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2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future. What is Cardiology Clearance?. Sheilah Bernard, MD, FACC Director, Cardiac Amb Services. Boston University School of Medicine May 19, 2006. 9:30-10:00am. Eight Steps to Best Possible Outcome.

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what is cardiology clearance

2nd Annual Ellison Pierce Symposium

Positioning Your ORs For The Future

What is Cardiology Clearance?

Sheilah Bernard, MD, FACC

Director, Cardiac Amb Services

Boston University School of Medicine

May 19, 2006


eight steps to best possible outcome
Eight Steps to Best Possible Outcome
  • Assess the patient’s clinical features
  • Evaluate functional status
  • Consider the patient’s surgery-specific risk
  • Decide if further noninvasive evaluation is needed
  • Decide when to recommend invasive evaluation
  • Optimize medical therapy
  • Perform appropriate perioperative surveillance
  • Design maximal long-term therapy

AHA/ACC Practice Guidelines Perioperative CV Evaluation for Noncardiac Surgery

2002, Eagle K et al. www.acc.org or www.americanheart.org

implementing guidelines
Implementing Guidelines
  • Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI)
    • Resources: ETT 88%47%; Cath 24%11%; revascularization 25%2%
    • Costs: $1087$171
  • Effect was sustained 2 years after guideline implementation

Froelich JB, J Vasc Surgery 2002 36L758-63


B&W Preadmission Testing Center (PATC) and last minute Cardiology consults for:

Dudley JC et al, AM HEART J 1996;131:245-9.


Adjusted Odds Ratio for In-Hospital Death Associated with Perioperative Beta-Blocker Therapy among Patients Undergoing Major Noncardiac Surgery, According to the RCRI Score and the Presence of Other Risk Factors in the Propensity-Matched Cohort and the Entire Study Cohort

Lindenauer, P. K. et al. N Engl J Med 2005;353:349-361

limitations in the perioperative beta blocker literature
Limitations in the perioperative beta blocker literature
  • Most trials inadequately powered
  • Few randomized trials of medical therapy have been performed
  • Few randomized trials have examined titration to effect (e.g. target heart rate)
  • Few randomized trials have examined the role of perioperative beta blocker therapy
  • Studies to determine role in intermediate and low risk populations are lacking.
  • Optimal beta blocker
  • No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom)

Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery

McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804


Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization

McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804

cabg pci before major elective vascular surgery no
?CABG/PCI before major elective vascular surgery? NO
  • In conclusion, this multicenter, randomized trial shows thatcoronary-artery revascularization before elective vascular surgerydoes not alter long-term survival.
  • Although the study was notpowered to detect a beneficial effect in the short term, therealso appears to have been no reduction in the number of postoperativemyocardial infarctions, deaths, or days in the hospital.
  • Onthe basis of these data, coronary-artery revascularization beforeelective vascular surgery among patients with stable cardiacsymptoms cannot be recommended.

Kaplan-Meier Survival Curves to One Year

Sandham, J. et al. N Engl J Med 2003;348:5-14

the statins for risk reduction in surgery starrs study
The Statins for Risk Reduction in Surgery (StaRRS) study
  • Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece
  • 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization
    • 157 complications occurred
      • 9.9% statin vs 16.5% non-statin

O’Neil-Callahan et al JACC 2005; 336-42

optimization before the or
Optimization before the OR
  • Pacing/ICD “Electrical” issues
    • Turn off ICD/magnet for VVI pacing
  • Valvular “Coagulation” issues
    • Reverse, hold or bridge warfarin
    • SBE prophylaxis
  • Myocardial “CHF” issues
    • PA catheter/CHF management
  • Coronary “ischemia” issues
    • Per AHA/ACC algorithm
is patient high cv risk 5
Is patient high CV risk (>5%)?
  • Unstable coronary syndromes
    • Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing
    • Unstable or severe angina CC III or IV
  • Decompensated heart failure
  • Significant arrhythmia
    • High degree AV block
    • Symptomatic ventricular arrhythmias in the presence of underlying heart disease
    • Supraventricular arrhythmia with uncontrolled ventricular rate
  • Severe valvular disease
hemodynamic changes with labor
Hemodynamic changes with labor
  • Uterine contractions cause up to 500 cc autotransfusion
  • C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR)
  • Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change
  • HR, volume, CO normalize by 5-6 weeks postpartum
areas in further need of research
Areas in further need of research
  • Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness
  • Cost-effectiveness of the various methods of noninvasive testing
  • Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients
  • Establishment of optimal guidelines for selected patient subgroups, especially elderly
  • Establishment of monitoring guidelines in treatment decisions and outcomes
what is cardiology clearance26
What is cardiology clearance?
  • Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management
  • Interdisciplinary management
  • Considerations in delivering the pregnant cardiac patient
  • Future operational strategies