PREOP CARDIAC EVALUATION FOR NONCARDIAC SURGERY

1. PREOP CARDIAC EVALUATION FOR NONCARDIAC SURGERY Yatish B. Merchant, MD, FACC Cardiology, New Jersey USA

2. Ultimate Goal • Quality of care and serving the patient’s best interests.

3. Goals • Understand how to estimate peri-operative CV risk • Know when to perform stress testing preoperatively • Learn how to reduce risk perioperatively in those at higher risk

4. 55 Years old man with history of hypertension & CAD but asymptomatic runs for 30 minutes daily, needs inguinal hernia repair. You are consulted to clear him for surgery. • 1) Order Nuclear stress test to evaluate CAD. • 2) Order Regular stress test • 3) Order Cardiac catheterization • 4) Clear for surgery

5. Inflammatory State Stress State Hypoxic State Triggers • Surgical Trauma • Anesthesia/analgesia • Intubation/extubation • Pain • Hypothermia • Bleeding/anemia • Fasting • Anesthesia/analgesia • Hypothermia • Bleeding/anemia • Surgical Trauma • Anesthesia/analgesia • Surgical Trauma • Anesthesia/analgesia Hypercoagulable State ↑TNF-α ↑IL-1 ↑IL-6 ↑CRP ↑ catecholamine and cortisol levels ↑ PAI-1 ↑ Factor VII ↑ Platelet reactivity ↓ antithrombin III ↓oxygen delivery Coronary artery shear stress ↑ BP ↑ HR ↑ FFAs ↑ relative insulin deficiency Plaque fissuring Plaque fissuring ↑ Oxygen demand Myocardial Ischemia Acute Coronary Thrombus Perioperative Myocardial Infarction

6. Overview • Risk Assessment • Preoperative Testing • Postoperative Management to Reduce Risk

8. Approaches to Risk Assessment • ASA/Dripps • Goldman Multifactorial Index • Detsky Modified Index • Revised Risk Index • ACC/AHA Task Force Recommendations Quantitative Strategic

9. Dripps/ASA Classification

10. Goldman Risk Index Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

11. Goldman Risk Index Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.

12. ACC/AHA Guidelines J Am Coll Cardiol, 2007; 50:1707-1732

13. Stepwise Approach to the Pre-operative Evaluation

14. Stepwise Approach to Preoperative Cardiac Assessment Vigilant perioperative and postoperative management Need for emergencynoncardiacsurgery Operating room Yes No Evaluate and treatper ACC/AHA Guidelines Active cardiac conditions Consider Operating Room Yes No Proceed withplanned surgery Low RiskSurgery Yes No Asymptomatic andgood functionalcapacity Proceed withplanned surgery Yes Manage based onclinical risk factors No

15. Active Cardiac Conditions High Risk: • Acute or recent MI (7-30 d) • Unstable coronary syndrome • Decompensated CHF • Significant Arrhythmias • Severe Valvular Disease Surgery

16. Stepwise Approach to Preoperative Cardiac Assessment Vigilant perioperative and postoperative management Need for emergencynoncardiacsurgery Operating room Yes No Evaluate and treatper ACC/AHA Guidelines Active cardiac conditions Consider Operating Room Yes No Proceed withplanned surgery Low RiskSurgery Yes No Asymptomatic andgood functionalcapacity Proceed withplanned surgery Yes Manage based onclinical risk factors No

17. Low Risk Surgery Risk < 1% • Endoscopic procedures • Superficial procedure • Cataract surgery • Breast surgery

18. Low Risk Situations Low Risk: • Low risk surgery • Good functional capacity • No cardiac symptoms • No “active cardiac conditions” • No clinical risk factors Reasonable to proceed with surgery

19. Functional Capacity : Metabolic Equivalents (METs) • Correlates with maximum oxygen uptake on treadmill testing • Demonstrated predictor of future cardiac events • Poor functional capacity may hide low threshold cardiac symptoms

20. What is basal O2 consumption (Vo2)? • 1.5 ml/kg/min • 2.5 ml/kg/min • 3.5 ml/kg/min • 4.5 ml/kg/min

21. Duke Activity Status Index 1 METCan you take care of yourself? Eat, dress, or use the toilet? Walk indoors around the house? Walk a block or two on level ground at 2-3 mph or 3.2-4.8 km/h? 4 METs Do light work around the house like dusting or washing clothes? MET = metabolic equivalent 4 METsClimb a flight of stairs or walk up a hill? Walk on level ground at 4 mph or 6.4 km/h? Run a short distance? Do heavy work around the house like scrubbing floors or lifting or moving heavy objects? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? 10 METsParticipate in strenuous sports like swimming, singles tennis, football, baseball, or skiing? Resting or basal O2 consumption(Vo2) of a 70 kg, 40 yrs old man is 3.5 mL per kg per min, or 1 MET.

