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Outpatients with Significant Cardiac History. Tamas Szabo, MD, PhD Ralph H. Johnson VAMC Medical University of South Carolina. South Carolina Society of Anesthesiologists Annual Meeting June 5, 2010. Outline. Perioperative Cardiovascular Evaluation Case Presentation

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outpatients with significant cardiac history

Outpatients with Significant Cardiac History

Tamas Szabo, MD, PhD

Ralph H. Johnson VAMC

Medical University of South Carolina

South Carolina Society of Anesthesiologists Annual Meeting

June 5, 2010

outline
Outline

Perioperative Cardiovascular Evaluation

Case Presentation

Update on Perioperative Beta Blockade

Patients with Stents

Cardiac Rhythm Management Devices

slide3

ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

Born: 1996

Reborn: 2002

Revised: 2007

changes in the 2007 guidelines
Changes in the 2007 Guidelines

Major Predictors: Active Cardiac Conditions

Intermediate Predictors: Revised Cardiac Risk Index

Minor Predictors: their presence is not an indication for further workup (but might lead to a higher suspicion of CAD)

Functional Capacity: increased emphasis

active cardiac conditions
Active Cardiac Conditions

ConditionExamples

Unstable coronary syndromes Unstable / severe angina

Recent MI (1 week-1 month)

Decompensated HF (NYHA IV.)

Significant arrhythmias Newly recognized ventricular tachycardia

Symptomatic ventricular arrhythmias

Symptomatic bradycardia

Supraventricular arrhythmias (>100/min)

Third degree AVB

Mobitz II. AVB

Severe valvular disease Severe AS (AVA<1 cm2, mean gradient >40 mmHg

Symptomatic MS (DOE, HF, syncope)

revised cardiac risk index lee
Revised Cardiac Risk Index (Lee)
  • Prediction of cardiac risk for stable patients undergoing elective major noncardiac surgery.
    • CAD (h/0 MI, NTG-use, CP, q-waves, +stress test)
    • CHF (h/o pulmonary edema, PND)
    • Cerebrovascular disease (stroke, TIA)
    • Diabetes (on insulin)
    • Creatinine > 2 mg/dl
validation of the lee score
Validation of the Lee-score

Dutch dataset with 108,593 noncardiac operations.

1 point each for CAD, CHF, CVD, IDDM, Cr >2, High-risk surgery.

0.5% Total cardiovascular deaths 543 (0.5%).

cardiac risk stratification for noncardiac surgeries
Cardiac Risk Stratification for Noncardiac Surgeries

Risk StratificationExamples

Vascular (cardiac risk > 5%) Aortic / Major vascular surgery

Peripheral vascular surgery

Intermediate (1-5%) Intraabdominal / Intrathoracic surgery

Carotid endarterectomy

Head and neck surgery

Orthopedic / Urology cases

Low (<1%) Ambulatory surgery

Endoscopic procedures

Cataracts

Breast surgery

case presentation
Case Presentation

80 yo male w/ after recent acute gallstone pancreatitis and cholecystitis presents for laparoscopic cholecystectomy.

PMH: Ischemic cardiomyopathy, dual-chamber PM for AVB (2008), 2 vessel CABG (1980), 4 vessel CABG (1994), HTN, Hyperlipidemia, COPD.

Functional capacity: 4 METs, but recently becoming less active 2 to SOB.

Abnormal stress test (12/2009): inducible anterior apical and inferior ischemia, EF: 40%.

how would you proceed
How would you proceed?

What would the cardiologist do?

Call in sick or cancel the case.

Bite the bullet and do the case.

Call cardiology for further workup and to interrogate the PM.

Repeat stress-test .

Cardiac cath.

Interrogation of the pacemaker.

What is your perioperative plan?

Nothing fancy.

Preinduction A-line, CVP, PAC, TEE, external pacer-pads.

Preinduction A-line, aggressive beta-blockade, ext. pacer-pads.

poise trial
POISE Trial

8331 patients undergoing noncardiac surgery

Metoprolol 100 mg or Placebo 2-4 hours preop and 6 hours postop

Metoprolol 200 mg or Placebo 18 hours postop for 30 days

Primary end point: composite of cardiovascular death, MI, and nonfatal cardiac arrest

Fewer Metoprolol patients reached the primary end point (5.8% vs. 6.9%, p<0.04) or had an MI (4.2% vs. 5.7%, p<0.0017).

More Metoprolol patients died (p=0.03), had a stroke (p=0.0053), developed significant hypotension (p<0.0001) and bradycardia (p<0.0001).

