2014 ACC/AHA PeriOp CVS Eval & Rx of Pts Having Non ... · By J Pigou & A Hollingworth 2014 ACC/AHA...
6
By J Pigou & A Hollingworth 2014 ACC/AHA PeriOp CVS Eval & Rx of Pts Having Non- Cardiac Surgery Clinical risk factors: Coronary artery disease – Wait >60days a-er MI before surgery. Heart failure – Significant risk for periop complica@on including mortality-Greater than AF and CAD. LVEF – If <30% worse outcome than >30%. Diastolic dysfunc@on +/- Systolic dysfunc@on associated with higher major adverse cardiac event (MACE). Risk of asymptoma@c LV dysfunc@on is unknown. Pre-op BNP predict CVS events post vascular surgery. Cardiomyopathies – liYle informa@on on preop evalua@on of nonischaemic cardiomyopathies prior to noncardiac surgery Restric@ve – Mul@disciplinary approach. Op@mise underlying pathology, volume status and HF. Hypertropic obstruc@ve cardiomyopathy. Avoid overdiuresis and iontropic agents not usually used because of increased LV ou]low gradient. Arrhythmogenic right ventricular cardiomyopathy +/- dysplasia. Peri-op mortality 9.5%. Need ICD. Peripartum cardiomyopathy. Can result in severe ventricular dysfunc@on. Presents up to 6mth postpartum. Emergency delivery may be lifesaving for both mother and baby. Valvular heart disease If clinically suspected moderate or severe valve lesion should have pre-op ECHO if -No prior ECHO within 1yr -Change in clinical status or physical exam since last ECHO. If valvular interven@on indicated on basis of symptoms and severity then interven@on before elec@ve non cardiac surgery is effec@ve in reducing periopera@ve risk. AS – Asymptoma@c severe AS – can proceed with elevated risk non cardiac surgery MS – Asymptoma@c severe MS – can proceed with elevated risk non cardiac surgery if valve morphology not favourable for percutaneous mitral balloon commissurotomy. AR and MR – beYer tolerated than steno@c lesions. Aim to maintain preload and avoid excessive a-erload. Asymptoma@c severe MR – can proceed with elevated risk non cardiac surgery. Asymptoma@c severe AR with normal LVEF – can proceed with elevated risk non cardiac surgery. Arrhythmias and conduc=on disorders Presence of an arrhythmia in pre-op secng should prompt inves@ga@on into underlying cause depending on nature and acuity of arrhythmia and pa@ents history. Cardiovascular implantable electronic devices (CIED) Before elec@ve surgery in pa@ent with a CIED the surgical/procedure team and clinician following the CIED should communicate in advance to plan periopera@ve management of the CIED. Pulmonary Vascular Disease – mortality rate 4-26% Chronic pulmonary vascular targeted therapy (ie. phosphodiesterase type 5 inhibitors, soluble guanylate cyclase s@mulators, endothelin receptor antagonists, and prostanoids) should be con@nued unless contraindicated or not tolerated in pa@ents with pulmonary hypertension who are undergoing noncardiac surgery. Unless risk of delay outweighs poten@al benefits pa@ents should be seen by pulmonary hypertension specialist pre-op Adult Congenital Heart Disease. Higher risk than normal popula@on. Related to nature of underlying ACHD, the surgical procedure and urgency of interven@on. Calcula=on of risk to predict periopera=ve cardiac morbidity: Validated risk predic@on tool can be useful in predic@ng risk of periopera@ve MACE. For pa@ents with a low risk of periopera@ve MACE, further tes@ng is not recommended before planned opera@on. Risk is dependent on surgery – PVD surgery amongst highest risk, lower risk those without fluid shi-s and stress such as plas@c surgery, cataracts. Emergency vs Elec@ve – Emergency increases risk. Lee’s criteria for periop CVS risk in non-cardiac surgery (3 day MACE risk): ‣ high risk surgery (abdo, thoracic or suprainguinal vasc surgery) ‣ Hx IHD ‣ Hx stroke/TIA ‣ Hx of heart failure ‣ chronic renal impairment = creat >177 ‣ DM on insulin ↳ Risk of cardiac events periop based on number of factors: - 0 = 0.4% - 1 = 1% - 2 = 6% - ≥3 = 11% - NB MACE = death, MI, cardiac arrest - note completely ignores rest disease, frailty, Parkinsonism, pHTN American College of Surgeons NSQIP MICA: single study- large and mul@centre. hYp://www.surgicalriskcalculator.com/miorcardiacarrest ACC/AHA Periop - 1
Transcript of 2014 ACC/AHA PeriOp CVS Eval & Rx of Pts Having Non ... · By J Pigou & A Hollingworth 2014 ACC/AHA...
