Acc aha 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery
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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

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Acc aha 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery l.jpg

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery

Dr. Sonia Anand

McMaster University


Overview l.jpg
Overview Evaluation and Care for noncardiac surgery

  • 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


Slide3 l.jpg

The Search For High Risk Evaluation and Care for noncardiac surgery


Methods for assessing risk pre operatively l.jpg
Methods for Assessing Risk Pre-Operatively Evaluation and Care for noncardiac surgery

Patient Based

  • High risk conditions

  • Functional Capacity

    Surgery Based

  • Vascular Surgery

  • Emergency surgery

    Intervention Based

  • Medications

  • Revascularization


Six independent predictors of cardiac risk l.jpg
Six Independent predictors of cardiac risk Evaluation and Care for noncardiac surgery

  • ischemic heart disease

  • 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 l.jpg
Active/Major Cardiac Conditions Evaluation and Care for noncardiac surgery

  • Unstable Coronary Conditions

  • Decompensated CHF

  • Significant arrhythmias (i.e. 3⁰HB, new Vtach)

  • Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????


Non active cardiac factors l.jpg
Non-Active Cardiac Factors Evaluation and Care for noncardiac surgery

  • Intermediate Risk

  • Hx of CHD

  • History of prior CHF

  • Hx of stroke

  • Diabetes

  • Renal insufficiency

  • Minor Risk*

  • Age > 70

  • Abnormal ECG

  • Nonsinus rhythm

  • Uncontrolled systolic BP

* Not associated with cardiac risk


Functional capacity l.jpg
Functional Capacity Evaluation and Care for noncardiac surgery

  • Functional status has shown to be a reliable periop and long-term predictor of cardiac events

  • Functional status determined based on ability to do ADL’s

  • MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest

  • Periop risk is increased if person cannot > 4 METS


Slide9 l.jpg

Moderate recreational golf, dancing, baseball Evaluation and Care for noncardiac surgery

Strenuous sports swimming, basketball

DO light house work i.e. Washing dishes

Climb a flight of stairs

Run a short distances

Eat, dress

10 MET

1 MET

4 MET


The trump card functional capacity l.jpg
The Trump Card: Evaluation and Care for noncardiac surgeryFunctional 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 l.jpg
Surgery Risk Evaluation and Care for noncardiac surgeryType


Surgery specific risk high risk l.jpg
Surgery-Specific Risk: Evaluation and Care for noncardiac surgeryHigh 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 l.jpg
Stepwise Approach Evaluation and Care for noncardiac surgery

  • 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 l.jpg
The Catheterization Questions to Ask Yourself Evaluation and Care for noncardiac surgery

  • 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 l.jpg
Is pre-op coronary revasc advantageous? Evaluation and Care for noncardiac surgery

  • 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 l.jpg
Functional Test Evaluation and Care for noncardiac surgery

  • 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 l.jpg

*** Evaluation and Care for noncardiac surgery

10

(n=314)

8.5

Periop MI

8

Death

6

*

4

3.0

2.8

*

***

2

1.1

0.6

0

0

No CAD

CAD:

Medical Rx

CAD:

CABG

Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry

Eagle et al. Circulation, 1997


Coronary revascularization does not improve immediate or long term outcomes l.jpg
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 l.jpg
High Risk Patients & Revascularization Pre-Op Long-Term Outcomes

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

0

3

6

9

12

Days since surgery

Months since surgery

Poldermans, D. JACC 2007; 49(17): 1763


The effect of percutaneous revascularization above optimal medical therapy courage l.jpg

1.0 Long-Term Outcomes

0.9

0.8

Survival Free of Death/MI

0.7

0.6

0.5

7

0

1

2

3

4

5

6

Years

The Effect of Percutaneous Revascularization Above Optimal Medical Therapy:COURAGE

2287 Pts w/myocardial ischemia and CAD randomized to PCI with

optimal medical therapy (PCI group) and 1138 to medical therapy alone.

Medical therapy

PCI + Medical therapy

Boden, W. NEJM 2007; 356:1503


Stents l.jpg
STENTS Long-Term Outcomes

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


Slide22 l.jpg

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 l.jpg
Medical tx or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

1) beta blockers-if on keep them if not....

2) Statins continue, ? Start -need randomized trials


Statins improve survival after vascular surgery l.jpg
Statins Improve Survival After Vascular Surgery or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

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 l.jpg

1.00 or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

.75

Survival

.50

.25

0

0

60

20

40

80

100

Time (months)

Statins Improve Long-Term Survival After Vascular Surgery

Retrospective review of 446 consecutive infrainguinal bypass surgeries

Statin (+)

p < 0.004

Statin (-)

Ward, RP. Int J Card 2005; 104(3):264


Other issues l.jpg
Other Issues or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

  • 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 l.jpg
Surveillance for Perioperative Myocardial Infarction or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

  • 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 l.jpg
High Risk Features or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

  • Severe obstructive or restrictive pulmonary disease

  • Diabetes

  • Renal impairment

  • Anemia, polycythemia, thrombocytosis


Pci pre op l.jpg
PCI pre-op or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

  • ST-elevation MI

  • Unstable angina

  • Non ST elevation MI


2007 acc aha perioperative guidelines l.jpg
2007 ACC/AHA Perioperative Guidelines or planned non cardiac sx that will necessitate d/c of antiplatelet agents is


Take home messages l.jpg
Take Home Messages or planned non cardiac sx that will necessitate d/c of antiplatelet agents is

  • 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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