Pre-operative Cardiovascular Evaluation: Guidelines and More
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Transcript of Pre-operative Cardiovascular Evaluation: Guidelines and More
Pre-operative Cardiovascular Evaluation:
Guidelines and MoreEric A. Brody MD, FACC
Medical Director, NA Cardiology and Medical ServicesAssociate Professor of Clinical Medicine
University of Arizona Medical Center
Objectives
• Review Algorithm for Pre-op risk assessment for current guidelines
• Define the roles of the cardiac/medical consultant for the non-cardiac surgery patient
• Discuss “clearance”
• Review the 10 commandments of the cardiac/medical consultant
Mechanisms of Perioperative MI
• Unique postoperative conditions lend themselves to AMI– Volume loss/Fluid Shifts– Anemia– Anxiety/Pain – Tachycardia– Temperature fluctuations– Coagulation cascade
MVO2
Shear Stresses
Excess Catechols
Platelet Activation
What Causes Perioperative MI?
Surgery Patient
Volume Shifts
Anemia
Medication withdrawal
Temperature fluctuation
Acidosis
Underlying CAD
Hypertension
Tachycardia
Anxiety/Pain
Hemostasis
Myocardial Infarction
Treatment of Peri-operative MI
Medical Therapy
Beta Blockers
Ca+ Channel. Blockers
ACE inhibitors/ARB
Antithrombotic Therapy
UFH/LMWH
Anti-thrombins
Thrombolysis
Interventional Therapy
PCI/Stent
Antiplatelet Therapy
ASA
GP2b3a
Thienopyridines
Role of the Medical Consultant
• Identify co-morbidities which may complicate surgery
• Airway/anaesthesia issues
• Functional status of the patient
• Clarify pre-op medications
• Peri-procedural cardiac risk
What is “Cleared”?Questions to answer.
• Patients condition is optimized prior to surgery??
• Benefits outweigh risk of surgery??
• OK to proceed??
• Medical Legal considerations removed???
What is “Cleared”?
• My preference- one of 2 options– “Patient is considered ______________
(low, moderate or high) risk for peri-op cardiovascular complications based on current ACC/AHA guidelines”
-” My recommendations for perioperative care include…..”
-”Patient requires additional testing to better clarify perioperative cardiac risk.”
http://www.americanheart.org/
ACC/AHA Perioperative Guidelines Updates: October 2007
• Last revision: 2002
• Significant changes to previous guidelines
• Dramatic change in perioperative evaluation algorithm.
JACC 2007: vol. 50 (17)
2007 Update
Perioperative Guidelines Algorithm
Need for Emergency non-cardiac Surgery?
Step 1
Operating Room
Perioperative Surveillance and
postop. Risk stratification. Risk Factor management
Yes
No
Step 2
Perioperative Guidelines Algorithm
Active Cardiac Conditions
Step 2
Evaluate and Treat per
ACC/AHA guidelines
Consider Operating
RoomYes
Active Cardiac Conditions:Patients require evaluation and treatment before non-
cardiac surgery
• Unstable Coronary Syndromes
• Decompensated CHF• Significant Arrhythmias• Severe Valvular Heart
disease
Unstable or Severe Angina (class III or IV) or recent MI >7
days but < one month
Active Cardiac Conditions:Patients require evaluation and treatment before non-
cardiac surgery
Significant Arrhythmias
• High grade AV block
• Mobitz II AVB
• Third degree AVB
• Symptomatic Vent. Arrhythmias/Bradycardia
• SVT/Afib with uncontrolled rate (>100/min)
• Unstable Coronary Syndromes
• Decompensated CHF• Significant Arrhythmias• Severe Valvular Heart
disease
Active Cardiac Conditions:Patients require evaluation and treatment before non-
cardiac surgery
Severe Valvular Heart disease
• Severe Aortic Stenosis
• Critical Mitral Stenosis
• Unstable Coronary Syndromes
• Decompensated CHF• Significant Arrhythmias• Severe Valvular Heart
disease
Perioperative Guidelines Algorithm
Active Cardiac Conditions
Step 2
Evaluate and Treat per
ACC/AHA guidelines
Consider Operating
RoomYes
No
Step 3
Perioperative Guidelines Algorithm
Low Risk non-cardiac Surgery?
Step 3
Proceed with planned surgery
Yes
• Endoscopic
• Superficial
• Breast
• Most ambulatory surgeries
• Cataracts/ocular
Low Risk Surgeries
Perioperative Guidelines Algorithm
Low Risk non-cardiac Surgery?
