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Update on Perioperative Medicine. Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco. Update on Perioperative Medicine. Who needs a preoperative cardiac stress test? What are the benefits and risks of  -blockers?

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update on perioperative medicine

Update on Perioperative Medicine

Hugo Quinny Cheng, MD

Division of Hospital Medicine

University of California, San Francisco

update on perioperative medicine2
Update on Perioperative Medicine
  • Who needs a preoperative cardiac stress test?
  • What are the benefits and risks of -blockers?
  • Can statins prevent postoperative MI?
  • When can patients with stents go to the OR?
  • How should chronic anticoagulation be managed?
  • Should arthroscopy patients get DVT prophylaxis?
  • Is preoperative smoking cessation beneficial?
preoperative stress testing
Preoperative Stress Testing
  • A 65 y.o. man with a history of coronary artery disease and long-standing diabetes will undergo radical prostatectomy. He had a myocardial infarction in 2003, but now has no cardiac symptoms.
  • Meds: lovastatin, atenolol, glyburide, benazepril, ASA
  • Exam: BP=115 / 70 HR=60; normal heart & lung exam
  • ECG: NSR, LVH, otherwise normal
65 y.o. man s/f radical prostatectomy. History of remote MI and long-standing diabetes. He is currently asymptomatic.
  • Stress test prior to surgery
  • No stress test is needed
  • Make him carry a copy of Harrison’s up a flight of stairs
new standard cardiac risk index
“New Standard” Cardiac Risk Index
  • Predictors:
  • Higher risk operation*
  • Ischemic heart disease
  • Congestive heart failure
  • Diabetes requiring insulin
  • Creatinine > 2 mg/dL
  • Stroke or TIA

Predictors Complications**

0 0.5%

1 1.3%

2 4%

3 or more 9%

* Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery

** Defined as MI, pulmonary edema, cardiac arrest, complete heart block

Lee, et al. Circulation, 1999

2007 acc aha guideline


Good Functional Capacity?

Go to OR

no or ?

no predictors*

1 or 2 predictors

≥ 3 predictors


Vascular surgery?


Go to OR

Consider stress test if results will change management (IIa)

Control HR & go to OR (IIa)

2007 ACC/AHA Guideline





352 with no or limited ischemia

34 with extensive ischemia (9%); 12 had PCI or CABG

30-day CV Death or MI





770 vascular patients with 1 or 2 of following:

Age > 70, MI, angina, CHF, DM, stroke / TIA, Cr > 1.8

No stress test (n = 384)

Stress test (n = 386)

Poldermans et al. JACC, 2006


Extensive Ischemia Predicts High Risk

101 patients undergoing vascular surgery, all with ≥ 3 risk predictors and stress test showing extensive ischemia

Poldermans, et al. JACC, 2007

reducing risk with medical management
Reducing Risk with Medical Management
  • A 75 y.o. woman will undergo hemicolectomy next week. She has a history of diabetes and a remote stroke, but no current cardiovascular symptoms.
  • Start a -blocker
  • Start a statin
  • Start both -blocker & statin
  • No new medications needed

Standard Care


Cardiac Mortality & Nonfatal MI (%)








Days after Surgery

- 111 patients undergoing vascular surgery- All had ischemic potential on dobutamine echo- Randomized to beta-blocker or standard care


Poldermans, et al. NEJM, 1999

poise perioperative ischemia evaluation
POISE: PeriOperative Ischemia Evaluation
  • 8351 patients with s/f major noncardiac surgery
  • CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery
  • Not already taking -blocker

Metoprolol XL (immediately preop until 30 days postop)


Patients followed for 30 days after surgery:

1° Endpoint: cardiac mortality & nonfatal arrest or MI

Poise Study Group. Lancet, 2008

poise results
POISE: Results
  • Metoprolol XL:
  • Reduced cardiac events (mostly nonfatal MI)
  • but
  • Increased risk of stroke & total mortality

Poise Study Group. Lancet, 2008

poise treatment protocol
POISE: Treatment Protocol

2-4 h


0-6 h

12 h

1st dose Metoprolol 100 mg XL*

2nd dose Metoprolol 100 mg XL*

3rd & daily dose Metoprolol 200 mg XL*^

* Study drug held for SBP < 100 or HR < 50

^ Daily dose reduced to 100 mg if persistent bradycardia or hypotension

decrease iii

497 statin naive patients s/f vascular surgery

  • Fluvastatin XL 80 mg/day
  • Started > 1 month preop
  • Continued > 1 mo postop


