Pre-operative Cardiac Risk Assessment for Non-Cardiac Surgery
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery Dr. Sonia Anand McMaster University Overview Guidelines- reflect evidence synthesis and consensus Evidence as of October 2007 Important Decision points: Urgent vs Elective Surgery High risk surgery vs intermediate vs low Active Cardiac Condition vs non-active The Search For High Risk
Methods for Assessing Risk Pre-Operatively Patient Based High risk conditions Functional Capacity Surgery Based Vascular Surgery Emergency surgery Intervention Based Medications Revascularization Six Independent predictors of cardiac risk 1) ischemic heart disease 2) congestive heart failure
3) cerebrovascular disease 4) high risk surgery (AAA, orthopedic sx) 5) pre-operative insulin tx for diabetes 6) preoperative creatinine for creat > 2 mg/dL Lee et al Active/Major Cardiac Conditions Unstable Coronary Conditions Decompensated CHF Significant arrhythmias (i.e. 3HB, new HB, new Vtach) Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm)???????)??????? Non-Active Cardiac Factors
Intermediate Risk Hx of CHD History of prior CHF Hx of stroke Diabetes Renal insufficiency * Not associated with cardiac risk Minor Risk* Age > 70
Abnormal ECG Nonsinus rhythm Uncontrolled systolic BP Functional Capacity Functional status has shown to be a reliable periop and long-term predictor of cardiac events Functional status determined based on ability to do ADLs MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest Periop risk is increased if person cannot > 4 METS 1 MET 4 MET
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Ea t, d as eb a ll The Trump Card: Functional Capacity Perioperative cardiac risk is increased in patients unable to exercise 4 METs Functional capacity can be estimated in the office Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs
Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs Swimming and singles tennis exceeds 10 METs Surgery Risk Type Type Cardiac risk examples High > 5% Aortic, peripheral vasc sx Intermediate risk
1-5% Intraperitoneal Intrathoracic Carotid End Head and neck Orthopedic Sx Prostate Sx Low <1% Endoscopic procedures Superficial Cataract Sx Breast Sx
Ambulatory Sx Surgery-Specific Risk: High Risk* Major emergency surgery Vascular surgery including: aortic surgery, infra-inguinal bypass Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5% Stepwise Approach Step 1: Determine urgency of surgery Step 2: Active cardiac condition?-test Step 3: Undergoing low-risk surgery? < 1%* Step 4: Good functional capacity? * Combined morbidity and mortality < 1% even in high risk
patients The Catheterization Questions to Ask Yourself Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now? Am I willing to send the patient to CABG? Am I doing this just to know the anatomy? Is pre-op coronary revasc advantageous? If high risk surgery and patient has active cardiac issue Functional test and perfusion Imaging and if L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis consider revasc pre-op
CARP if none of these no advantage of revasc Functional Test Exercise test with ECG If abnormal ECG, Rx perfusion imaging Adenosine Dipyridamole Dobutamine Dobutamine stress echo Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry 10 (n=314) *** 8.5
Periop MI Death 8 6 4 * 2.8 3.0 * 2 *** 0.6 1.1
0 0 No CAD CAD: Medical Rx CAD: CABG Eagle et al. Circulation, 1997 Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes 510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized to Revasc (PCI 59%, CABG 41%) or conservative management.
25 20 15 10 5 0 Post-Op MI 30 Day 2.7 Year Mortality Mortality Revascularization Conservative Mgmt McFalls, E. CARP Trial;AHA 2004 High Risk Patients & Revascularization Pre-Op
101 pts with extensive ischemia randomly assigned to pre-op revascularization or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up. 50 40 % 30 20 2VD in 12 (24%), 3VD in 33 (67%), Left main in 4 (8%). 10 0 7 14
21 28 Days since surgery 0 3 6 9 12 Months since surgery Poldermans, D. JACC 2007; 49(17): 1763 The Effect of Percutaneous Revascularization
Above Optimal Medical Therapy: COURAGE Survival Free of Death/MI 2287 Pts w/myocardial ischemia and CAD randomized to PCI with optimal medical therapy (PCI group) and 1138 to medical therapy alone. 1.0 0.9 0.8 0.7 Medical therapy 0.6 PCI + Medical therapy
0.5 0 1 2 3 4 Years 5 6 7 Boden, W. NEJM 2007; 356:1503
STENTS If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after If received DES.... 1) postpone sx until > 12 months, 2) do sx on both asa+clop 3) do sx on single ap tx Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended Medical tx 1) beta blockers-if on keep them if
not.... 2) Statins continue, ? Start -need randomized trials Statins Improve Survival After Vascular Surgery 100 pts randomized 20 mg atorvastatin or placebo for 45 days. Vascular surgery ~ 30 days after randomization. F/U 6 months Primary Endpoint CV death + NFMI+ Ischemic stroke+ Unstable Angina Durazzo, AES. JVS 2004:39(5):975 Statins Improve Long-Term
Survival After Vascular Surgery .75 .50 Statin (+) p < 0.004 .25 Statin (-) 0 Survival 1.00
Retrospective review of 446 consecutive infrainguinal bypass surgeries 0 20 60 40 Time (months) 80 100 Ward, RP. Int J Card 2005; 104(3):264 Other Issues
DVT/PE prophylaxis Anesthetic technique-volatile agent with general anesthetic - troponin LV function >> propofol, midazolam, balanced anesthesia (Grade B) No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes Routine troponin monitoring not recommended Surveillance for Perioperative Myocardial Infarction ECGs All intermediate and high-risk patients should get a post-op ECG. As need for signs or symptoms of ischemia
Troponin / CK In patients with signs or symptoms of ischemia Do not do screening biomarkers High Risk Features Severe obstructive or restrictive pulmonary disease Diabetes Renal impairment Anemia, polycythemia, thrombocytosis PCI pre-op ST-elevation MI Unstable angina Non ST elevation MI 2007 ACC/AHA Perioperative Guidelines
Take Home Messages Unstable syndromes require management prior to surgery. Look for Unstable angina Signs of heart failure Stenotic valve lesions Ventricular arrhythmias Functional tolerance is the best single predictor of outcome Be very specific in your history (one step at at time, regular or slow pace, etc) If patient on beta blockers & statins continue them, more trials to mandate them PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.
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