Cardiac Issues With Noncardiac Surgery Joseph F. Winget, MD FACC Clinical Assistant Professor...
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Cardiac Issues With Noncardiac Surgery
Joseph F. Winget, MD FACC
Clinical Assistant Professor
University of Vermont Medical School
Champlain Valley Cardiovascular Associates, P.C.
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Objectives
• Preoperative risk assessment
• Anticoagulation and antithrombotic issues
• Postoperative Management
• Endocarditis prophylaxis
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Disclosures
• None
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Surgery or not?
• 87 year old white female with known critical AS fall and breaks her hip.
• No CHF, MI, syncope• Stable and relatively
independent before the fall.
• LVEF 65%
• 82 year old white male with known CAD. Stable angina pectoris.
• Catheterization shows occluded LAD which was fed by collaterals
• No CHF• AODM and HTN• Severe worsening spinal
stenosis and weakness• LVEF 50%
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Preoperative cardiac issues
• How healthy is the patient?
• How active is the patient?
• How risky in the planned surgery?
• Is preoperative cardiac testing necessary?
• What preventive measures can be taken to reduce cardiac risk?
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L’Italien JACC 1996;27:779
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JACC 2002; 39:542
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JACC 2002 39:542
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Is testing predictive of outcomes?
Circ 1997; 95: 53
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Cardiac event rates and dobutamine echocardiography
JAMA 2001; 285:1865
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Who to test?
• Intermediate risk patients undergoing intermediate or high risk surgery
• Testing does not add additional information in low risk or high risk patient groups.
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What test?
• Well validated– Exercise or
pharmacologic echocardiography
– Exercise or pharmacologic Cardiolite
• Not well validated– CTA– MRI– Cardiac angiography*
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Therapies to reduce perioperative cardiac complications
• Revascularization– Percutaneous revascularization– CABG
• Medical therapy
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Benefit of CABG
Circ 1997; 96: 1882
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McFalls E et al. N Engl J Med 2004;351:2795-2804
Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery
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McFalls E et al. N Engl J Med 2004;351:2795-2804
Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization
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Medical therapy to lower risk
Lindenauer, PK JAMA. 2004 May 5; 291(17)2092
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Beta blocker use?
NEJM 1996; 335:1713
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Beta blocker use?
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Recommendations
• Revascularization for appropriate clinical indications
• Maximize adjuvant medical therapy– Aspirin– Statin– Beta blocker
• Close perioperative follow-up– Prolonged telemetry monitoring
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Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of
age or greater
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Surgery or not?
• 87 year old white female with known critical AS fall and breaks her hip.
• No CHF, MI, syncope• Stable and relatively
independent before the fall.
• 82 year old white male with known CAD. Stable angina pectoris
• Catheterization shows occluded LAD which was fed by collaterals
• No CHF• AODM• Severe worsening spinal
stenosis and weakness
![Page 26: Cardiac Issues With Noncardiac Surgery Joseph F. Winget, MD FACC Clinical Assistant Professor University of Vermont Medical School Champlain Valley Cardiovascular.](https://reader038.fdocuments.us/reader038/viewer/2022103022/56649d095503460f949db939/html5/thumbnails/26.jpg)
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Cardiac Issues in noncardiac surgery
• Establish patient risk
• Assign procedural risk
• Test intermediate risk patients undergoing intermediate or high risk surgery
• Optimize medical therapy
• Revascularization when clinically indicated
• ACC/AHA Guidelines JACC 2007; 50: 1707-1732
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Anticoagulation / Antiplatelet Agents
• 55 year old male s/p CABG in 2000. Drug eluting stent placed to native vessel in August of 2008.
• Needs colonoscopy • Can plavix and aspirin
be safely stopped?
• 70 year old white female with chronic AF needs shoulder surgery
• History of CVA• Warfarin 5 mg daily• Does the patient need
some form of bridging preoperatively?
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Anticoagulation / Antithrombotic Issues
• Anticoagulants – warfarin– Atrial fibrillation– Venous thrombosis – Prosthetic heart valves
• Antithrombotic agents – clopidogrel– Bare metal stents vs. drug eluting stents
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Do you need to stop antiplatelet / anticoagulation therapy?
• Procedural risk for bleeding– Low risk for bleeding
• Athrocentesis• Cataract surgery• Dental cleaning / extraction• Cutaneous surgery
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CHADS score - AF
Circulation 2004; 110:2287 JAMA 2001; 285:2864
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Atrial fibrillation
• Bridge– AF and prosthetic
valves– AF and significant LV
dysfunction (EF<40%)– AF and any prior
thrombotic event (CVA, TIA, arterial emboli)
– “high risk” patients
• No bridging– Low risk patients
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How to bridge
• Stop warfarin for 48 hours
• Start lovenox at 1mg/kg SQ BID for 6 doses
• Stop lovenox the morning before surgery
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Prosthetic heart valves
• Bioprosthetic valves– All, if in atrial fibrillation
• Mechanical valves– All, regardless of rhythm
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Venous thrombosis
• Deep venous thrombosis
• Pulmonary emboli
• Hypercoagulable states– Factor V Leiden– Protein C / S deficiencies– Lupus anticoagulant
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How to Bridge
• Stop warfarin
• Start replacement therapy once INR < 2.0– IV heparin– SQ low molecular weight heparin - lovenox
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Coronary stents
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Recommendations – stent patients
• Bare Metal Stents– Delay elective
procedures for at least 1 month and preferably 6 months
– Restart clopidogrel as soon as possible
– Loading dose?
• Drug eluting stents– Delay elective
procedures for 1 year– Continue aspirin– Restart clopidogrel as
soon possible– Loading dose?
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Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion
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Improved cardiac care for noncardiac surgery?
Yes, we can!
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Perioperative Medication Management
• Beta Blockers continue
• Alpha agonists continue
• Calcium blockers continue prn
• ACE / ARB stop preoperatively start when stable
• Statins continue
• Diuretics as needed
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Endocarditis prophylaxis
• 70 year old female with rheumatic valvular heart disease and Bjork-Shiley MVR in 1984 needs dental work.
• Are antibiotics required?
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SBE prophylaxis
• Antibiotics – All Prosthetic valves– Prior bacterial
endocarditis– Cyanotic congenital
heart disease (CHD)– Any repair CHD with
prosthetic material *
• No Antibiotics– Uncomplicated
valvular heart disease– Pacemakers or
defibrillators– Hypertrophic
cardiomyopathy
Circ 2007; 115