By J Pigou & A Hollingworth
2014 ACC/AHA PeriOp CVS Eval & Rx of Pts Having Non-
Cardiac Surgery
Clinicalriskfactors:
Coronaryarterydisease–Wait>60daysa-erMIbeforesurgery.Heartfailure–Significantriskforperiopcomplica@onincludingmortality-GreaterthanAFandCAD.LVEF–If<30%worseoutcomethan>30%.Diastolicdysfunc@on+/-Systolicdysfunc@onassociatedwithhighermajoradversecardiacevent(MACE).Riskofasymptoma@cLVdysfunc@onisunknown.Pre-opBNPpredictCVSeventspostvascularsurgery.Cardiomyopathies–liYleinforma@ononpreopevalua@onofnonischaemiccardiomyopathiespriortononcardiacsurgeryRestric@ve–[email protected]@miseunderlyingpathology,volumestatusandHF.Hypertropicobstruc@vecardiomyopathy.AvoidoverdiuresisandiontropicagentsnotusuallyusedbecauseofincreasedLVou]lowgradient.Arrhythmogenicrightventricularcardiomyopathy+/-dysplasia.Peri-opmortality9.5%.NeedICD.Peripartumcardiomyopathy.Canresultinsevereventriculardysfunc@on.Presentsupto6mthpostpartum.Emergencydeliverymaybelifesavingforbothmotherandbaby.ValvularheartdiseaseIfclinicallysuspectedmoderateorseverevalvelesionshouldhavepre-opECHOif
-NopriorECHOwithin1yr-ChangeinclinicalstatusorphysicalexamsincelastECHO.
Ifvalvularinterven@onindicatedonbasisofsymptomsandseveritytheninterven@onbeforeelec@venoncardiacsurgeryiseffec@[email protected]–Asymptoma@csevereAS–canproceedwithelevatedrisknoncardiacsurgeryMS–Asymptoma@csevereMS–canproceedwithelevatedrisknoncardiacsurgeryifvalvemorphologynotfavourableforpercutaneousmitralballooncommissurotomy.ARandMR–beYertoleratedthansteno@clesions.Aimtomaintainpreloadandavoidexcessivea-erload.Asymptoma@csevereMR–canproceedwithelevatedrisknoncardiacsurgery.Asymptoma@csevereARwithnormalLVEF–canproceedwithelevatedrisknoncardiacsurgery.Arrhythmiasandconduc=ondisordersPresenceofanarrhythmiainpre-opsecngshouldpromptinves@ga@onintounderlyingcausedependingonnatureandacuityofarrhythmiaandpa@entshistory.Cardiovascularimplantableelectronicdevices(CIED)Beforeelec@vesurgeryinpa@entwithaCIEDthesurgical/procedureteamandclinicianfollowingtheCIEDshouldcommunicateinadvancetoplanperiopera@vemanagementoftheCIED.PulmonaryVascularDisease–mortalityrate4-26%Chronicpulmonaryvasculartargetedtherapy(ie.phosphodiesterasetype5inhibitors,solubleguanylatecyclases@mulators,endothelinreceptorantagonists,andprostanoids)shouldbecon@nuedunlesscontraindicatedornottoleratedinpa@entswithpulmonaryhypertensionwhoareundergoingnoncardiacsurgery.Unlessriskofdelayoutweighspoten@albenefitspa@entsshouldbeseenbypulmonaryhypertensionspecialistpre-opAdultCongenitalHeartDisease.Higherriskthannormalpopula@on.RelatedtonatureofunderlyingACHD,thesurgicalprocedureandurgencyofinterven@on.