22. Clinical Risk Factors • Known Ischemic Heart Disease • Compensated or Prior Heart Failure • Diabetes • Renal Insufficiency • Cerebrovascular disease

23. Stepwise Approach to Preoperative Cardiac Assessment Vigilant perioperative and postoperative management Need for emergencynoncardiacsurgery Operating room Yes No Evaluate and treatper ACC/AHA Guidelines Active cardiac conditions Consider Operating Room Yes No Proceed withplanned surgery Low RiskSurgery Yes No Asymptomatic andgood functionalcapacity Proceed withplanned surgery Yes Manage based onclinical risk factors No

24. Clinical Risk Factors • History of heart disease • Compensated or prior CHF • Cerebrovascular disease • Diabetes Mellitus • Renal Insufficiency Proceed Cautiously

25. Asymptomatic butpoor/unknown functionalcapacity Manage based onclinical risk factors 3 or more clinical risk factors* 1 or 2 clinical risk factors* No clinical risk factors* Vascular Surgery Intermediate risk surgery Vascular Surgery Intermediate risk surgery Consider Testing Proceed with planned surgery with HR controlor consider non-invasive testing Proceed withplanned surgery *Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal insufficiency, cerebrovascular disease

26. Intermediate Risk Surgery Risk < 5% • Carotid endarterectomy • Endovascular AAA repair • Head and neck • Intraperitoneal and intrathoracic • Orthopedic • Prostate

27. High Risk Surgery Risk > 5% • Emergent major operations (3-5 times more risk) • Aortic and other major vascular • Peripheral vascular • Anticipated prolonged or associated with large fluid shifts and/or blood loss

28. Overview • Risk Assessment • Preoperative Testing • Postoperative Management to Reduce Risk

29. Most preoperative testing assesses for presence of obstructive CAD and NOT plaque vulnerability which truly predicts the risk. Unfortunately we have no way of predicting this.

30. ACC/AHA Recommendations • Echocardiography: • Dyspnea of unknown origin (Class IIa) • Current or hx of HF and no echo in 12 months (Class IIa) • 12 Lead ECG • Vascular surgery and 1 CRF (class I) • CRFs and intermediate risk surgery (class I) • All vascular surgery (class IIa)

31. ACC/AHA Recommendations • Treadmill stress testing • High cardiac risk conditions • 3 CRFs, poor functional capacity & vascular surgery (class IIa) • Nuclear stress testing

32. Which test to choose? Most ambulatory patients Treadmill Stress Test Abnormal resting ECG (dig, LVH) Exercise echo or sestamibi LBBB DSEAdenosine sestamibi dipyridamole sestamibi Unable to exercise

33. Preoperative TestingNegative Predictive Value Freedom from MI or Death Eagle et al. JACC 1996;27:910.

34. Preoperative Testing Caveats • Whenever feasible, an exercise stress test is best choice • Dipyridamole or adenosine perfusion scan and DSE are reasonable choices if: • unable to exercise • BBB or other resting ECG abnormality • Avoid dipyridamole and adenosine scan if bronchspasm • Avoid DSE if serious arrhythmias or severe hypertension

35. Overview • Risk Assessment • Preoperative Testing • Perioperative Management to Reduce Risk

36. 60 yrs old man with history of CAD, HTN, DM & Creatinine of 2.5 showed small I W ischemia on nuclear stress test at 10 METS & asymptomatic, needs to have prostatectomy for Ca. How would you treat? • Cardiac cath & PCI as indicated. • Cancel surgery & request other Rx option. • BB with heart rate control perioperative. • Give nitrates & CCB & proceed with surgery.

37. Perioperative Nitrates? Dodds, et al. Anesth. Analg. 1993;76:705-13

38. Perioperative Management • Revascularization • Beta blockers • Statins • Alpha-2 agonists • Calcium channel blockers

39. Revascularization • 5859 vets screened prior to vascular surgery;4669 excluded • 510 randomized to: • Revascularization (258) • 99 CABG • 141 PCI • 18 not revascularized • 252 no revascularization • 9 revascularized • 143 medical rx McFalls, et al. NEJM 2004;351:2795-2804

40. Intervention is rarely necessary to simply lower the risk of surgery. Revascularization (surgery or PCI) should be considered only if standard indications are present.

41. PCI before anticipated surgery Acute MIHigh Risk ACSHigh risk anatomy Bleeding risk of anticipated surgery Stent and continued Dual-antiplatelet rx Low Not low 14 to 29 Days 30 – 365 Days > 365 Days Balloon angioplasty Bare-metalstent Drug-elutingstent

42. Timing of Surgery After PCI Balloon angioplasty Bare-metalstent Drug-elutingstent < 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days Delay Surgery with ASA Delay Surgery with ASA Delay Surgery with ASA

43. Perioperative Management • Revascularization • Beta blockers • Statins • Alpha-2 agonists • Calcium channel blockers

44. Postoperative Mortality ReductionBeta-Blockers • 200 pts undergoing non-cardiac surgery • Random assignment to: • IV followed by oral atenolol or • Placebo • Double-blind follow-up over 2 years Mortality Mangano, et al. NEMJ 1996;335:1713.

45. Postoperative Cardiac Events In High Risk Patients • 173 patients undergoing vascular surgery with positive DSE • Randomized to BB 1 week pre-op or placebo • Followed for 30 days Placebo n=53 Bisoprolol n=59 Poldermans et al. NEJM 1999;341:1789.

46. Perioperative Beta Blockers AHA/ACC Recommendations: 2006 Update • Beta blockers required in recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension • Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery • Patients undergoing vascular surgery and with identified CAD • Vascular surgery and multiple cardiac risk factors • Moderate or high risk surgery and multiple cardiac risk factors Key Point: if known or suspected CAD and undergoing moderate or high risk surgery, use a beta blocker!

47. Perioperative Management • Revascularization • Beta blockers • Statins • Alpha-2 agonists • Calcium channel blockers

48. Perioperative Statins? • 100 patients pre-op before vascular surgery • Random assignment: • Atorvastatin 20 mg • Placebo • Started 30 days preoperatively • Follow-up 6 month • Endpoint: • Cardiac death • Non-fatal MI • USA • Stroke J Vasc. Surgery 2004;39:967

49. Perioperative Statins Hindler, et al. Anesthesiology 2006;105:1260-72

50. Perioperative Statins • 44% reduction in mortality after all types of surgery. • 59 % after vascular surgery alone Hindler, et al. Anesthesiology 2006;105:1260-72