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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


Perioperative Guidelines Algorithm

Step 2

Evaluate and Treat per ACC/AHA guidelines

Consider Operating Room

Active Cardiac Conditions

Yes


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


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


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


Assessing functional capacity1
Assessing Functional Capacity


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.


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


Perioperative Guidelines Algorithm

Step 5

Proceed with planned surgery

No Clinical Risk Factors


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


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


Best treatment of perioperative mi
Best Treatment of Perioperative MI

Prevention


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


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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