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Pre-operative Cardiovascular Evaluation: Guidelines and More. Eric A. Brody MD, FACC Medical Director, NA Cardiology and Medical Services Associate Professor of Clinical Medicine University of Arizona Medical Center. Objectives.

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pre operative cardiovascular evaluation guidelines and more

Pre-operative Cardiovascular Evaluation: Guidelines and More

Eric A. Brody MD, FACC

Medical Director, NA Cardiology and Medical Services

Associate Professor of Clinical Medicine

University of Arizona Medical Center

objectives
Objectives
  • Review Algorithm for Pre-op risk assessment for current guidelines
  • Define the roles of the cardiac/medical consultant for the non-cardiac surgery patient
  • Discuss “clearance”
  • Review the 10 commandments of the cardiac/medical consultant
mechanisms of perioperative mi
Mechanisms of Perioperative MI

MVO2

Shear Stresses

Excess Catechols

Platelet Activation

  • Unique postoperative conditions lend themselves to AMI
    • Volume loss/Fluid Shifts
    • Anemia
    • Anxiety/Pain
    • Tachycardia
    • Temperature fluctuations
    • Coagulation cascade
what causes perioperative mi
What Causes Perioperative MI?

Surgery

Patient

Underlying CAD

Hypertension

Tachycardia

Anxiety/Pain

Hemostasis

Volume Shifts

Anemia

Medication withdrawal

Temperature fluctuation

Acidosis

Myocardial Infarction

treatment of peri operative mi
Treatment of Peri-operative MI

Antithrombotic Therapy

UFH/LMWH

Anti-thrombins

Thrombolysis

Antiplatelet Therapy

ASA

GP2b3a

Thienopyridines

Medical Therapy

Beta Blockers

Ca+ Channel. Blockers

ACE inhibitors/ARB

Interventional Therapy

PCI/Stent

role of the medical consultant
Role of the Medical Consultant
  • Identify co-morbidities which may complicate surgery
  • Airway/anaesthesia issues
  • Functional status of the patient
  • Clarify pre-op medications
  • Peri-procedural cardiac risk
what is cleared questions to answer
What is “Cleared”?Questions to answer.
  • Patients condition is optimized prior to surgery??
  • Benefits outweigh risk of surgery??
  • OK to proceed??
  • Medical Legal considerations removed???
what is cleared
What is “Cleared”?
  • My preference- one of 2 options
    • “Patient is considered ______________

(low, moderate or high) risk for peri-op cardiovascular complications based on current ACC/AHA guidelines”

-” My recommendations for perioperative care include…..”

-”Patient requires additional testing to better clarify perioperative cardiac risk.”

acc aha perioperative guidelines updates october 2007
ACC/AHA Perioperative Guidelines Updates: October 2007
  • Last revision: 2002
  • Significant changes to previous guidelines
  • Dramatic change in perioperative evaluation algorithm.

JACC 2007: vol. 50 (17)

perioperative guidelines algorithm
Perioperative Guidelines Algorithm

Step 1

Perioperative Surveillance and postop. Risk stratification. Risk Factor management

Need for Emergency non-cardiac Surgery?

Operating Room

Yes

No

Step 2

slide13

Perioperative Guidelines Algorithm

Step 2

Evaluate and Treat per ACC/AHA guidelines

Consider Operating Room

Active Cardiac Conditions

Yes

slide14

Active Cardiac Conditions:Patients require evaluation and treatment before non-cardiac surgery

  • Unstable Coronary Syndromes
  • Decompensated CHF
  • Significant Arrhythmias
  • Severe Valvular Heart disease

Unstable or Severe Angina (class III or IV) or recent MI >7 days but < one month

active cardiac conditions patients require evaluation and treatment before non cardiac surgery
Significant Arrhythmias

High grade AV block

Mobitz II AVB

Third degree AVB

Symptomatic Vent. Arrhythmias/Bradycardia

SVT/Afib with uncontrolled rate (>100/min)

Active Cardiac Conditions:Patients require evaluation and treatment before non-cardiac surgery
  • Unstable Coronary Syndromes
  • Decompensated CHF
  • Significant Arrhythmias
  • Severe Valvular Heart disease
active cardiac conditions patients require evaluation and treatment before non cardiac surgery1
Active Cardiac Conditions:Patients require evaluation and treatment before non-cardiac surgery
  • Unstable Coronary Syndromes
  • Decompensated CHF
  • Significant Arrhythmias
  • Severe Valvular Heart disease
  • Severe Valvular Heart disease
  • Severe Aortic Stenosis
  • Critical Mitral Stenosis
slide17

Perioperative Guidelines Algorithm

Step 2

Evaluate and Treat per ACC/AHA guidelines

Consider Operating Room

Active Cardiac Conditions

Yes

No

Step 3

low risk surgeries

Perioperative Guidelines Algorithm

Low Risk Surgeries

Step 3

  • Endoscopic
  • Superficial
  • Breast
  • Most ambulatory surgeries
  • Cataracts/ocular

Low Risk non-cardiac Surgery?

Proceed with planned surgery

Yes

perioperative guidelines algorithm1
Perioperative Guidelines Algorithm

Step 3

Proceed with planned surgery

Low Risk non-cardiac Surgery?