Step 3
Proceed with planned surgery
No
Step 4
Perioperative Guidelines Algorithm
Good Functional Capacity without symptoms
(>4 mets)
Step 4
Proceed with planned surgery
Yes
Assessing Functional Capacity
1 Met 4 mets
ADL’s
Eat, Dress or Toilet
Walk Indoors
Walk 1-2 blocks,
level ground
Light House Work
Assessing Functional Capacity
4 mets >10 mets
Climb 1 flight stairs or walk uphill Walk 4
mph
Run a short distance
Heavy Housework
Strenuous Sports
Moderate sports
Assessing Functional Capacity
Another Way to look at This!!
• No Clinical Risk Factors and Low or intermediate risk surgeries with
good functional capacity may proceed directly to the OR.
Perioperative Guidelines Algorithm
Good Functional Capacity without symptoms
(>4 mets)
Step 4
Proceed with planned surgery
Yes
No or Unknown
Step 5
Clinical Risk Factors
• Ischemic Heart Disease
• Compensated or Prior CHF
• DM (insulin requiring)
• Renal Insufficiency (creat. >2.0)
• Cerebrovascular Disease
Step 5
Lee et al. Circulation. 1999;100:1043-1049.)
Revised Cardiac Risk Index
Procedure Type
Perc
ent
AAA Other Vascular Thoracic Abdominal Orthopedic Other
Perioperative Guidelines Algorithm
No Clinical Risk Factors
Step 5
Proceed with planned surgery
Perioperative Guidelines Algorithm
1 or 2 Clinical Risk
Factors
Step 5
Intermediate Risk Surgery
Vascular Surgery
Proceed to OR with
HR control or
Consider Non
invasive testing
Class IIa, LOE B
Class IIb, LOE B
Cardiac Risk Stratification: High Risk Procedures
• Reported Cardiac Risk often >5%
– Emergent major operations, particularly in elderly patients
– Aortic and other major vascular
– Peripheral vascular
– Anticipated prolonged procedures with large fluid shifts or blood loss
Cardiac Risk Stratification: Intermediate Risk Procedures
• Reported cardiac risk generally <5%
– Carotid endarterectomy
– Major head and neck, especially for CA
– Intraperitoneal and intrathoracic
– Orthopedic, especially in elderly
– Radical prostatectomy
Perioperative Guidelines Algorithm
3 or more Clinical Risk
Factors
Step 5
Intermediate Risk Surgery
Vascular Surgery
Proceed to OR with
HR control or consider
Non invasive testing
Consider Non-
invasive testing
Class IIa, LOE B
TYPE of Surgery
http://www.surgicalriskcalculator.com/miorcardiacarrest
On line tool to calculate patient and procedure specific risk for planned
surgery
ACC/AHA Perioperative Guidelines Updates: October
2007Miscellaneous
ACC/AHA Perioperative Guidelines Updates: October 2007
• Who Needs an ECG??• Undergoing Vascular surgery (one or more clinical
risk factors) Class I
• Undergoing Vascular Surgery (no risk factors) IIa
• Intermediate risk surgery with established CVD (CAD, PVD, Cerebrovascular disease) Class I
• Intermediate Risk surgery with one or more clinical risk factors
ACC/AHA Perioperative Guidelines Updates: October 2007
• Who Needs an ECG??– CLASS III- ECG not needed in asymptomatic
patients undergoing low risk surgical procedures.
Recommendations for Statin Therapy
ACC/AHA Perioperative Guidelines Updates: October 2007
• Class I- (LOE B)
– Patients taking statins should be continued on this therapy at time of non-cardiac surgery
Best Treatment of Perioperative MI
Conclusions: Ways to Avoid Cardiac Complications
• Know the Patient’s History
– Prior MI or known CAD
– Prior CHF and LVEF
– Renal Failure/ baseline Creatinine
– History of significant Valvular heart disease
• Stenosis > regurgitation
Conclusions: Ways to Avoid Cardiac Complications
• Know what your surgeons and anesthesiologists did– Speak with them directly to coordinate
perioperative care.– Blood loss/serial hematocrits– Fluid resuscitation– Check the post op orders yourself
Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007
• Our own insecurities– Long history of “clearance” performed
by cardiologists
• Changing the Culture– Surgeons
– Anesthesiologists
Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007
• Getting the surgeons to listen to peri-operative recommendations– “You lost me at ‘Cleared’…..”
– Importance of continuing statin therapy and beta blocker therapy in those already taking these medications
Conclusions: Ways to Avoid Cardiac Complications
• Know the patients’ medications
– Continue Beta Blockers if on these preoperatively
– Prophylactic beta blockade is not indicated in all patients
Challenges for Primary ProvidersACC/AHA Perioperative Guidelines Updates: October 2007
• The “Business” of stress testing and preoperative evalutation
• Who’s going to pay?
Preoperative Evaluation
Keep it simple!!