  • Patients followed for 30 days after surgery:
    • Clinical Endpoint: cardiac death or nonfatal MI

Poldermans et al. Presented at ESC, 2008

decrease iii results
  • Fluvastatin XL:
  • Reduced the composite outcome of cardiac death & nonfatal MI
  • No difference in rates of LFT or CPK elevation

Poldermans et al. Presented at ESC, 2008

decrease iv
  • 1066 patients with estimated 1-6% risk of postoperatived cardiac complications
  • Randomized to: Bisoprolol
  • Fluvastatin XL
  • Bisoprolol + Fluvastatin
  • Double placebo
  • Drugs started average 34 days prior to surgery
  • Primary endpoint: 30-day CV death or nonfatal MI
decrease iv results

Bisoprolol-treated patients had fewer complications

Trend towards benefit with statins

No safety issues

* P < .002



Dunkelgrun et al. Ann Surg, 2009

perioperative blockers in 2009
Perioperative -blockers in 2009
  • Strong indications:
    • Already using -blocker to treat angina, HTN, arrhythmia
    • Patients with ischemic potential having vascular surgery
  • Possible indications:
    • Patients with ischemic potential having high-risk nonvascular surgery (e.g., > 5 hours or > 500 cc blood loss)
    • Multiple risk predictors* in vascular or other high-risk surgery

(*Coronary disease, renal insufficiency, diabetes)

  • Titrate dose up gradually (rarely start immediately preop)
statins 2007 acc aha guideline
Statins: 2007 ACC/AHA Guideline
  • Definite indications (class I):
    • Continue statin if already taking prior to surgery
  • Probable indications (class IIa):
    • All vascular surgery patients
  • Possible indications (class IIb):
    • At least one risk predictor* in any intermediate risk surgery

*Coronary disease, renal insufficiency, diabetes, CVA/TIA

delaying surgery after coronary stent
Delaying Surgery After Coronary Stent
  • A woman falls and suffers a cervical spine fracture. One month ago, she received a sirulimus-eluting stent for stable angina. The neurosurgeon won’t operate unless aspirin and clopidogrel are held for her surgery. Non-operative management in a halo for next 2 months is offered as an alternative.
  • What do you recommend to the patient & surgeon?

Patient with recently placed drug-eluting stent has a c-spine fracture. Surgeon won’t operate unless aspirin & clopidogrel are held perioperatively.

  • Hold ASA & clopidogrel
  • Hold ASA & clopidogrel but bridge with heparin
  • Keep her in a halo for next 2 months
does heparin bridge prevent stent related complications
Does Heparin Bridge Prevent Stent-related Complications?
  • Prospective study of 103 patients with coronary stent placed within 12 months having noncardiac surgery
    • Antiplatelet drugs continued or held < 3 days
    • All patients received heparin drip or enoxaparin
  • 14% of patient stented within 35 days of surgery suffered cardiac death or MI, or needed re-do PCI
  • Conclusion: High rate of cardiac complications even when bridging anticoagulants used

Vicenzi et al. Br J Anaesth, 2006

acc aha guidelines for pci
ACC/AHA Guidelines for PCI
  • Avoid PCI unless patient has independent indications
  • Avoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapy
  • Delay elective surgery in patients with recent PCI
        • Balloon angioplasty: 2 - 4 weeks
        • Bare metal stent: 4 weeks
        • Drug eluting stent: 12 months
  • If clopidogrel must be stopped, try to continue ASA
  • No evidence for bridging with other agents
managing perioperative anticoagulation
Managing Perioperative Anticoagulation
  • Two patients who take coumadin underwent THA. One has atrial fibrillation due to HTN. The other has a mechanical AVR. Neither has a history of stroke or any other comorbidity.
  • Heparin bridge for AVR only
  • Heparin bridge for AF only
  • Heparin bridge for both
  • Heparin bridge for neither

Two patients who take coumadin underwent THA. One has AF due to HTN. The other has a mechanical AVR. Neither has a history of stroke any other comorbidity.

