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
Tamas Szabo, MD, PhD
Ralph H. Johnson VAMC
Medical University of South Carolina
South Carolina Society of Anesthesiologists Annual Meeting
June 5, 2010
Perioperative Cardiovascular Evaluation
Update on Perioperative Beta Blockade
Patients with Stents
Cardiac Rhythm Management Devices
ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
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
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
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)
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%).
Vascular (cardiac risk > 5%) Aortic / Major vascular surgery
Peripheral vascular surgery
Intermediate (1-5%) Intraabdominal / Intrathoracic surgery
Head and neck surgery
Orthopedic / Urology cases
Low (<1%) Ambulatory surgery
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%.
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 .
Interrogation of the pacemaker.
What is your perioperative plan?
Preinduction A-line, CVP, PAC, TEE, external pacer-pads.
Preinduction A-line, aggressive beta-blockade, ext. pacer-pads.
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
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.
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.”
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).
Coronary Stents ≠ less perioperative problems and complications
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.
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.
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 surgeries should be delayed to meet the above time-limits.
D/C-d antiplatelet drugs:
risk for perioperative stent thrombosis,
MI and death
potential for surgical bleeding
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.
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.
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.
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.
Pacing without sensing at a fixed rate (asynchronous modes: AOO, VOO, DOO).
Pacing capability is not affected.
The antitachycardia (shock) function will be temporarily disabled and will become active once the magnet is removed.
The shock function will first be suspended and then turned off.
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.
Position defibrillation/cardioversion pads as far as possible from the pulse generator (anterior-posterior application preferable).
Use clinically appropriate energy levels.
Medtronic (800) 633-8766
Guidant (800) 227-3422
St. Jude Medical (800) 722-3774
Biotronik (800) 547-0394
ELA (800) 352-6466
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