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Update on Perioperative Medicine

Update on Perioperative Medicine. Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco. Update on Perioperative Medicine. Who needs a preoperative cardiac stress test? What are the benefits and risks of  -blockers?

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Update on Perioperative Medicine

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  1. Update on Perioperative Medicine Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco

  2. Update on Perioperative Medicine • Who needs a preoperative cardiac stress test? • What are the benefits and risks of -blockers? • Can statins prevent postoperative MI? • When can patients with stents go to the OR? • How should chronic anticoagulation be managed? • Should arthroscopy patients get DVT prophylaxis? • Is preoperative smoking cessation beneficial?

  3. Preoperative Stress Testing • A 65 y.o. man with a history of coronary artery disease and long-standing diabetes will undergo radical prostatectomy. He had a myocardial infarction in 2003, but now has no cardiac symptoms. • Meds: lovastatin, atenolol, glyburide, benazepril, ASA • Exam: BP=115 / 70 HR=60; normal heart & lung exam • ECG: NSR, LVH, otherwise normal

  4. 65 y.o. man s/f radical prostatectomy. History of remote MI and long-standing diabetes. He is currently asymptomatic. • Stress test prior to surgery • No stress test is needed • Make him carry a copy of Harrison’s up a flight of stairs

  5. “New Standard” Cardiac Risk Index • Predictors: • Higher risk operation* • Ischemic heart disease • Congestive heart failure • Diabetes requiring insulin • Creatinine > 2 mg/dL • Stroke or TIA Predictors Complications** 0 0.5% 1 1.3% 2 4% 3 or more 9% * Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery ** Defined as MI, pulmonary edema, cardiac arrest, complete heart block Lee, et al. Circulation, 1999

  6. yes Good Functional Capacity? Go to OR no or ? no predictors* 1 or 2 predictors ≥ 3 predictors no Vascular surgery? yes Go to OR Consider stress test if results will change management (IIa) Control HR & go to OR (IIa) 2007 ACC/AHA Guideline or (IIb) * CAD, CHF, DM, CKD, CVA/TIA

  7. 352 with no or limited ischemia 34 with extensive ischemia (9%); 12 had PCI or CABG 30-day CV Death or MI 1.8% 1.1% 15% 2.3% 770 vascular patients with 1 or 2 of following: Age > 70, MI, angina, CHF, DM, stroke / TIA, Cr > 1.8 No stress test (n = 384) Stress test (n = 386) Poldermans et al. JACC, 2006

  8. Extensive Ischemia Predicts High Risk 101 patients undergoing vascular surgery, all with ≥ 3 risk predictors and stress test showing extensive ischemia Poldermans, et al. JACC, 2007

  9. Reducing Risk with Medical Management • A 75 y.o. woman will undergo hemicolectomy next week. She has a history of diabetes and a remote stroke, but no current cardiovascular symptoms. • Start a -blocker • Start a statin • Start both -blocker & statin • No new medications needed

  10. Standard Care 30 Cardiac Mortality & Nonfatal MI (%) 20 10 Bisoprolol 7 14 21 28 Days after Surgery - 111 patients undergoing vascular surgery- All had ischemic potential on dobutamine echo- Randomized to beta-blocker or standard care 40 Poldermans, et al. NEJM, 1999

  11. POISE: PeriOperative Ischemia Evaluation • 8351 patients with s/f major noncardiac surgery • CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery • Not already taking -blocker Metoprolol XL (immediately preop until 30 days postop) Placebo Patients followed for 30 days after surgery: 1° Endpoint: cardiac mortality & nonfatal arrest or MI Poise Study Group. Lancet, 2008

  12. POISE: Results • Metoprolol XL: • Reduced cardiac events (mostly nonfatal MI) • but • Increased risk of stroke & total mortality Poise Study Group. Lancet, 2008