The usual initial daily dose of Metoprolol is 25-100 mg for HTN

Poise Pts could receive up to 400 mg on the first day

decrease iv trial
DECREASE IV Trial

1066 intermediate-risk patients undergoing noncardiac surgery

4 groups: Bisoprolol, Fluvastatin, both or nothing.

Primary end point: composite of cardiac death and nonfatal MI.

Bisoprolol was started 30 days before surgery and was titrated to a HR 50-70/min. It was continued until 30 days postop.

The Bisoprolol group had a lower incidence of cardiac death and nonfatal MI (2.1% vs. 6.0%, p=0.002). Ischemic stroke rate was not significantly different between the groups.

poldermans study decrease group
Poldermans Study (Decrease-group)

770 intermediate-risk patients undergoing vascular surgery

Patients were randomly assigned to cardiac stress testing or no testing.

All Pts received beta blockers titrated to a resting HR 60-65/min.

Pts assigned to no testing had a similar incidence of cardiac events as those assigned to testing (1.8% vs. 2.3%, p=ns). Pts with a HR<65/min had lower risk than the rest (1.3% vs. 5.2%, p=0.003).

“Cardiac testing can safely be omitted in intermediate-risk patients, provided that beta-blockers aiming at tight heart rate control are prescribed.”

summary for perioperative beta blocker therapy
Summary for Perioperative Beta Blocker Therapy

Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACC/AHF Class I guideline indications for the drugs. (Class I)

Several Class II recommendations exist for Pts undergoing vascular or intermediate-risk surgeries with multiple clinical risk factors.

Initiation well before a planned procedure with careful titration to achieve adequate HR-control (60-80/min) while avoiding frank bradycardia and hypotension is also suggested.

Routine administration, particularly higher fixed-dose regimens begun on the day of surgery, cannot be advocated (POISE).

slide18
Why?

Coronary Stents ≠ less perioperative problems and complications

des thrombosis

A,B: 8/2005 LAD PCI with DES

Stopped Plavix in 5/2006

C,D : 8/2006 MI 2 to LAD stent occlusion

Emergent balloon dilatation

DES Thrombosis

E,F : platelets, fibrin and inflammatory cells (neutrophils and eosinophils) in the thrombus

cardiac risk of noncardiac surgery after pci with bms
Cardiac Risk of Noncardiac Surgery after PCI with BMS

899 patients undergoing noncardiac surgery after BMS placement.

5.2% experienced MACEs (STEMI, NSTEMI, stent thromboses, repeat revascularizations and deaths).

The risk of MACEs after NCS was found to be the highest within 30 days of PCI w/ BMS (10.5%), and lowest after 90 days (2.8%). Bleeding complications were not associated with antiplatelet therapy.

cardiac risk of noncardiac surgery after pci with des
Cardiac Risk of Noncardiac Surgery after PCI with DES

520 patients undergoing noncardiac surgery after DES placement.

5.4% experienced MACEs (STEMI, NSTEMI, stent thromboses, repeat revascularizations and deaths).

The rate of MACEs did not change significantly with time after placement. Bleeding complications were few and were not associated with antiplatelet therapy.

cruden study
Cruden study

Scotland-wide retrospective cohort study.

1953 patients were treated with DES (n=570) or BMS (n=1383) and subsequently underwent noncardiac surgery.

There were no differences in in-hospital mortality or MI between the 2 groups, however perioperative death and ischemic cardiac events occurred more frequently when noncardiac surgery was performed within 42 days of stent implantation. Mortality between 6 weeks – 1 year was still 4x higher than beyond 1 year.

elective noncardiac surgery and pci
Elective Noncardiac Surgery and PCI

Elective surgeries should be delayed to meet the above time-limits.

the perioperative dilemma
The Perioperative Dilemma

D/C-d antiplatelet drugs:

risk for perioperative stent thrombosis,

MI and death

Continuedplavixandaspirin:

potential for surgical bleeding

dual antiplatelet therapy
Dual Antiplatelet Therapy

Current ACC/AHA recommendations for the prevention of stent thrombosis after coronary stent implantation state that patients should be treated with clopidogrel 75 mg and aspirin 325 mg for one month after bare-metal stent implantation, 3-6 months (ideally 12 months) after DES implantation if they are not at high risk for bleeding.

However, these recommendations were based on the antiplatelet regimen used in trials to obtain FDA approval in low-risk patients with low-risk lesions. DES are now being used high-risk lesions.

