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Howard Weitz, M.D. February 2012

The Patient with Cardiac Disease Who Undergoes Noncardiac Surgery How to Assess and Reduce Risk El manejo del paciente con enfermedad cardiaca, que require cirugia no cardiaca. Howard Weitz, M.D. February 2012. ACC / AHA Guideline 2002 Philosophy.

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Howard Weitz, M.D. February 2012

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  1. The Patient with Cardiac Disease Who Undergoes Noncardiac Surgery How to Assess and Reduce RiskEl manejo del paciente con enfermedad cardiaca, que require cirugia no cardiaca Howard Weitz, M.D. February 2012

  2. ACC / AHA Guideline 2002Philosophy • “… the concept of “medical clearance” for surgery is short sighted. • Goals of the preoperative consult: • Evaluate current medical status • Advise on disease management in the periop period. • At times recommend preventive measures for future. • Define your role in care (Co-manager?, subspecialty consultant?, etc)

  3. Case You have been asked to evaluate a 60 year old man for resection of a pulmonary nodule. Hx: hypertension, hypercholesterolemia Smokes 2ppd many years. Does not exercise but climbs 1 flight stairs daily without difficulty Bp 120/70 HR 60 Exam unremarkable. ECG: Normal sinus rhythm. Within normal limits

  4. Case In an effort to aid in his preoperative evaluation you suggest: A. Exercise ECG (no imaging) B. Exercise stress thallium C. Exercise echo D. Pharmacologic stress test E. None of the above

  5. October 23, 2007 400 new articles reviewed since 2002 guideline

  6. Key Elements of Risk Stratification • Emergency surgery • Active cardiac conditions • Low risk surgery • Functional capacity • Clinical risk factors • Will testing – preop intervention change management ?

  7. Step 1 Step 1 Need for emergency noncardiac surgery? YES Perioperative surveillance and postoperative risk stratification Operating room NO Step 2

  8. Step 2 Step 2 Active cardiac conditions Evaluate and treat per ACC/AHA guidelines Consider operating room YES NO • Active Cardiac Conditions • Unstable coronary syndromes • Unstable or severe angina • Recent MI • Decompensated HF • Significant arrhythmias • Severe valvular disease Step 3

  9. Step 3 Step 3 Low risk surgery YES Proceed with planned surgery NO Step 4 • Low Risk Surgery • Endoscopic procedures • Superficial procedures • Cataract surgery • Breast surgery

  10. Step 4 Step 4 Good functional capacity (METS > 4) without symptoms YES Proceed with planned surgery No or Unknown Step 5

  11. Step 5 Step 5 Clinical Risk Factors • History of ischemic heart disease • History of compensated or prior HF • History of cerebrovascular disease • Diabetes • Renal insufficiency

  12. Step 5 Step 5 Clinical Risk Factors (Isch HD, CHF hx, Cereb vasc dx, DM, Cr >2 3 or more 1 or 2 None Vascular surgery Intermediate Risk surgery Proceed with planned surgery Vascular or intermediate risk surgery Consider testing if it will change management Proceed with planned surgery with HR control or consider Noninvasive testing if it will change management

  13. Case In an effort to aid in his preoperative evaluation you suggest: A. Exercise ECG (no imaging) B. Exercise stress thallium C. Exercise echo D. Pharmacologic stress test E. None of the above

  14. Case In an effort to aid in his preoperative evaluation you suggest: A. Exercise ECG (no imaging) B. Exercise stress thallium C. Exercise echo D. Pharmacologic stress test E. None of the above

  15. National Surgical Quality Improvement Database >250 hospitals >200,000 pts/year Predictors of perioperative (up to 30 day) MI, Arrest ASA Class Functional status Age Serum Cr Type of surgery

  16. Problems - Limitations • MI (one or more of the following) • STEMI; new LBBB, new Q waves • Tn • > 3 times top normal

  17. Problems-Limitations • HF not a predictor • NSQIP database does not record: • Preop stress test • Echo • Arrhythmia history / occurrence • Aortic valve disease • Beta blocker use • Remote history of CAD (except prior PTCA or CABG)

  18. Risk Reduction Strategies • Medications • Anesthesia • Monitoring • Interventions

  19. Perioperative Beta BlockersWhat really is the evidence?

  20. [ High risk N Engl J Med 1999;341:1789-94

  21. In the absence of major contraindications, therapeutic dosesof beta-adrenergic antagonists should be given to patients withan intermediate or high risk of cardiac complications. Patientswho are not already receiving beta-blockers should be givenone of these agents. Even if the drug causes complications,such as fatigue or impotence, these side effects can be toleratedduring the perioperative period. Patients who are already receivinga beta-blocker should be evaluated to ensure that therapeuticserum concentrations have been achieved. Lee, T.: Reducing Cardiac Risk in Noncardiac Surgery. N Engl J Med: 341:1838-40, 1999

  22. Perioperative Beta BlockersWhat really is the evidence?

  23. Mangano, 1996 • “In hospital” post op adverse events not counted. • “In hospital” atenolol group 4 deaths, control group 2 deaths. If included the difference in death between the two groups not significant • Did beta blocker withdrawl favor the beta blocker group? • 8 patients taken off beta blocker to enter placebo group • 40% did not tolerate full dose atenolol, 15% did not tolerate any atenolol • Trend toward sicker patients (prior MI, angina, diabetes,prior coronary revasc) in placebo group. • Atenolol group trended toward more comprehensive cardiac therapy (ie ACE inhibitors) at discharge

  24. 59 pts beta blocker 53 pts std care59 p N Engl J Med 1999;341:1789-94

  25. ????

