Pre-operative Cardiovascular Evaluation: Guidelines and More

1. 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

2. 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

3. 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

4. What Causes Perioperative MI? Surgery Patient Underlying CAD Hypertension Tachycardia Anxiety/Pain Hemostasis Volume Shifts Anemia Medication withdrawal Temperature fluctuation Acidosis Myocardial Infarction

5. 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

6. 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

7. 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???

8. 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.”

9. http://www.americanheart.org/

10. 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)

11. 2007 Update

12. 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

13. Perioperative Guidelines Algorithm Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Active Cardiac Conditions Yes

14. 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

15. 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

16. 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

17. Perioperative Guidelines Algorithm Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Active Cardiac Conditions Yes No Step 3

18. 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

19. Perioperative Guidelines Algorithm Step 3 Proceed with planned surgery Low Risk non-cardiac Surgery? No Step 4

20. Perioperative Guidelines Algorithm Step 4 Good Functional Capacity without symptoms (>4 mets) Proceed with planned surgery Yes

22. Assessing Functional Capacity Walk 1-2 blocks, level ground ADL’s Walk Indoors Eat, Dress or Toilet Light House Work 4 mets 1 Met

23. 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

24. Assessing Functional Capacity

25. 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.

26. Perioperative Guidelines Algorithm Step 4 Good Functional Capacity without symptoms (>4 mets) Proceed with planned surgery Yes No or Unknown Step 5

27. 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.)

28. Revised Cardiac Risk Index Percent AAA Other Vascular Thoracic Abdominal Orthopedic Other Procedure Type

29. Perioperative Guidelines Algorithm Step 5 Proceed with planned surgery No Clinical Risk Factors

30. 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

31. 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

32. 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

33. 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

35. TYPE of Surgery

36. http://www.surgicalriskcalculator.com/miorcardiacarrest On line tool to calculate patient and procedure specific risk for planned surgery

37. ACC/AHA Perioperative Guidelines Updates: October 2007 Miscellaneous

38. 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

39. ACC/AHA Perioperative Guidelines Updates: October 2007 • Who Needs an ECG?? • CLASS III- ECG not needed in asymptomatic patients undergoing low risk surgical procedures.

40. 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

41. Best Treatment of Perioperative MI Prevention

42. 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

43. 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

44. 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

45. 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

46. 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

47. Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007 • The “Business” of stress testing and preoperative evalutation • Who’s going to pay?

48. Preoperative Evaluation Keep it simple!!