There is no evidence that warfarin, antithrombotics, or glycoprotein IIb/IIIa agents reduce the risk of stent thrombosis after discontinuation of oral antiplatelet agents.

preoperative evaluation
Preoperative Evaluation

Establish whether the patient has a CMRD.

Define the type of CMRD.

Have the device interrogated by cardiology.

Determine dependency on pacing function of the CMRD.

Determine whether EMI is likely to occur intraoperatively.

Determine whether reprogramming pacing function to asynchronous mode or disabling rate responsive function is advantageous.

Suspend antitachycardia functions if present.

Have temporary pacing and defibrillation equipment immediately available.

electromagnetic interference
Electromagnetic Interference

Pacemaker/AICD response to EMI:

Temporary or permanent resetting to a backup pacing mode.

Temporary or permanent inhibition of pacemaker output.

Increase in pacing rate (rate-responsive PMs).

AICD inappropriate shock.

Myocardial injury at the lead tip: failure to sense or capture.

Sources:

Electrocautery

Radiofrequency ablation

MRI (contraindicated!)

Radiation therapy

ESWL

ECT

electrocautery
Electrocautery

Assure that the electrosurgical receiving plate (aka “ground patch”) is positioned so that the current pathway does not pass through or near the CMRD system.

Avoid the proximity of the cautery’s electrical field to the pulse generator or leads.

Use short, intermittent or irregular bursts at the lowest energy levels.

Use bipolar electrocautery system or harmonic scalpel.

what does the magnet do
What Does The Magnet Do?

Pacemaker:

Pacing without sensing at a fixed rate (asynchronous modes: AOO, VOO, DOO).

AICD:

Pacing capability is not affected.

The antitachycardia (shock) function will be temporarily disabled and will become active once the magnet is removed.

OR

The shock function will first be suspended and then turned off.

emergency defibrillation or cardioversion
Emergency Defibrillation or Cardioversion

For a patient with an AICD and magnet-disabled therapies:

Terminate all sources of EMI while magnet is removed.

Remove the magnet to activate the shock function.

Observe the patient and the monitors for appropriate device therapy.

External defibrillation:

Position defibrillation/cardioversion pads as far as possible from the pulse generator (anterior-posterior application preferable).

Use clinically appropriate energy levels.

if everything else fails
If Everything Else Fails:

Medtronic (800) 633-8766

Vitatron

Guidant (800) 227-3422

CPI

Intermedics

St. Jude Medical (800) 722-3774

Ventritex

Pacesetter

Teletronics

Biotronik (800) 547-0394

ELA (800) 352-6466

references

Boersma E. Perioperative Cardiovascular Mortality in Noncardiac Surgery: Validation of the Lee cardiac Risk Index. Am J Med. 2005;118:1134-41

Caplan RA. Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents. Anesthesiology. 2009;110:22-3

Cruden NL. Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Nincardiac Surgery. Circ Cardiovasc Interv. 2010 (Epub ahead of print)

Deveraux PJ. Effects of Extended-release Metoprolol Succinate in Patients Undergoing Non-cardiac Surgery (POISE trial): A Randomized Controlled Trial. Lancet. 2008;371:1839-47

Dunkelgrun M. Bisoprolol and Fluvastatin for the Reduction of Perioperative Cardiac Mortality and Myocardial Infarction in Intermediate-risk Patients Undergoing Noncardiovascular Surgery : A Randomized Controlled trial. Ann Surg. 2009;249:921-6

Fleischmann KE. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:2123-51

Fleisher LA. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007;116:418-500

Grines CL. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. Circulation. 2007;115:813-8

Lee TH. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation. 1999;100:1043-9

Nuttall GA. Time and Cardiac Risk of Surgery after Bare-metal Stent Percutaneous Coronary Intervention. Anesthesiology. 2008;109:588-95

Poldermans D. Should Major Vascular Surgery be Delayed because of Preoperative Cardiac Testing in Intermediate-risk Patients Receiving Beta-blocker Therapy with Tight Heart-rate Control? J Am Coll Cardiol. 2006;48:964-9

Rabbitts JA. Cardiac Risk of Noncardiac Surgery after Percutaneous Coronary Intervention with Drug-eluting Stents. Anesthesiology. 2008;109:596-604

Rade JJ. Noncardiac Surgery for Patients with Coronary Artery Stents. Anesthesiology. 2008;109:573-5

Zaidan JR. Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter- Defibrillators. Anesthesiology. 2005;103:186-98

References