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PREOPERATIVE CARDIAC EVALUATION : REAPPRAISAL OF CURRENT PRACTICE PARADIGMS. Martin R. Back, MD Associate Professor, USF Division of Vascular & Endovascular Surgery, Chief, Vascular Surgery, JA Haley VA. OVERVIEW. How common are adverse cardiac events ?

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preoperative cardiac evaluation reappraisal of current practice paradigms

PREOPERATIVE CARDIAC EVALUATION : REAPPRAISAL OF CURRENT PRACTICE PARADIGMS

Martin R. Back, MD

Associate Professor,

USF Division of Vascular & Endovascular Surgery,

Chief, Vascular Surgery, JA Haley VA

overview
OVERVIEW
  • How common are adverse cardiac events ?
  • What is relationship between underlying cardiac disease and peri-op events ?
  • How to identify “at risk” patients ?
  • Who decides (responsibility / ‘turf’ bias) ?
  • How extensive an evaluation ?
  • Does CRA impact outcomes ?
  • Overall utility ?
surgery physiological insult
SURGERY = PHYSIOLOGICAL INSULT
  • Operative magnitude - invasiveness and operative time
  • Cardiopulmonary implications - beyond blood loss and operative ‘fluid shifts’
    • Stress hormone response
    • Proinflammatory cytokines
    • Anesthetic effects
    • Post-op complications
incidence cardiac complications
INCIDENCE CARDIAC COMPLICATIONS

US estimates non-cardiac surgery (NEJM 1995,2001)

25-27 million pts / yr - 8 million with athero risk factors (30%)

- 3 million with suspected CAD (11%)

- 1 million cardiac events (3.7%)

- 50,000 MIs (0.19 %)

- half of 40,000 op deaths due to MI

- $ 20 billion cost of care

Vascular surgery (Hertzer Ann Surg 1984,Krupski JVS 2002)

AAA : 36 % CAD 2.2 % MI

Carotid : 32 % CAD 1.0 % MI

LE occl dz : 28 % CAD 4.0 % MI

peri op mi how bad is bad
PERI-OP MI : HOW BAD IS BAD ?

Transmural, Q-wave MI

  • less common
  • more likely hemodynamically significant, arrhythmias
  • peri-infarct mortality up to 50 % (older data)
  • predict long term cardiac events, shortened survival

‘Chemical’ MI

  • elevated CK MB fraction or troponin ‘leak’
  • more common
  • low mortality risk (newer data)
  • associated with late adverse events ?

Adverse cardiac event - broad definition

  • MI, CHF/pulm edema, post-op angina, arrhythmias
risk factors for cardiac events
RISK FACTORS FOR CARDIAC EVENTS

YES- CHF

- MI (especially recent < 6 mo)

- unstable/crescendo angina

- arrhythmias

- severe valvular disease

- type of surgery (not anesthetic route)

MAYBE - stable angina

- diabetes

- age

NO- hypertension

- smoking

- elevated lipids

cardiac risk assessment
CARDIAC RISK ASSESSMENT

Goldman risk index(NEJM 1977)

complex point system, validated, no evaluation algorithm

Detsky risk index(J Gen Int Med 1986)

modified Goldman

Eagle criteria(Ann Int Med 1989) – Vascular Surgery

age > 70, DM, angina, prior MI, CHF, ventricular arrhythmia

dipyridamole thallium testing for 1 or 2 risk factors

Lee risk index(Circulation 1999)

Eagle criteria + prior stroke, renal insufficiency (Cr > 2)

American College of Physicians guidelines(Ann Int Med 1997)

Detsky risk index + evaluation / intervention algorithm

American Heart Association / American College of Cardiology (AHA / ACC) guidelines(Circulation 1996, JACC 2002)

evaluation modalities
EVALUATION MODALITIES
  • Use of risk index only - other testing since events occur in low risk pts ?
  • Resting 2-D echocardiography - low (<35%) EF predictive, unsuspected valve dz
  • Exercise / treadmill testing - few pts can achieve target HR
  • Stress cardiac imaging

Dipyridamole – thallium or sestamibi scintigraphy

Dobutamine stress echo (DSE)

  • Coronary angiography - would the pt be offered coronary revascularization (PCI / CABG) prior to noncardiac surgery ?
cardiac stress imaging
CARDIAC STRESS IMAGING

Who should be tested ?