No

Step 4

perioperative guidelines algorithm2
Perioperative Guidelines Algorithm

Step 4

Good Functional Capacity without symptoms (>4 mets)

Proceed with planned surgery

Yes

slide22

Assessing Functional Capacity

Walk 1-2 blocks, level ground

ADL’s

Walk Indoors

Eat, Dress or Toilet

Light House Work

4 mets

1 Met

assessing functional capacity
Assessing Functional Capacity

Climb 1 flight stairs or walk uphill

Heavy Housework

Moderate sports

Walk 4 mph

Strenuous Sports

Run a short distance

>10 mets

4 mets

another way to look at this
Another Way to look at This!!
  • No Clinical Risk Factors and Low or intermediate risk surgeries with good functional capacity may proceed directly to the OR.
slide26

Perioperative Guidelines Algorithm

Step 4

Good Functional Capacity without symptoms (>4 mets)

Proceed with planned surgery

Yes

No or Unknown

Step 5

clinical risk factors
Clinical Risk Factors

Step 5

  • Ischemic Heart Disease
  • Compensated or Prior CHF
  • DM (insulin requiring)
  • Renal Insufficiency (creat. >2.0)
  • Cerebrovascular Disease

Lee et al. Circulation. 1999;100:1043-1049.)

revised cardiac risk index
Revised Cardiac Risk Index

Percent

AAA Other Vascular Thoracic Abdominal Orthopedic Other

Procedure Type

slide29

Perioperative Guidelines Algorithm

Step 5

Proceed with planned surgery

No Clinical Risk Factors

slide30

Perioperative Guidelines Algorithm

Step 5

Class IIa, LOE B

Intermediate Risk Surgery

Proceed to OR with HR control or

Consider Non invasive testing

1 or 2 Clinical Risk Factors

Vascular Surgery

Class IIb, LOE B

cardiac risk stratification high risk procedures
Cardiac Risk Stratification: High Risk Procedures
  • Reported Cardiac Risk often >5%
    • Emergent major operations, particularly in elderly patients
    • Aortic and other major vascular
    • Peripheral vascular
    • Anticipated prolonged procedures with large fluid shifts or blood loss
cardiac risk stratification intermediate risk procedures
Cardiac Risk Stratification: Intermediate Risk Procedures
  • Reported cardiac risk generally <5%
    • Carotid endarterectomy
    • Major head and neck, especially for CA
    • Intraperitoneal and intrathoracic
    • Orthopedic, especially in elderly
    • Radical prostatectomy
slide33

Perioperative Guidelines Algorithm

Step 5

Proceed to OR with HR control or consider Non invasive testing

Intermediate Risk Surgery

3 or more Clinical Risk Factors

Consider Non- invasive testing

Vascular Surgery

Class IIa, LOE B

http www surgicalriskcalculator com miorcardiacarrest

http://www.surgicalriskcalculator.com/miorcardiacarrest

On line tool to calculate patient and procedure specific risk for planned surgery

acc aha perioperative guidelines updates october 20072
ACC/AHA Perioperative Guidelines Updates: October 2007
  • Who Needs an ECG??
      • Undergoing Vascular surgery (one or more clinical risk factors) Class I
      • Undergoing Vascular Surgery (no risk factors) IIa
      • Intermediate risk surgery with established CVD (CAD, PVD, Cerebrovascular disease) Class I
      • Intermediate Risk surgery with one or more clinical risk factors
acc aha perioperative guidelines updates october 20073
ACC/AHA Perioperative Guidelines Updates: October 2007
  • Who Needs an ECG??
    • CLASS III- ECG not needed in asymptomatic patients undergoing low risk surgical procedures.
recommendations for statin therapy acc aha perioperative guidelines updates october 2007
Recommendations for Statin TherapyACC/AHAPerioperative Guidelines Updates: October 2007
  • Class I- (LOE B)
    • Patients taking statins should be continued on this therapy at time of non-cardiac surgery
conclusions ways to avoid cardiac complications
Conclusions: Ways to Avoid Cardiac Complications
  • Know the Patient’s History
    • Prior MI or known CAD
    • Prior CHF and LVEF
    • Renal Failure/ baseline Creatinine
    • History of significant Valvular heart disease
      • Stenosis > regurgitation
conclusions ways to avoid cardiac complications1
Conclusions: Ways to Avoid Cardiac Complications
  • Know what your surgeons and anesthesiologists did
    • Speak with them directly to coordinate perioperative care.
    • Blood loss/serial hematocrits
    • Fluid resuscitation
    • Check the post op orders yourself
challenges for primary providers acc aha perioperative guidelines updates october 2007
Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007
  • Our own insecurities
    • Long history of “clearance” performed by cardiologists
  • Changing the Culture
    • Surgeons
    • Anesthesiologists
challenges for primary providers acc aha perioperative guidelines updates october 20071
Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007
  • Getting the surgeons to listen to peri-operative recommendations
    • “You lost me at ‘Cleared’…..”
    • Importance of continuing statin therapy and beta blocker therapy in those already taking these medications
conclusions ways to avoid cardiac complications2
Conclusions: Ways to Avoid Cardiac Complications
  • Know the patients’ medications
    • Continue Beta Blockers if on these preoperatively
    • Prophylactic beta blockade is not indicated in all patients
slide47

Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007

  • The “Business” of stress testing and preoperative evalutation
  • Who’s going to pay?
preoperative evaluation

Preoperative Evaluation

Keep it simple!!

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