Calcula=onofrisktopredictperiopera=vecardiacmorbidity:
Validatedriskpredic@ontoolcanbeusefulinpredic@[email protected]@entswithalowriskofperiopera@veMACE,furthertes@[email protected]–PVDsurgeryamongsthighestrisk,lowerriskthosewithoutfluidshi-sandstresssuchasplas@csurgery,cataracts.EmergencyvsElec@ve–Emergencyincreasesrisk.Lee’s criteria for periop CVS risk in non-cardiac surgery (3 day MACE risk):
‣ high risk surgery (abdo, thoracic or suprainguinal vasc surgery) ‣ Hx IHD ‣ Hx stroke/TIA ‣ Hx of heart failure ‣ chronic renal impairment = creat >177 ‣ DM on insulin
↳ Risk of cardiac events periop based on number of factors: - 0 = 0.4% - 1 = 1% - 2 = 6% - ≥3 = 11%
- NB MACE = death, MI, cardiac arrest - note completely ignores rest disease, frailty, Parkinsonism, pHTN AmericanCollegeofSurgeonsNSQIPMICA:[email protected]://www.surgicalriskcalculator.com/miorcardiacarrest
ACC/AHA Periop - �1
By J Pigou & A Hollingworth
AmericanCollegeofSurgeonsNSQIPSurgicalRiskCalculator:Collecteddataonopera@onsperformedinmorethan525par@cipa@nghospitalsintheUnitedStates.Thisriskcalculatormayofferthebestes@ma@onofsurgery-specificriskofaMACEanddeath.Issuesisithasnotbeenvalidatedinanexternalpopula@onoutsidetheNSQIP,andthedefini@onofMIincludesonlyST-segmentMIsoralargetroponinbump(>3@mesnormal)thatoccurredinsymptoma@[email protected]:(BNP,CRP)inclusioninriskscoresmayprovideincrementalpredic@vevalue.
ApproachtoPeriopera=veCardiacTes=ngUsestepwiseapproach:- Whatissurgeryfor:Prolonglife?Relievesymptoms- Definelifeexpectancy(excludingsurgery):
‣ Age/sex/ethnicity‣ Socio-economicstatus‣ Smoking/DM/HTN/chol‣ ACS/stroke/PVD
- Definesurgicalrisk:‣ Riskofsurgeryieinsult/size‣ Pa@entfactorsieco-morbidi@es(stable,op@mised),physiologicalreserve
- DefineriskofdoingnothingegAAA- Usebiddataadjuncts:POSSUM,NSQIP,ASA,Frailtyindex,LeeRevisedIndex↳useallabovetodecideon:
‣ ?proceedtosurgery‣ waystoriskmi@gate‣ teamrequired‣ hospitaltoperformsurgery‣ Pre-opop@misa@onegballooninAS
Exercisecapacityandfunc=onalcapacityReliablepredicatorofperi-opandlongtermcardiacevents.Periopera@vecardiacandlong-termrisksareincreasedinpa@entsunabletoperform4METsofworkduringdailyac@vi@esInpa@entswithelevatedriskandexcellent(>10METs)func@onalcapacity,itisreasonabletoforgofurtherexercisetes@ngwithcardiacimagingandproceedtosurgeryForpa@entswithelevatedriskandunknownfunc@onalcapacity,itmaybereasonabletoperformexercisetes@ngtoassessforfunc@onalcapacityifitwillchangemanagementForpa@entswithelevatedriskandmoderatetogood(≥4METsto10METs)func@onalcapacity,itmaybereasonabletoforgofurtherexercisetes@ngwithcardiacimagingandproceedtosurgeryForpa@entswithelevatedriskandpoor(<4METs)orunknownfunc@onalcapacity,itmaybereasonabletoperformexercisetes@ngwithcardiacimagingtoassessformyocardialischemiaifitwillchangemanagement
