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PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. What is the appropriate cardiac evaluation?. Case #1

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preoperative cardiac clearance gme chief retreat september 2010 august 5th 2009

PreOperative Cardiac ClearanceGME Chief RetreatSeptember 2010August 5th, 2009

AGS

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

what is the appropriate cardiac evaluation
What is the appropriate cardiac evaluation?

Case #1

A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

what is the appropriate cardiac evaluation1
What is the appropriatecardiac evaluation?

Case #2

An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

what is the appropriate cardiac evaluation2
What is the appropriatecardiac evaluation?

Case #3

A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

cardiac preoperative evaluation
Cardiac PreOperative Evaluation

AHA 2007 Guidelines on Perioperative

Cardiovascular Evaluation for Non-cardiac Surgery

  • Clinical Cardiac Risk Factors
  • Operative Risk
  • Functional Capacity

Circulation (2007) 116:1971.

slide9

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

OR = operating room

slide10

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Active Cardiac Condition

STEP 2

clinical risk factor assessment
CLINICAL RISK FACTOR ASSESSMENT
  • Major Risk Factors
  • Unstable coronary syndromes
    • Unstable/severe angina
    • Recent MI
  • Decompensated CHF
  • Significant arrhythmia
  • Severe valvular disease

Circulation (2007) 116:1971.

slide12

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

slide13

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Low-Risk Operation

STEP 3

operation risk stratification
OPERATION RISK STRATIFICATION

Circulation (2007) 116:1971.

slide15

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

slide16

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low Risk Operation

STEP 3

OR

No

STEP 4

Functional Capacity

 4 METs

metabolic equivalents
METABOLIC EQUIVALENTS

Can you…

Take care of yourself?

Eat, dress, toilet?

Walk a block or two at 3 mph?

Do light work around the house like dusting or washing?

Can you…

Climb a flight of stairs?

Walk at 4 mph?

Do heavy housework (scrubbing, lifting)?

Participate in strenuous sports (swim, football, ski)?

1 MET

4 METs

4 METs

>10 METs

Circulation (2007) 116:1971.

slide18

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Consider OR

Active Cardiac Condition

Non-Invasive Stress Test / Treat

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

No/Unknown

slide19

Circulation (2007) 116:1971.

Yes

Emergency Operation?

STEP 1

OR

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

clinical risk factor assessment1
CLINICAL RISK FACTOR ASSESSMENT
  • Other Risk Factors
  • History of heart disease
  • Compensated prior CHF
  • Prior cerebrovascular disease
  • Diabetes mellitus
  • Renal insufficiency
  • Major Risk Factors
  • Unstable coronary syndromes
    • Unstable/severe angina
    • Recent MI
  • Decompensated CHF
  • Significant arrhythmia
  • Severe valvular disease

Circulation (2007) 116:1971.

slide21

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

OR

slide22

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

1. Proceed with planned surgery with HR control

2. Consider non-invasive testing

OR

slide23

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

Intermediate Risk

Vascular Surgery

Consider testing

Consider treating

1. Proceed with planned surgery with heart rate control

2. Consider non-invasive testing

OR

coronary revascularization prior to surgery
Coronary Revascularization Prior to Surgery?

Coronary Artery Revascularization Prophylaxis (CARP) Trial

  • 510 patients prior to major vascular surgery
  • ≥ 70% stenosis of 1 or more coronary arteries
  • Randomized to receive:
    • Revascularization prior to surgery
    • No revascularization prior to surgery

NEJM (2004) 351:2795.

coronary revascularization prior to surgery1
Coronary Revascularization Prior to Surgery?

Coronary Artery Revascularization Prophylaxis (CARP) Trial

NEJM (2004) 351:2795.

coronary revascularization prior to surgery2
Coronary Revascularization Prior to Surgery?

Coronary Artery Revascularization Prophylaxis (CARP) Trial

NEJM (2004) 351:2795.

slide27

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

Intermediate Risk

Vascular Surgery

Consider testing

Consider treating

1. Proceed with planned surgery with heart rate control

2. Consider non-invasive testing

OR

Slide 27

perioperative beta blockade
PeriOperative Beta-Blockade
  • Dosing 30 minutes prior and immediately post-op
  • IF HR  55 and SBP  100 AND no evidence of CHF, 3º heart block, bronchospasm
  • THEN
  • Atenolol 5 mg IV over 5 minutes
  • Wait for 5 minutes
  • If HR and SBP criteria still met, repeat dose once

NEJM (1996) 335:1713.

postoperative beta blockade
PostOperative Beta-Blockade
  • Intravenous (twice-daily dosing)
  • Same dosing as perioperative protocol
  • OR
  • Oral (once-daily dosing)
  • If HR  65 and SBP  100, then atenolol 100 mg
  • If HR  55 and SBP  100, then atenolol 50 mg
  • Continue until discharge or 7 days post-op

NEJM (1996) 335:1713.

evidence for beta blockade
Evidence for Beta-Blockade

NEJM (1996) 335:1713.

what is the appropriate cardiac evaluation3
What is the appropriatecardiac evaluation?

Case #1 revisited

A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

slide32

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

Intermediate Risk

Vascular Surgery

Consider testing

Consider treating

1. Proceed with planned surgery with heart rate control

2. Consider non-invasive testing

OR

Slide 32

what is the appropriate cardiac evaluation4
What is the appropriatecardiac evaluation?

Case #2 revisited

An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

slide34

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

Intermediate Risk

Vascular Surgery

Consider testing

Consider treating

1. Proceed with planned surgery with heart rate control

2. Consider non-invasive testing

OR

Slide 34

what is the appropriate cardiac evaluation5
What is the appropriatecardiac evaluation?

Case #3 revisited

A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

slide36

Circulation (2007) 116:1971.

Yes

Emergency Operation?

OR

STEP 1

No

Yes

Active Cardiac Condition

Non-Invasive Stress Test / Treat

Consider OR

STEP 2

No

Yes

Low-Risk Operation

STEP 3

OR

No

STEP 4

Yes

Functional Capacity

 4 METs

OR

STEP 5

No/Unknown

 3 Clinical Risk Factors

1 or 2 Clinical Risk Factors

No Clinical Risk Factors

Intermediate Risk

Vascular Surgery

Consider testing

Consider treating

1. Proceed with planned surgery with heart rate control

2. Consider non-invasive testing

OR

Slide 36

thank you for your time
Thank you for your time!

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