Preoperative CardiacPreoperative Cardiac...
Transcript of Preoperative CardiacPreoperative Cardiac...
Preoperative CardiacPreoperative Cardiac Evaluation 2012Evaluation 2012
John E. Ellis MDUniversity of Pennsylvania (USA)y y ( )
WHAT’S THE GOAL OF PREOPEVAL?
•Is patient in best possible shape?C th ti t b d b tt ?•Can the patient be made better?
•Risk assessment?Risk assessment?•Who should not have surgery?
What will kill the patient?p
•T i l l CAD•Triple vessel CAD•L ft i CAD•Left main CAD•A ti t i•Aortic stenosis
Anesthesiology 2010; 113:794 – 805
PERIOP CV EVAL 2012•Falling periop event rates make aggressive workup less rewardingaggressive workup less rewarding•What’s it worth to reduce complications 50%50%…
•From 10% to 5%? (NNT = 20)From 2% to 1%? (NNT = 100)•From 2% to 1%? (NNT = 100)
Who is at risk for perioperativemyocardial infarction?
What tools to use?What tools to use?• American Society of• American Society of
Anesthesiologists?• Charlson comorbidity?• Lee (Goldman) cardiac risk index?Lee (Goldman) cardiac risk index?• Eagle• F ilt ?• Frailty?
Pathophysiologic differences?Pathophysiologic differences?
•Different risk factors•Different risk factorsoSmokinggoObesity
Di b toDiabetesoSleep apneaoSleep apnea
“BEDSIDE” RISK FACTORS
Lee TH et al Circulation 1999
“BEDSIDE” RISKFACTORS
•High risk surgeryh/o ischemic heart disease•h/o ischemic heart disease
•h/o CHF•h/o CVAInsulin Rx•Insulin Rx
•Creatinine > 2.0 mg/dL
Lee TH et al Circulation 1999
By definition, patients undergoing AAA, thoracic, and abdominal procedures were excluded from class I.
Risk class predicts cardiovascular morbidity
Class 1: 0 riskClass 2: 1 risksClass 3: 2 risksClass 3: 2 risksClass 4: >3 risks
But that’s not allBut that s not all…Changing nature of cardiovascular
disease
Circulation 2011, 124:289-296: originally published online June 27, 2011
Circulation 2011, 124:289-296: originally published online June 27, 2011
Wh t b t h t i ?What about hypertension?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 6 (December), 2010: pp 927-930
Limitations of "traditional" evaluationevaluation
T d t f 1Tend to focus on 1 organ systemsystemOften the heartOften the heart
Yet surgical morbidityYet, surgical morbidity and mortality have ychanged
The Elderly PatientThe Elderly Patient
Aging DemographicsAging DemographicsLife RankLife expectancy
Rank
Australia 81.81 9thust a a 8 8 9t
Hong Kong 82.04 8th
New Zealand 80.59 23rd
https://www.cia.gov/library/publications/the‐world‐factbook/rankorder/2102rank.html
Functional status in elderlyFunctional status in elderly
http://www.nytimes.com/2012/08/25/sports/25iht-athlete25.html?_r=0
• Unintentional weight loss ≥10 pounds in lastyear.yea
• Decreased grip strength (weakness).• ExhaustionExhaustion.• Low physical activity.• Slowed walking speed (walk 15 feet)Slowed walking speed (walk 15 feet).
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
Who “needs” a stress test?Cardiology consultation?
LAURA C•55 yo F•s/p CVA MI CHF IDDM•s/p CVA, MI, CHF, IDDM•Gangrenous toesF di t l b d•Fem-distal bypass proposed
Does she need a stress test?
JOHN B•75 yo WM for iliac angioplasty•Cath, stented RCA s/p MI 2 years agoCat , ste ted C s/p yea s ago
•No symptoms since•Medical Rx
•ACE-I•Beta blocker•Statin•Aspirin
Does he need a stress test?
I will argueLaura C maybe needs a stress
test (or maybe straight to cardiac th)cath)
J h B d tJohn B does not
WHAT DOES STRESS TEST ADD?
•L’Italien et alROC (P ti•ROC curve areas (Prognostic accuracy)
•74% by clinical criteria•81% by clinical criteria + stress81% by clinical criteria stress tests
J Am Coll Cardiol. 1996 Mar 15;27(4):779-86.
It’s the history!It s the history!
Once again, history and physical more important than “specialized” testing
S SStep 1: Emergency Surgery
Proceed to surgery with medical risk reduction and perioperativerisk reduction and perioperativesurveillance
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
St 2 A ti C di C ditiStep 2: Active Cardiac Conditions• Unstable angina, recent MI• Decompensated CHF• Decompensated CHF• Significant arrhythmias• Severe valvular disease• Severe valvular disease
Postpone surgery until stabilized or corrected
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
or corrected
St 3 L Ri k S ( i k <1%)Step 3: Low Risk Surgery (risk <1%)• Superficial or endoscopic• Cataract or breast• Cataract or breast• Ambulatory
Proceed to surgery
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
St 4 F ti l C itStep 4: Functional Capacity• Good• > 4 METs• > 4 METs
o Can walk flight of stairs without symptomssymptoms
Proceed to surgery
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
Risk factors• DMCVA / TIA• CVA / TIA• CHF• CAD
• Cr > 2 0• Cr > 2.0
No risk factors: 1 2 risk factors AND >3 risk factors:No risk factors:
PROCEED TO
1-2 risk factors ANDvascular / intermed.
surgery:
>3 risk factors:
CONSIDER STRESS TESTINGPROCEED TO
SURGERY PROCEED TO SURGERY WITH
HR CONTROL
STRESS TESTINGIF IT WILL CHANGE
MANAGEMENT
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
Ann Surg. 2012 Sep 7. [Epub ahead of print]
Ann Surg. 2012 Sep 7. [Epub ahead of print]
TABLE 5. Predictors of Preoperative Cardiac Stress Testing (N = 74,117)
Female
Year of surgery
Charlson comorbidity indexCharlson comorbidity index
Size of MSA
US region
Hospital size
Least in Pacific NW
Hospital size
MSA indicates metropolitan statistical area.All P < 0 05
Ann Surg. 2012 Sep 7. [Epub ahead of print]
All P < 0.05
J Clin Anesth. 2010 Sep;22(6):402-9
ConclusionsConclusions• Declining cardiac event rates change theDeclining cardiac event rates change the
value of preop testing• Preop evaluation should be guided by historyPreop evaluation should be guided by history• Other factors important besides CAD:
o Heart failureo Heart failureo Arrhythmiaso Valvular heart diseaseoo Fraility
• Stress tests are marginally useful to g yreclassify intermediate risk patients