SupplementalPreopera=veEvalua=onECG.Pre-opECGisreasonableforpa@entswithknowncoronaryheartdisease,significantarrhythmia,peripheralarterialdisease,cerebrovasculardisease,orothersignificantstructuralheartdisease,exceptforthoseundergoinglow-risksurgeryPre-opECGmaybeconsideredforasymptoma@cpa@entswithoutknowncoronaryheartdisease,exceptforthoseundergoinglow-risksurgeryRou@nepreopera@veres@ng12-leadECGisnotusefulforasymptoma@cpa@entsundergoinglow-risksurgicalproceduresAssessmentofLVFunc=onPre-opevalua@onofLVfunc@onisreasonablein:- pa@entswithdyspnoeaofunknownorigin- HFwithworseningdyspnoeaorotherchangeinclinicalstatus- Reassessmentinstablepa@entwithknownLVdysfunc@onifnoassessmentwithinayrRou@nepreopera@veevalua@onofLVfunc@onisnotrecommendedExerciseStressTes=ngforMyocardialIschemiaandFunc=onalCapacityRou@nescreeningwithnoninvasivestresstes@ngisnotusefulforpa@entsatlowriskfornoncardiacsurgeryCardiopulmonaryExerciseTes=ng:Maybeconsideredforpa@entsundergoingelevatedriskproceduresinwhomfunc@onalcapacityisunknownLowanaerobicthresholdwaspredic@[email protected]/kg/minproposedasop@[email protected]=ngNoninvasivePharmacologicalStressTes@ng(eitherDSEorpharmacologicalstressMPI)isreasonableforpa@entswhoareatanelevatedriskfornoncardiacsurgeryandhavepoorfunc@onalcapacity(<4METs)ifitwillchangemanagement.Rou@nescreeningwithnoninvasivestresstes@ngisnotusefulforpa@entsundergoinglow-risknoncardiacsurgeryPreopera=veCoronaryAngiography:Rou@nepreopera@vecoronaryangiographyisnotrecommended
ACC/AHA Periop - �2
By J Pigou & A Hollingworth
Inves=ga=onstoDelineatePhysiologicalReserveNon-Invasive- Stair climb - not standardised - 6MWT with SpO2 probe - >560m = good; <427m ⟹ CPET - Incremental shuttle test - CPET Biomarkers - Pre-op TNT >14. Can add to Lee criteria as extra variable. (highest risk seen in x2 TNT) - BNP ECHO - is a resting test - helps understand baseline function: LV function, diastolic function, PA pressures, hypertrophy, RV function Stress Tests - ETT-vintense&poorlytolerated- DSE-
‣ givemassivedosesofdobutamine.‣ Usefulasruleouttestieifreachmaxdoseandnosymptomsisreassuring‣ if>4areasofRWMAthenshouldhavefurtherdiscussion‣ 1-3RWMAthen?proceed
- CTcoronaryangiogram- cardiacMRI
ACC/AHA Periop - �3
Criticisms of this Algorithm - METS only measurable via CPET - Algorithm used to only to define MACE
risk - In AS & CHF: functional status is more
impt than any ECHO finding - Can have ↓functional capacity with
normal coronaries eg diastolic dysfunction
- No evidence that revascularisation prior to surgery effects mortality/outcome
By J Pigou & A Hollingworth
Periopera=veTherapy
CoronaryRevasculariza=onBeforeNoncardiacSurgeryRevasculariza@onbeforenoncardiacsurgeryisrecommendedincircumstancesinwhichrevasculariza@onisindicatedaccordingtoexis@ngCPGsIndica@onsforCABG:
‣ LMS>50%‣ proxLADorLcx>7p%‣ 3VD>50%‣ unstableangina‣ recentSTEMI/NSTEMI
Itisnotrecommendedthatrou@necoronaryrevasculariza@onbeperformedbeforenoncardiacsurgeryexclusivelytoreduceperiopera@vecardiaceventsasshownbyCARPtrial-mortalitysameat2yrs(excludedptswithindica@onsforCABGasabove)
TimingofElec=veNoncardiacSurgeryinPa=entswithPreviousPCI:Delayelec@venoncardiacsurgeryfor:
-14daysa-erballoonangioplasty-365daysa-erdrug-elu@ngstent(DES)implanta@on- 180daysa-erDESimplanta@oniftheriskoffurtherdelayisgreaterthantheexpectedrisksofischemiaandstentthrombosis
- NBotherdelayperiods:‣ postCABG=3/12‣ postMI=2/12‣ poststroke6/52(3-6/12isbeYer)
Delayelec@venoncardiacsurgeryinpa@entswhomDAPTwillneedtobediscon@nuedperi-op:30daysBMSand12monthsDESInpa@entsinwhomnoncardiacsurgeryisrequired,aconsensusdecisionamongtrea@ngcliniciansastotherela@verisksofsurgeryanddiscon@nua@onorcon@nua@onofan@platelettherapycanbeuseful.
