ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery

1. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery Dr. Sonia Anand McMaster University

2. Overview • Guidelines- reflect evidence synthesis and consensus • Evidence as of October 2007 • Important Decision points: • Urgent vs Elective Surgery • High risk surgery vs intermediate vs low • Active Cardiac Condition vs non-active

3. The Search For High Risk

4. Methods for Assessing Risk Pre-Operatively Patient Based • High risk conditions • Functional Capacity Surgery Based • Vascular Surgery • Emergency surgery Intervention Based • Medications • Revascularization

5. Six Independent predictors of cardiac risk • ischemic heart disease • congestive heart failure 3) cerebrovascular disease 4) high risk surgery (AAA, orthopedic sx) 5) pre-operative insulin tx for diabetes 6) preoperative creatinine for creat > 2 mg/dL Lee et al

6. Active/Major Cardiac Conditions • Unstable Coronary Conditions • Decompensated CHF • Significant arrhythmias (i.e. 3⁰HB, new Vtach) • Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????

7. Non-Active Cardiac Factors • Intermediate Risk • Hx of CHD • History of prior CHF • Hx of stroke • Diabetes • Renal insufficiency • Minor Risk* • Age > 70 • Abnormal ECG • Nonsinus rhythm • Uncontrolled systolic BP * Not associated with cardiac risk

8. Functional Capacity • Functional status has shown to be a reliable periop and long-term predictor of cardiac events • Functional status determined based on ability to do ADL’s • MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest • Periop risk is increased if person cannot > 4 METS

9. Moderate recreational golf, dancing, baseball Strenuous sports swimming, basketball DO light house work i.e. Washing dishes Climb a flight of stairs Run a short distances Eat, dress 10 MET 1 MET 4 MET

10. The Trump Card: Functional Capacity • Perioperative cardiac risk is increased in patients unable to exercise 4 METs • Functional capacity can be estimated in the office • Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs • Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs • Swimming and singles tennis exceeds 10 METs

11. Surgery Risk Type

12. Surgery-Specific Risk: High Risk* • Major emergency surgery • Vascular surgery including: aortic surgery, infra-inguinal bypass • Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5%

13. Stepwise Approach • Step 1: Determine urgency of surgery • Step 2: Active cardiac condition?-→test • Step 3: Undergoing low-risk surgery? < 1%* • Step 4: Good functional capacity? *Combined morbidity and mortality < 1% even in high risk patients

14. The Catheterization Questions to Ask Yourself • Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now? • Am I willing to send the patient to CABG? • Am I doing this just to know the anatomy?

15. Is pre-op coronary revasc advantageous? • If high risk surgery and patient has active cardiac issue • Functional test and perfusion Imaging and if • L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op • CARP – if none of these – no advantage of revasc

16. Functional Test • Exercise test with ECG • If abnormal ECG, Rx perfusion imaging • Adenosine • Dipyridamole • Dobutamine • Dobutamine stress echo

17. *** 10 (n=314) 8.5 Periop MI 8 Death 6 * 4 3.0 2.8 * *** 2 1.1 0.6 0 0 No CAD CAD: Medical Rx CAD: CABG Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry Eagle et al. Circulation, 1997

18. Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes 510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized to Revasc (PCI 59%, CABG 41%) or conservative management. 25 20 15 10 5 0 Post-Op MI 30 Day 2.7 Year Mortality Mortality Revascularization Conservative Mgmt McFalls, E. CARP Trial;AHA 2004

19. High Risk Patients & Revascularization Pre-Op 101 pts with extensive ischemia randomly assigned to pre-op revascularization or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up. 50 40 30 % 20 2VD in 12 (24%), 3VD in 33 (67%), Left main in 4 (8%). 10 0 7 14 21 28 0 3 6 9 12 Days since surgery Months since surgery Poldermans, D. JACC 2007; 49(17): 1763

20. 1.0 0.9 0.8 Survival Free of Death/MI 0.7 0.6 0.5 7 0 1 2 3 4 5 6 Years The Effect of Percutaneous Revascularization Above Optimal Medical Therapy:COURAGE 2287 Pts w/myocardial ischemia and CAD randomized to PCI with optimal medical therapy (PCI group) and 1138 to medical therapy alone. Medical therapy PCI + Medical therapy Boden, W. NEJM 2007; 356:1503

21. STENTS If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after If received DES.... • 1) postpone sx until > 12 months, • 2) do sx on both asa+clop • 3) do sx on single ap tx

22. Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended

23. Medical tx 1) beta blockers-if on keep them if not.... 2) Statins continue, ? Start -need randomized trials

24. Statins Improve Survival After Vascular Surgery 100 pts randomized 20 mg atorvastatin or placebo for 45 days. Vascular surgery ~ 30 days after randomization. F/U 6 months Primary Endpoint CV death + NFMI+ Ischemic stroke+ Unstable Angina Durazzo, AES. JVS 2004:39(5):975

25. 1.00 .75 Survival .50 .25 0 0 60 20 40 80 100 Time (months) Statins Improve Long-Term Survival After Vascular Surgery Retrospective review of 446 consecutive infrainguinal bypass surgeries Statin (+) p < 0.004 Statin (-) Ward, RP. Int J Card 2005; 104(3):264

26. Other Issues • DVT/PE prophylaxis • Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B) • No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes • Routine troponin monitoring not recommended

27. Surveillance for Perioperative Myocardial Infarction • ECGs • All intermediate and high-risk patients should get a post-op ECG. • As need for signs or symptoms of ischemia • Troponin / CK • In patients with signs or symptoms of ischemia • Do not do screening biomarkers

28. High Risk Features • Severe obstructive or restrictive pulmonary disease • Diabetes • Renal impairment • Anemia, polycythemia, thrombocytosis

29. PCI pre-op • ST-elevation MI • Unstable angina • Non ST elevation MI

30. 2007 ACC/AHA Perioperative Guidelines

31. Take Home Messages • Unstable syndromes require management prior to surgery. Look for • Unstable angina • Signs of heart failure • Stenotic valve lesions • Ventricular arrhythmias • Functional tolerance is the best single predictor of outcome • Be very specific in your history (one step at at time, regular or slow pace, etc) • If patient on beta blockers & statins continue them, more trials to mandate them • PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.