  • Heparin bridge for AVR only
  • Heparin bridge for AF only
  • Heparin bridge for both
  • Heparin bridge for neither
thromboembolic risks with non rheumatic atrial fibrillation
Thromboembolic Risks with Non-rheumatic Atrial Fibrillation

CHADS-2 Score:

1 point for CHF, HTN, Age > 75, DM

2 points for Stroke/TIA

Score 0 - 2: < 5% annual stroke risk Score 3 - 4: 5-10%

Score 5 - 6: > 10%

Annual Stroke Risk

Albers et al. Chest, 2001

thromboembolic risks with mechanical valves
Thromboembolic Risks with Mechanical Valves

Annual Incidence

Cannegieter, et al. Circulation, 1994

effect of mechanical valve location design on thromboembolic risk
Effect of Mechanical Valve Location & Design on Thromboembolic Risk
  • Valve Location:
  • Aortic RR = 1.0
  • Mitral RR = 1.8
  • Valve Design:
  • Caged Ball RR = 1.0
  • Tilting Disk RR = 0.7
  • Bi-leaflet RR = 0.6

Cannegieter, et al. Circulation, 1994

perioperative anticoagulation 2008 accp guidelines
Perioperative Anticoagulation: 2008 ACCP Guidelines

Full dose = therapeutic dose of heparin IV or LMWH SC

Low dose = DVT prophylaxis dose of heparin SC or LMWH SC

dvt prophylaxis
DVT Prophylaxis
  • Which DVTs matter?
    • Symptomatic versus asymptomatic
    • Proximal versus distal
  • 2008 American College of Chest Physicians:
    • Weights DVT risk greater than bleeding risk
    • Treats asymptomatic DVT as important
rct of lmwh in knee arthroscopy
RCT of LMWH in Knee Arthroscopy
  • Background:2008 ACCP guidelines recommend LMWH if additional risk factors for DVT are present.
  • Study Design: ~1300 patients randomized to compression hose or LMWH x 7 days after knee arthroscopy. All patients underwent screening ultrasound.
  • Results: Combined incidence of death or any clot reduced in patients receiving LMWH (0.9% vs 3.2%). Almost all clots were either asymptomatic or distal. Non-significant trend for increased bleeding.
  • Conclusions: LMWH superior to compression hose after knee arthroscopy (NNT = 43). Impact on symptomatic DVT small.

Camporese et al. Ann Intern Med, 2008.

preoperative smoking cessation
Preoperative Smoking Cessation
  • A middle-aged man will undergo repair of a ventral hernia in 1 month. He currently smokes one pack of cigarettes per day. How do you counsel him?
  • Quit smoking now to prevent postoperative complications.
  • It’s always good to quit, but it’s too late to affect your risk of complications.
  • Don’t stop smoking! You will actually increase your surgical risk by quitting!
effect of smoking cessation
Effect of Smoking Cessation

Time since quitting

p < .001

Complication Rate (%)

Warner, Anesthesiology 1984

preoperative smoking cessation counseling
Preoperative Smoking Cessation Counseling
  • RCTs of Preoperative Smoking Cessation Counseling:
    • 120 patients undergoing arthroplasty in 6-8weeks
    • 117 patients undergoing various operations in 4 weeks
    • 60 patients undergoing colorectal resection in 2-3 weeks

Intervention:Smoking cessation counseling at weekly meetings (or by telephone) & offer free nicotine replacement products

Outcomes:Postop complications, especically wound related (e.g., dehiscence, infection, hematoma)

smoking cessation 4 weeks before surgery
Smoking Cessation 4 Weeks Before Surgery

Lindstrom et al. Ann Surg, 2008.

smoking cessation 2 3 weeks before colorectal surgery
Smoking Cessation 2-3 Weeks Before Colorectal Surgery

Sorensen, et al. Colorectal Dis, 2003

take home points
Take Home Points
  • Reserve stress testing for higher risk patients

-- Limited ischemia ok, but extensive ischemia = high risk

  • Start -blocker cautiously & only in high risk patients
  • Delay surgery in patients with recent stent placement
  • Individualize thrombotic risk assessment when managing perioperative anticoagulation
  • Consider LMWH for knee arthroplasty patients
  • Smoking cessation for ≥ 4 weeks may be beneficial