Periopera=veMedicalTherapyPrehabili@a@on- rou@neexerciseinclsimplewalkingshowntobeofsigbenefit
BetaBlockersIfonabetablockercon@nue,ifintermediateorhighriskofMIperi-op(>3RCRIriskfactors-diabetesmellitus,HF,CAD,renalinsufficiency,cerebrovascularaccident)canstartbetablockerpre-op,iflongtermindica@onbutnoRCRIriskfactorsunknownifshouldbestarted.Ifitisini@ated,startitinadvance>1daybeforesurgery.Donotstartitontheday.- @trateBBtotargetHR60-80&SBP120-160.Increasedoseinminimumintervalsof1week
Sta@nsIfonasta@[email protected],ifanyclinicalindica@onwithelevatedriskprocedurestartit.
Alpha2Agonist.Arenotrecommendedinpa@entswhoareundergoingnoncardiacsurgery
Calciumchannelblocker:CalciumchannelblockerswereassociatedwithtrendstowardreduceddeathandMIAlarge-scaletrialisneededtodefinethevalueoftheseagents
Angiotensin-Conver@ngEnzymeInhibitors:Con@nueperiopera@vely,ifwithheldpre-oprestartassoonasclinicallyfeasiblepostop.
An@plateletAgents-Inpa@entsundergoingurgentnoncardiacsurgeryduringthefirst4to6weeksa-erBMSorDESimplanta@on,DAPTshouldbecon@nuedunlesstherela@veriskofbleedingoutweighsthebenefitofthepreven@onofstentthrombosis.-Inpa@entswhohavereceivedcoronarystentsandmustundergosurgicalproceduresthatmandatethediscon@nua@onofP2Y12plateletreceptor–inhibitortherapy,itisrecommendedthataspirinbecon@nuedifpossibleandtheP2Y12plateletreceptor–inhibitorberestartedassoonaspossiblea-ersurgery.-Managementoftheperiopera@vean@platelettherapyshouldbedeterminedbyaconsensusofthesurgeon,anesthesiologist,cardiologist,andpa@ent,whoshouldweightherela@[email protected]@entsundergoingnonemergency/nonurgentnoncardiacsurgerywhohavenothadpreviouscoronarysten@ng,itmaybereasonabletocon@nueaspirinwhentheriskofpoten@alincreasedcardiaceventsoutweighstheriskofincreasedbleeding-Ini@a@onorcon@nua@onofaspirinisnotbeneficialinpa@entsundergoingelec@venoncardiacnoncaro@dsurgerywhohavenothadpreviouscoronarysten@ngunlesstheriskofischemiceventsoutweighstheriskofsurgicalbleeding
An@coagulantsUseoftherapeu@corfull-dosean@coagulantsisgenerallydiscouragedbecauseoftheirharmfuleffectontheabilitytocontrolandcontainsurgicalbloodloss.Insomeinstancesinwhichthereisminimaltonoriskofbleeding,suchascataractsurgeryorminordermatologicprocedures,itmaybereasonabletocon@nuean@coagula@onperiopera@vely.
ACC/AHA Periop - �4
By J Pigou & A Hollingworth
Therisksofbleedingforanysurgicalproceduremustbeweighedagainstthebenefitofremainingonan@coagulantsonacase-by-casebasisPa@entswithmechanicalmitralvalve,orpa@entswithanaor@cvalveand≥1addi@onalriskfactorbridgingan@coagula@onmaybeappropriate.
ManagementofPostopera@veArrhythmiasandConduc@onDisordersAFandatrialfluYer-mostcommon,Peakincidenceoccurs1to3dayspost-op.Treatmentofpostopera@veAFissimilartothatforotherformsofnew-onsetAFVentricularratecontrolintheacutesecngisgenerallyaccomplishedwithbetablockersornondihydropyridinecalciumchannelblockers(i.e.,dil@azemorverapamil),withdigoxinreservedforpa@entswithsystolicHForwithcontraindica@onsorinadequateresponsetootheragents.