  13. POISE: Treatment Protocol 2-4 h OR 0-6 h 12 h 1st dose Metoprolol 100 mg XL* 2nd dose Metoprolol 100 mg XL* 3rd & daily dose Metoprolol 200 mg XL*^ * Study drug held for SBP < 100 or HR < 50 ^ Daily dose reduced to 100 mg if persistent bradycardia or hypotension

  14. DECREASE III 497 statin naive patients s/f vascular surgery • Fluvastatin XL 80 mg/day • Started > 1 month preop • Continued > 1 mo postop Placebo • Patients followed for 30 days after surgery: • Clinical Endpoint: cardiac death or nonfatal MI Poldermans et al. Presented at ESC, 2008

  15. DECREASE III: Results • Fluvastatin XL: • Reduced the composite outcome of cardiac death & nonfatal MI • No difference in rates of LFT or CPK elevation Poldermans et al. Presented at ESC, 2008

  16. DECREASE-IV • 1066 patients with estimated 1-6% risk of postoperatived cardiac complications • Randomized to: Bisoprolol • Fluvastatin XL • Bisoprolol + Fluvastatin • Double placebo • Drugs started average 34 days prior to surgery • Primary endpoint: 30-day CV death or nonfatal MI

  17. DECREASE-IV Results Bisoprolol-treated patients had fewer complications Trend towards benefit with statins No safety issues * P < .002 * * Dunkelgrun et al. Ann Surg, 2009

  18. Perioperative -blockers in 2009 • Strong indications: • Already using -blocker to treat angina, HTN, arrhythmia • Patients with ischemic potential having vascular surgery • Possible indications: • Patients with ischemic potential having high-risk nonvascular surgery (e.g., > 5 hours or > 500 cc blood loss) • Multiple risk predictors* in vascular or other high-risk surgery (*Coronary disease, renal insufficiency, diabetes) • Titrate dose up gradually (rarely start immediately preop)

  19. Statins: 2007 ACC/AHA Guideline • Definite indications (class I): • Continue statin if already taking prior to surgery • Probable indications (class IIa): • All vascular surgery patients • Possible indications (class IIb): • At least one risk predictor* in any intermediate risk surgery *Coronary disease, renal insufficiency, diabetes, CVA/TIA

  20. Delaying Surgery After Coronary Stent • A woman falls and suffers a cervical spine fracture. One month ago, she received a sirulimus-eluting stent for stable angina. The neurosurgeon won’t operate unless aspirin and clopidogrel are held for her surgery. Non-operative management in a halo for next 2 months is offered as an alternative. • What do you recommend to the patient & surgeon?

  21. Patient with recently placed drug-eluting stent has a c-spine fracture. Surgeon won’t operate unless aspirin & clopidogrel are held perioperatively. • Hold ASA & clopidogrel • Hold ASA & clopidogrel but bridge with heparin • Keep her in a halo for next 2 months

  22. Does Heparin Bridge Prevent Stent-related Complications? • Prospective study of 103 patients with coronary stent placed within 12 months having noncardiac surgery • Antiplatelet drugs continued or held < 3 days • All patients received heparin drip or enoxaparin • 14% of patient stented within 35 days of surgery suffered cardiac death or MI, or needed re-do PCI • Conclusion: High rate of cardiac complications even when bridging anticoagulants used Vicenzi et al. Br J Anaesth, 2006

  23. ACC/AHA Guidelines for PCI • Avoid PCI unless patient has independent indications • Avoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapy • Delay elective surgery in patients with recent PCI • Balloon angioplasty: 2 - 4 weeks • Bare metal stent: 4 weeks • Drug eluting stent: 12 months • If clopidogrel must be stopped, try to continue ASA • No evidence for bridging with other agents

  24. Managing Perioperative Anticoagulation • Two patients who take coumadin underwent THA. One has atrial fibrillation due to HTN. The other has a mechanical AVR. Neither has a history of stroke or any other comorbidity. • Heparin bridge for AVR only • Heparin bridge for AF only • Heparin bridge for both • Heparin bridge for neither