All patients low yield

Selected pts not for low risk pts (0-1 risk factors)

yes for intermediate risk pts

coronary angio for high risk pts

Not useful fairly accurate for detecting CAD but poorprognostic value for adverse events

(PPV < 25 % despite NPV > 90 %)

 no difference in event rates / outcomes in vascular series with and without routine use stress testing

 post-op MIs due to non-significant (<50%) coronary stenoses

peri op cardiac optimization
PERI-OP CARDIAC OPTIMIZATION

Medical

Intra-op normothermia

Invasive monitoring - hemodynamic optimization

ICU utilization / prolonged telemetry

beta – blockers - reduce MI/death rate (Mangano NEJM 1996, Poldermans NEJM 1999)

- effective low and high risk pts (Boersma JAMA 2001)

alpha 2 – adrenergic agonists (clonidine, mivazerol)

nitrates, calcium channel blockers, ACE inhibitors

antiplatelet agents (aspirin)

peri op cardiac optimization11
PERI-OP CARDIAC OPTIMIZATION

Interventional = coronary revascularization

PCI (coronary angioplasty / stenting), CABG

Prophylactic pre-op revascularization

- nopriorprospective randomized data

- CARP trial

- added morbidity of coronary revasc

Prior coronary revascularization

- danger of surgery early after PCI (< 1-2 mo)

- Coronary Artery Surgery Study (CASS) – CABG v. med tx for symptomatic multi-vessel CAD

- Bypass Angioplasty Revasc Invest (BARI) – CABG v. PCI for sympt CAD

- long term protection ?

aha acc guidelines risk assessment
AHA/ACC GUIDELINES RISK ASSESSMENT

Functional capacity

Ability to perform at 4 METS (minimal exertion activities) ?

Clinical risk factors

Major = recent MI, unstable angina, decompensated CHF, severe valvular dz, hemodynamically significant arrhythmias

Intermediate = DM, angina, prior MI or CHF

Minor = age > 70, abnl EKG, poorly controlled HTN, prior stroke, low functional capacity

Procedure – specific risk

High = emergency operation, major vascular (aortic, LE bypass), complex/redo surgery

Intermediate = CEA, head & neck, major cavitary, major orthopedic

Low = endoscopic, superficial, opthalmologic, breast

usf vascular analyses
USF VASCULAR ANALYSES
  • Evaluate prognostic value and utility of pre-op risk stratification before vascular surgery using AHA/ACC guidelines
  • Evaluate the potential protective effect of previous coronary revascularization on peri-op outcomes
  • Evaluate survival and long – term prognostic factors after vascular operations
conclusions usf experience
CONCLUSIONS - USF EXPERIENCE
  • Risk stratification using AHA/ACC algorithm predicts peri-op adverse cardiac events
  • 3-vessel CAD predictive fatal and non-fatal early cardiac events
  • Low yield and lack of prognostic value of stress testing
  • More recent (< 5 yr) coronary revascularization modest protection against peri-op cardiac events & early mortality
  • Age, peri-op cardiac events, and risk stratification level predict long-term survival
  • More recent (< 5 yr) coronary revascularization has subtle effect (at best) on long term survival
slide30

N Engl J Med 2004

  • CARP trial = multicenter, randomized, prospective study comparing prophylactic coronary revascularization (PCI or CABG) and best medical management before elective major arterial reconstruction (aortic, lower extremity)

5859 pts screened

1190 coronary angio

510 randomized

633 decline

363 0-v CAD

1654 no/low risk

258 revasc

215 non-revasc

1025 urgent OR

252 med tx

54 L main dz

626 asx prior cabg/pci

731 severe comorbidity

19 EF, valve dz

carp results
CARP RESULTS

REVASC Group CABG PCI

41 % 59 %

periop MI 7 % 5 %

periop death 2 % 1.4 %

REVASC MED TX

interval to vascular surgery 54 days 18 days

periop MI 11.6 % 14.3 % p=.37

periop death 3.1 % 3.4 % p=.87

slide32

CARP RESULTS

Equivalent long-term use of cardiac medications in revasc and medical tx groups

Median F/U = 2.7 yrs, equivalent all-cause mortality revasc group (22%) v. medical tx group (23%) & no high-risk subgroup benefitting from prophylactic revasc

conclusions
CONCLUSIONS
  • Use of AHA/ACC algorithm predicts outcomes, reduces resource utilization (stress testing/angio/revasc) compared to routine testing, and minimizes adverse events

(Froehlich JVS 2002)

  • Routine use beta-blockers  not disputed
  • Standard practice of prophylactic pre-op coronary revascularization can not be supported  disparate opinions, consensus
  • ‘pre-op coronary revascularization appropriate only if indicated independent of the need for non-cardiac surgery’ – acute coronary syndromes, left main dz, multivessel CAD ?

(Fleisher/Eagle NEJM 2001)