Periopera@veManagementofPa@entsWithCIEDs:Pa@entswithICDswhohavepreopera@vereprogrammingtoinac@vatetachytherapyshouldbeoncardiacmonitoringcon@nuouslyduringtheen@reperiodofinac@va@on,andexternaldefibrilla@onequipmentshouldbereadilyavailable.SystemsshouldbeinplacetoensurethatICDsarereprogrammedtoac@vetherapybeforediscon@nua@onofcardiacmonitoringanddischargefromthefacility
ACC/AHA Periop - �5
By J Pigou & A Hollingworth
Anaesthe=cConsidera=onandIntraopera=veManagement
NeuraxialVersusGeneralAnesthesia:Thereisnoevidencetosuggestacardioprotec@vebenefitfromtheuseoraddi@onofneuraxialanesthesiaforintraopera@veanesthe@cmanagement
Vola=leGeneralAnesthesiaVersusTotalIntravenousAnesthesia:Useofeitheravola@leanesthe@cagentortotalintravenousanesthesiaisreasonableforpa@entsundergoingnoncardiacsurgery,andthechoiceisdeterminedbyfactorsotherthanthepreven@onofmyocardialischemiaandMI
MonitoredAnesthesiaCareVersusGeneralAnesthesia:TherearenoRCTstosuggestapreferenceformonitoredanaesthesiacareovergeneralanaesthesiaforreducingmyocardialischemiaandMI
Periopera=vePainManagement:Neuraxialanesthesiaforpostopera)vepainreliefcanbeeffec@veinpa@entsundergoingabdominalaor@[email protected]@veepiduralanalgesiamaybeconsideredtodecreasetheincidenceofpreopera)vecardiaceventsinpa@entswithahipfracture
Prophylac=cPeriopera=veNitroglycerinProphylac@cintravenousnitroglycerinisnoteffec@veinreducingmyocardialischemiainpa@entsundergoingnoncardiacsurgery
Intraopera=veMonitoringTechniquesTheemergencyuseofperiopera@vetransesophagealechocardiogram(TEE)isreasonableinpa@entswithhemodynamicinstabilityundergoingnoncardiacsurgerytodeterminethecauseofhemodynamicinstabilitywhenitpersistsdespiteaYemptedcorrec@vetherapy,[email protected]@neuseofintraopera@veTEEduringnoncardiacsurgerytoscreenforcardiacabnormali@esortomonitorformyocardialischemiaisnotrecommendedinpa@entswithoutriskfactorsorproceduralrisksforsignificanthemodynamic,pulmonary,orneurologiccompromise.
MaintenanceofBodyTemperature:Maintainingnormothermiamayreduceperi-opcardiacevents.
HemodynamicAssistDevicesUseofhemodynamicassistdevicesmaybeconsideredwhenurgentoremergencynoncardiacsurgeryisrequiredinthesecngofacuteseverecardiacdysfunc@on(i.e.,acuteMI,cardiogenicshock)thatcannotbecorrectedbeforesurgery
Periopera=veUseofPulmonaryArteryCathetersConsideruseofPACwhenunderlyingmedicalcondi@onsthatsignificantlyaffecthemodynamicscannotbecorrectedbeforesurgeryRou@neuseofPACinpa@ents,eventhosewithelevatedrisk,isnotrecommended
Periopera=veAnaemiaManagementMaintainHb≥8g/dL(restric@vetransfusionstrategy)
Periopera=veSurveillance
Measurementoftroponinlevelsisrecommendedinthesecngofsignsorsymptomssugges@veofmyocardialischemiaorMIObtaininganECGisrecommendedinthesecngofsignsorsymptomssugges@veofmyocardialischemia,MI,orarrhythmiaTheusefulnessofpostopera@vescreeningwithtroponinlevelsinpa@entsathighriskforperiopera@veMI,butwithoutsignsorsymptomssugges@veofmyocardialischemiaorMI,isuncertainintheabsenceofestablishedrisksandbenefitsofadefinedmanagementstrategy.Theusefulnessofpostopera@vescreeningwithECGsinpa@entsathighriskforperiopera@veMI,butwithoutsignsorsymptomssugges@veofmyocardialischemia,MI,orarrhythmia,isuncertain
ACC/AHA Periop - �6