  25. Two patients who take coumadin underwent THA. One has AF due to HTN. The other has a mechanical AVR. Neither has a history of stroke any other comorbidity. • Heparin bridge for AVR only • Heparin bridge for AF only • Heparin bridge for both • Heparin bridge for neither

  26. Thromboembolic Risks with Non-rheumatic Atrial Fibrillation CHADS-2 Score: 1 point for CHF, HTN, Age > 75, DM 2 points for Stroke/TIA Score 0 - 2: < 5% annual stroke risk Score 3 - 4: 5-10% Score 5 - 6: > 10% Annual Stroke Risk Albers et al. Chest, 2001

  27. Thromboembolic Risks with Mechanical Valves Annual Incidence Cannegieter, et al. Circulation, 1994

  28. Effect of Mechanical Valve Location & Design on Thromboembolic Risk • Valve Location: • Aortic RR = 1.0 • Mitral RR = 1.8 • Valve Design: • Caged Ball RR = 1.0 • Tilting Disk RR = 0.7 • Bi-leaflet RR = 0.6 Cannegieter, et al. Circulation, 1994

  29. Perioperative Anticoagulation: 2008 ACCP Guidelines Full dose = therapeutic dose of heparin IV or LMWH SC Low dose = DVT prophylaxis dose of heparin SC or LMWH SC

  30. DVT Prophylaxis • Which DVTs matter? • Symptomatic versus asymptomatic • Proximal versus distal • 2008 American College of Chest Physicians: • Weights DVT risk greater than bleeding risk • Treats asymptomatic DVT as important

  31. RCT of LMWH in Knee Arthroscopy • Background:2008 ACCP guidelines recommend LMWH if additional risk factors for DVT are present. • Study Design: ~1300 patients randomized to compression hose or LMWH x 7 days after knee arthroscopy. All patients underwent screening ultrasound. • Results: Combined incidence of death or any clot reduced in patients receiving LMWH (0.9% vs 3.2%). Almost all clots were either asymptomatic or distal. Non-significant trend for increased bleeding. • Conclusions: LMWH superior to compression hose after knee arthroscopy (NNT = 43). Impact on symptomatic DVT small. Camporese et al. Ann Intern Med, 2008.

  32. Preoperative Smoking Cessation • A middle-aged man will undergo repair of a ventral hernia in 1 month. He currently smokes one pack of cigarettes per day. How do you counsel him? • Quit smoking now to prevent postoperative complications. • It’s always good to quit, but it’s too late to affect your risk of complications. • Don’t stop smoking! You will actually increase your surgical risk by quitting!

  33. Effect of Smoking Cessation Time since quitting p < .001 Complication Rate (%) Warner, Anesthesiology 1984

  34. Preoperative Smoking Cessation Counseling • RCTs of Preoperative Smoking Cessation Counseling: • 120 patients undergoing arthroplasty in 6-8weeks • 117 patients undergoing various operations in 4 weeks • 60 patients undergoing colorectal resection in 2-3 weeks Intervention:Smoking cessation counseling at weekly meetings (or by telephone) & offer free nicotine replacement products Outcomes:Postop complications, especically wound related (e.g., dehiscence, infection, hematoma)

  35. Smoking Cessation 6-8 Weeks Before TKA or THA Moller et al. Lancet, 2002

  36. Smoking Cessation 4 Weeks Before Surgery Lindstrom et al. Ann Surg, 2008.

  37. Smoking Cessation 2-3 Weeks Before Colorectal Surgery Sorensen, et al. Colorectal Dis, 2003

  38. Take Home Points • Reserve stress testing for higher risk patients -- Limited ischemia ok, but extensive ischemia = high risk • Start -blocker cautiously & only in high risk patients • Delay surgery in patients with recent stent placement • Individualize thrombotic risk assessment when managing perioperative anticoagulation • Consider LMWH for knee arthroplasty patients • Smoking cessation for ≥ 4 weeks may be beneficial

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