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Cardiologists?!

Cardiologists?!. Google UCL Robert Stephens. Dr Rob CM Stephens. Contents. Introduction Periop MI – frequency, pathology Morbidity Do cardiologists make a difference?. Introduction. The Cashpoint Private Practice Harley Street Doshville Dear Anaesthetist

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Cardiologists?!

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  1. Cardiologists?! Google UCL Robert Stephens Dr Rob CM Stephens

  2. Contents • Introduction • Periop MI – frequency, pathology • Morbidity • Do cardiologists make a difference?

  3. Introduction The Cashpoint Private Practice Harley Street Doshville Dear Anaesthetist Many thanks for referring Mr George Smart  I think anaesthesia would be safe so long as you avoid hypotension or hypoxia’. I’d have thought a spinal would be OK. Yours Sincerely Dr Graham Jones MRCP

  4. Introduction: What’s the problem? • Paucity of evidence CPEx • Paucity of large RCT’s Preoperative assessment • Evidence of lack of effect • Perioperative MI pathology not understood • Cardiology investigations / interventions • Positive tests: poor positive predictive value • No generally agreed protocol Ix Mx • Studies quote MI/Cardiac not all cause mortality

  5. Introduction: Endpoints important! • POISE Lancet 2008 • 8351 patients • with/at risk of, atherosclerotic disease • non-cardiac surgery • B Block 24 hrs preoperatively – 30 days postop • Metoprolol vs Placebo • MI 4·2% vs 5·7% 0·84 p=0·002 Deaths 3·1% vs 2·3% 1·33 p=0·03 Stroke 1·0% vs 0·5% 2·17 p=0·005 BP 15.0% vs. 9.7% p < 0.0001 Bradycardia 6.6% vs. 2.4% p < 0.0001

  6. Perioperative MI • Frequency • Goldman 1.9% 1001 • Lee rCRI 2% 2893 • CASS 2.7% 582 • CARP 7% 240 troponin • Decrease V ~32% 101 troponin

  7. Pathology MI • Non Perioperative • 64%–100% coronary artery plaque fissuring +/or • 65%–95% acute luminal thrombus • Dawood 1996 Cohen 1999 Landesberg 2003 Ellis 1996 Biccard 2010 • Perioperative (day 1-3 vs later?) • 10-15% exhibited plaque fissuring • Only ~1/3 had an intracoronary thrombus • Preop severity angiogram related to periop MI • Site coronary artery stenosis ≠ infarct territory • Multiple factors

  8. Periop Complications • Consistent with inadequate organ oxygenation • POM Survey @ day 5 ; n=438 ✜ 1.6% • 31% Gastrointestinal • 15% Renal • 10% Respiratory • 7% Infectious • 5% Cardiovascular • 5% Haematological • 1% Wound • Attempts to increase perfusion ‘optimisation’  reduce complications / mortality Bennett-Guerrero 1999

  9. CASS Coronary Artery Surgery Study • 24,959 Pts undergoing Coronary Angiogram 1970’s • Pts randomised to CABG vs Medical • Retrospectively examined • ~3500 Patients non-cardiac operations in Yr 1 • Hi risk Thoracic, Abdominal Max Fax • vs low risk Eagle 1997

  10. But CABG associated deaths excluded ! CASS Eagle 1997

  11. CARPCoronary-Artery Revascularization Prophylaxis • 5859 Vascular patients screened • Clinical score + Stress testing • 510 had angiogram • 49% 2 rCRI factors, 13% 3 rCRI factors • 225 revascularisation • ✜3.1% MI 11.6% • 237 conservative • ✜3.4% MI 14.3% rCRI High-risk surgery Ischemic heart disease (MI/ExTT+ve/Q / Nitrates / Pain) Congestive Heart Failure Cerebrovascular diseaseInsulin Preop serum creatinine >177mmol Mcfalls 2004 Lee 1999

  12. DECREASE- V Pilot • Those with extensive Ischemic Ht Disease • 1888 Vascular Pts Screened • 430 ≥3 rCRI factors =  • ECHO/ Nuclear imaging • 101 = extensive ischemia on imaging; • 50% had angina; 43% had LEVF< 35% • randomised- • Medical • Angiogram/Revascularised – 67% 3 vessel, 8% LMS • B blocked- vascular surgery Poldermans 2007

  13. DECREASE- V Pilot Medical Revascularised n=52 n=49 MI30 34.7% 30.8% MI365 36.7% 36.5% Death365 26.5% 23.1% Poldermans 2007

  14. Caveats: ?should discuss AHA/ACC unstable angina acute ST-elevation myocardial infarction (MI) ?stable angina and left main stem disease, triple vessel disease (particularly if the left ventricular ejection fraction is < 50%) Mostly- coincidental findings suggesting asymptomatic coronary artery disease are probably best left alone.

  15. Summary • Periop MI does occur, pathology not understood • Studies Imperfect, vascular patients Evidence that preoperative revascularisation not helpful • AHA/ACC suggest non invasive testing

  16. References Bennett-Guerrero et al Anesth Analg 1999;89:514 –9 Mcfalls et al N Engl J Med 2004;351:2795-804. Poldermans et al JACC Vol. 49, No. 17, 2007 Schouten et al Heart 2006;92:1866–1872 Snowden et al Ann Surg 251(3):535-41 (2010) Dawood et al Int J Cardiol 1996 57 37-44 Cohen et al Cardiovasc Path 1999 8 133-9 Landesberg et al J Am Coll Cardiol 2003;42:1547–1554 Ellis et al J Cardiol1996 77 1126-8 Biccard et al Anaesthesia2010 65 733-41 Lee et al Circulation 1999;100;1043-1049

  17. IHD • Prevalence • Depends on population eg vascular • Depends on risk factors • Problem? Periop MI • Problem • CPET any good at detecting? • Timing: elective/emergency • Can we do anything about it? • Caveats

  18. IHD • Prevalence • Depends on population eg vascular • Depends on risk factors • Problem? Periop MI • CPET any good at detecting? • Timing: elective/emergency • Can we do anything about it? • Caveats

  19. Heart Failure • Postop morbidity/mortality..is flow related • CPEx good at measuring function • VO2 peak used lots scenarios

  20. Valves

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