy prior to surgery

Beta blockers and possibly ACEIs and ARBs should be continued perioperatively Valvular Heart Disease Severe aortic stenosis

AVA <1.0 cm2 or mean AV gradient >40 mm Hg, even in absence of symptoms Should have AVR prior to noncardiac surgery, preferably with a tissue prosthesis TAVR for high risk patients New guidelines suggest that asymptomatic patients with severe AS may have surgery Requires hemodynamic monitoring postop Severe mitral stenosis

Can usually be treated with balloon valvuloplasty Regurgitant lesions are well tolerated in the absence of previous heart failure if LV function is normal Arrhythmias-Atrial Fibrillation Chronic atrial fibrillation and flutter

Control ventricular rate with beta blockers Determine if bridging with Lovenox is necessary Some procedures can be done without stopping anticoagulants Newly diagnosed atrial fibrillation Control ventricular rate, preferably with beta blockers

Proceed with surgery Institute anticoagulation and specific antiarrhythmic therapy postoperatively Medical or electrical cardioversion postoperatively Bradycardias Mobitz I Review medications No need for pacing if asymptomatic, proceed with surgery

Mobitz II and 3rd degree block Review medications If reversible causes not present, permanent pacemaker indicated before surgery Sick sinus syndrome Review medications If asymptomatic, proceed with surgery If symptomatic, permanent pacemaker indicated May be useful to walk patient and observe HR response

Preoperative Stress Testing and Outcomes May lead to adverse outcomes Appropriate in selected patients High risk surgery Poor exercise tolerance Symptoms of possible ischemia Exertional chest pain, tightness, heaviness DOE

Routine stress imaging in asymptomatic patients is poor at identifying patients who will have adverse outcomes Preoperative revascularization does not affect outcomes Preoperative PCI

BARI trial No improvement in outcomes vs medical treatment of angina preoperatively Increased operative mortality if PCI within 12 days before surgery Similar outcomes for PCI vs Bypass Results duplicated in several trials Preoperative CABG No benefit in several studies

CASS CARP CASS registry High risk vascular surgery patients randomized to CABG vs medical treatment Medical rx-2.4% mortality CABG-0.9% mortality BUT PREOP BYPASS HAD 1.4% MORTALITY, MAKING MEDICAL AND CABG ARMS EQUIVALENT

CARP Study Mortality Why Doesnt Revascularization Improve Outcomes? Stress imaging is poor in identifying patients with adverse outcomes Angiography not always good at detecting disease

Less occlusive plaque is often the most unstable In autopsy studies, the infarct vessel was often not the most stenotic on previous cath Surgery and anesthesia can cause plaque disruption and hyper-coaguable states In nonsurgical populations revascularization has no benefit over medical treatment in stable patients

Problems Introduced by Preoperative Revascularization Delayed surgery Anticoagulation and antiplatelet issues Morbidity and mortality inherent in the revascularization procedure

Cost effectiveness Class of Recommendations I-Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective IIa- Weight of evidence is in favor of usefulness or

efficacy IIb-Usefulness or efficacy is less well established by evidence or opinion III-Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful EKG-Recommendations

LV Function-Recommendations Stress TestingRecommendations Stress ImagingRecommendations Perioperative Drug Therapy Beta blockers Statins

ACEIs, ARBs Aspirin ADP receptor antagonists(antiplatelet drugs) Beta Blockers-Current

Guidelines Class I Continue beta blocker therapy in patients receiving Rx for angina, arrhythmias, hypertension or other Class I indications Level of evidence-B Beta Blockers-Class IIa Management of beta blockers postop

should be guided by clinical circumstances, independent of when the drug was started May require temporary discontinuation due to hypotension, bradycardia, or other conditions LOE-B Beta Blockers-Class IIb

Patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification testing (LOE C) Patients with 3+ RCRI risk factors (LOE B) Patients with compelling long-term indications for beta blocker therapy but no other RCRI risk factors (LOE B) Initiate beta blocker therapy long enough in advance to assess safety and tolerability

(LOE B) Beta Blockers-Class III Patients with absolute contraindications to beta blocker therapy Risks outweigh benefits Do not start on the day before or the day

of surgery (LOE B) Beta Blockers-General Considerations Little evidence to support >30 day timeline Can be started 2-7 days before

Optimal dosing and timing not defined Elevated perioperative stroke risk However, incidence of MACE much higher than stoke. Effect of Resting Heart Rate on Postoperative Cardiac Events Beta Blockers

Initiate 2-7 or up to 30 days prior to surgery Titrate to resting pulse rate of 60-80 Titrate to blood pressure of 130/80 or less Avoid hypotension

Statins Cardioprotective effects in perioperative period Improves endothelial morphology and function Plaque stabilization