  26. N Engl J Med 2005; 353:349-61 (July 28, 2005)

  27. Lindenauer et al. N Engl J Med, 2005 • Retrospective database review • 329 Hospitals ( small – mid sized, non-teaching) • 663635 pts without contraindication to beta blocker • 122338 pts received beta blocker during first 2 hosp days • Revised Cardiac Risk Index Score (RCRI) • High risk surgery (thoracic, intraperitoneal, suprainguinal vascular) • Ischemic heart disease • Cerebrovascular disease • Renal insuficiency • Diabetes

  28. Adjusted Odds Ratio for In-Hospital Death Associated with Perioperative Beta-Blocker Therapy among Patients Undergoing Major Noncardiac Surgery, According to the RCRI Score and the Presence of Other Risk Factors in the Propensity-Matched Cohort and the Entire Study Cohort RCRI High risk surgery Ischemic Ht dx Cerebrovasc dx Renal insufficiency Diabetes 50% RCRI 0 38% RCRI 1 12% RCRI 2 2% RCRI 3 <1% RCRI >4 Lindenauer, P. et al. N Engl J Med 2005;353:349-361

  29. ACC / AHA 2006 Perioperative Beta Blocker Update • Most trials inadequately powered • Few randomized trials of medical therapy to prevent perioperative cardiac complications • Few randomized trials examined therapy titration • Few randomized trials re: role of periop beta blockers • Studies lacking to determine role of beta blockers in intermediate and low risk populations • No studies have addressed how, when, by whom perioperative beta blockade should be implemented or monitored

  30. Perioperative Beta BlockersPOISE Trial • PeriOperative ISchemic Evaluation • Canadian Institutes of Health Research • Noncardiac surgery • Hx: cad, pvd, cva, chf within 3 yrs of surgery, or vascular surgery • 30 days of controlled release metoprolol • Metoprolol CR 100 mg 2-4 hrs preop • IV or po metoprolol 6 hrs postop (equiv metoprolol CR 100mg) • Metoprolol CR 200 mg daily for 30 days • Outcomes: cardiovascular death; fatal MI; non-fatal MI • 190 centers, 23 countries • Goal 10000 patients (final enrollment 8351)

  31. POISE trial online release; Lancet May 13, 2008

  32. POISE • Metoprolol prevented MI but increased risk of stroke, death. • Metoprolol decreased incidence Afib. • Metoprolol increased hypotension, bradycardia.

  33. PREVENT 15 MI 3 Coronary revasc 7 Afib POISE: Metoprolol sustained release 1000 patients

  34. PREVENT 15 MI 3 Coronary revasc 7 Afib CAUSE 8 Death 5 Stroke 53 sig hypotension 42 significant bradycardia POISE: Metoprolol sustained release 1000 patients

  35. POISE Trial Design: POISE was a randomized trial of metoprolol (n = 4,174) or placebo (n = 4,177) in patients undergoing noncardiac surgery. Study drug was given 2 to 4 hours prior to surgery and for the next 30 days. Primary endpoint was major CV events (defined as CV death, MI, or cardiac arrest through 30 days. • Results • Primary endpoint of CV death, MI, or cardiac arrest ↓ in metoprolol (Figure), driven by ↓ nonfatal MI (3.6% vs. 5.1%, HR 0.70, p = 0.0007) • Total mortality ↑ in metoprolol group (Figure) as did stroke (1.0% vs. 0.5%, HR 2.17, p = 0.005) • Metoprolol group also had ↑ rates of significant hypotension (15.0% vs. 9.7%, p < 0.0001) and significant bradycardia (6.6% vs. 2.4%, p < 0.0001) • Conclusions • Among patients undergoing noncardiac surgery, treatment with beta-blocker metoprolol was associated with reduction in primary endpoint of CV death, MI, or stroke at 30 days compared with placebo, but total mortality and stroke were increased with metoprolol • Prior studies with prophylactic beta-blocker in patients undergoing vascular surgery have shown mixed results • While post-surgical CV event rate was high, given increased risk of death, stroke, and severe hypotension with metoprolol, routine prophylactic therapy does not appear to be a safe approach to reducing CV events in this population CV Death, MI, or Cardiac Arrest (HR 0.83, p = 0.04) Total Mortality (HR 1.33, p = 0.03) % Metoprolol Placebo Presented at AHA 2007

  36. Why didn’t the beta blocker decrease mortality in POISE?

  37. POISE • ? Started too soon before surgery to have a plaque stabilizing effect. • POBBLE and DIPOM both started beta blocker less than 24 hours preop and showed no protective beta blocker effect) • High dose beta blocker • Doses not titrated • Beta blocker only stopped if systolic BP dropped < 100 mm Hg • Beta blocker related significant hypotension contributed to 37% of deaths • Beta blocker related significant hypotension was most common prelude to stroke

  38. Perioperative beta blockade Class I recommendation (2009)(evidence / agreement that treatment is beneficial, useful, effective) • Beta blockers should be continued for patients who are receiving them to treat angina, symptomatic arrhythmia, hypertension, or other Class I guideline indications.

  39. Perioperative beta blockade Class IIa recommendation(evidence / opinion in favor of usefulnes, effective) • Beta blockers when used should be titrated to heart rate and blood pressure. • Beta blockers probably for vascular surgery when high risk due to CAD or ischemia on preop testing. • Beta blockers probably for vascular surgery in patients at high cardiac risk (defn:presence of> 1 clinical risk factor). • Beta blockers probably for patient with CAD or high cardiac risk (defn >1 clinical risk factor) who is to undergo intermediate-risk surgery. Clinical risk factors: Ischemic heart disease; CHF; Cerebrovasc disease; DM; Renal insuf

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