Discontinuation of chronic therapy preoperatively is associated with adverse outcomes May benefit even started the day before surgery Start therapy in high risk patients 7-30 days before procedure-Class I, level B Do not discontinue statin therapy preoperativelyClass I, level C Effect of Statins on Perioperative Cardiac Events Statins-Recommendations ACEIs, ARBs

LV dysfunction Continue for high risk surgery-Class I, level C Consider continuing for low risk surgery-Class IIa, level C Hypertension-Consider transient discontinuation to avoid hypotensionClass IIb, level C Recommendations based on low level of

evidence Aspirin Aspirin for secondary prevention usually should not be discontinued in patients with previous stents 15 % of recurrent ACS in stable CAD patients due to discontinuing aspirin

Increased risk of stroke Should only stop if expected bleeding risks and sequelae are greater than known risk of stopping Intracranial or back surgery Posterior eye chamber Prostate ADP Receptor Antagonists

Most often arises after PCI Premature discontinuation increases perioperative M&M without reducing risk of bleeding Elective surgeries should be postponed PTCA-2-6 weeks Bare metal stent-30 days-The longer the better Drug eluting stents-12 months

Emergency surgeries should be done on aspirin at least and preferably on dual antiplatelet therapy Exceptions are intracranial, intraspinal, and retinal surgery Perioperative MI- The POISE Study

Defined on basis of EKG changes and troponin elevations 65% of MIs were asymptomatic 11% died within 30 days (58% of those within 48h) Troponin elevation >3x normal was independent risk factor in absence of symptoms or EKG findings Conclusion-At risk patients should be monitored for perioperative infarction with EKGs and enzymes for first three days Perioperative and Postoperative Surveillance-Recommendations

Class I Class IIb Troponin level recommended if signs or symptoms of myocardial ischemia or MI (LOE A)

EKG recommended if Sx or signs of ischemia or MI(LOE B) Usefulness of troponin or EKG in high risk patients is uncertain without sx of signs of ischemia (LOE B) Class III Routine screening with EKG or troponin in unselected patients without Sx or signs is not useful for guiding postoperative care Preoperative Evaluation-What Is Essential?

1-Determine if the patient has had prior revascularization-When and what? 2-Has patient had a cardiac workup in the last several years?-What were the results? 3-Assess the patients functional capacity

4-Determine preoperative risk (RCRI or ACS risk calculator) 5-Determine the pretest probability of cardiac complications based on type of surgery and institutional experience 6-Assess whether stress testing will alter pretest probability of risk. Most of the time it will not. Preoperative Evaluation-What Is Essential?

7-For elective surgery, determine if benefits outweigh perioperative risk. 8-Determine if there are opportunities to reduce cardiac complications by modifying preoperative or intraoperative care 9-Develop strategies to minimize perioperative risk, especially beta blockers and statins 10-Utilize careful postoperative monitoring to identify nonfatal cardiac events and modifiable risk factors to tailor long term therapy and follow up

What to Do If You Determine That the Patient is at High Risk Tell the patient Find out how badly the patient wants the surgery Emphasize that the risks may outweigh the benefits Call the surgeon How urgent is the operation? Is there a less invasive alternative?

Endovascular or laproscopic procedures Is the surgeon willing to operate with patient on antiplatelet drugs? Dont back down if you really think the risk is too high. Most surgeons do worry about operative mortality. What to Do if You Determine That the Patient is at High Risk Determine if there are risk factors that can be modified to reduce risk and allow surgery at a

later date Uncompensated heart failure Uncontrolled diabetes Uncontrolled hypertension Arrhythmias COPD Get a consult There is no reason to do an elective operation under less than optimal conditions

Emergency Operations Often no opportunity for preoperative assessment or risk reduction Try to do risk stratification before OR Postoperative monitoring for cardiac events becomes more important in this setting

Question 1 The most important clinical indicator of perioperative cardiovascular outcome is: A-Previous revascularization B-History of heart failure

C-Functional capacity D-The type of surgical procedure Question 2 A 74 y/o man is referred prior to THR. He has a history of previous bypass 10 years ago. He is asymptomatic but severely limited by his arthritis. As part of his preop evaluation he should have:

A-A treadmill GXT B-Cardiac catheterization C-Pharmacologic stress imaging D-EKG

Question 3 The man in the previous question is on aspirin, lisinopril, and metformin. Prior to surgery his regimen should be changed as follows: A-Add a long acting beta blocker B-Stop aspirin

C-Add a statin D-Make no changes Question 4 A 68 y/o woman comes in for preop evaluation for colon resection for carcinoma. She has no symptoms. Her pulse is 110 and irregular, BP 120/74, and an EKG shows atrial fibrillation. She takes losartan and HCTZ. You should:

A-Clear for surgery B-Start anticoagulation and postpone surgery until after cardioversion C-Start beta blocker therapy and postpone surgery until resting pulse rate <80

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