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Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery

Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery. Thomas Vrobel, M.D. Antonio Cooper, M.D. with thanks to Robert Finkelhor, M.D. November 4, 2003. Perioperative MI Scope of the Problem. 27 M noncardiac operations/year

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Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery

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  1. Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery Thomas Vrobel, M.D. Antonio Cooper, M.D. with thanks to Robert Finkelhor, M.D. November 4, 2003

  2. Perioperative MIScope of the Problem • 27 M noncardiac operations/year • 8 M with known CAD or risk factors • CAD leading cause of nonsurgical postoperative death

  3. Perioperative MIScope of the Problem • 50,000 perioperative MI (~0.2% of surgeries) • 30-50% mortality with MI • 1 M cardiac complications (~4%) • $20 billion added cost to surgery

  4. Perioperative MIMechanisms • Unstable plaque • Catecholamines • pain • anemia • BP swings • pain • anemia/hypovolemia

  5. Post MI Noncardiac Surgery Risk Mortality % Months post MI

  6. Recent MI (<6 mos) Unstable angina CHF Abdominal or thoracic surgery Severe AS Emergent surgery Age >70 Rhythm other than sinus S3 Other medical/metabolic problems Goldman Criteria

  7. Cardiac Risk Stratification Proposals • Goldman • Detsky • Eagle • ASA

  8. Revised Cardiac Risk IndexIndependent PredictorsLee et al. Circ 1999;100:1043. • High risk surgery • History of ischemic heart disease • History of CHF • History of CVA • Diabetes requiring insulin • Cr>2.0 mg/dl

  9. Revised Cardiac Risk IndexLee et al. Circ 1999;100:1043. ROC Curves Validation Set, n=1422 Goldman (0.70) Detsky (0.58) ASA (0.71) Revised (0.81) 0.5 1 0 Specificity

  10. Revised Cardiac Risk Index *Cardiac death, MI, pulmonary edema, arrhythmic arrest, heart block Lee et al. Circ 1999;100:1043.

  11. Revised Cardiac Risk IndexLee et al. Circ 1999;100:1043. Number of Risk Factors * Thoracic, Abdominal, Orthopedic, etc.

  12. Perioperative Cardiac Mortality with CABG N=1001 Hertzer, Ann Surg 1984;199:223.

  13. Preoperative TestingPositive Predictive Value MI or Death Eagle et al. JACC 1996;27:910.

  14. Preoperative TestingNegative Predictive Value Freedom from MI or Death Eagle et al. JACC 1996;27:910.

  15. Functional CapacityMetabolic Equivalents (METs) • Low (< 4 METs) • increased surgical risk • Intermediate (4-10 METs) • Excellent (> 10 METs) Eating Dressing Walking around the house Dishwashing

  16. Postoperative MortalityPreoperative Hemoglobin Carson et al. Lancet 1996;348:1055.

  17. Perioperative Cardiac Mortality with CABG N=1001 Hertzer, Ann Surg 1984;199:223.

  18. Proven Indications for CABG • Significant left main disease • 3 V CAD and LV dysfunction • 2 V CAD with proximal LAD involvement • Intractable ischemia

  19. Perioperative Cardiac Events with PTCAVascular Patients % Death and Nonfatal MI Khot UN, Ellis SG. ACC Current J Rev 2001;10:57.

  20. PROBLEMS WITH PREOP CORONARY INTERVENTIONS No proven benefit May not treat the “culprit” Delays surgery versus higher coronary risk PTCA : only few days but higher restenosis risk Stent : two to six weeks

  21. Postoperative Mortality ReductionBeta-Blockers Mangano, et al. NEMJ 1996;335:1713.

  22. Postoperative Cardiac Events In High Risk Patients Placebo n=53 Bisoprolol n=59 Poldermans et al. NEJM 1999;341:1789.

  23. BETA-BLOCKERSUNKNOWN FACTORS What is the optimal dose? How frequent are complications? Who should receive therapy? Are all beta blockers effective? When should they be started? How long should they be used? Are Alpha-Blockers also effective?

  24. Statin Use and Perioperative Death • Patients: PV surgery 1991-2000 • Study Type: retrospective case-controlled • 160 deaths (5.6% of total) • 2:1 survivors: non-survivors • Vascular death: 104 (65% cases) • Statin use: • 8% cases vs 25% controls (p<0.001) • odds ratio 0.22, (95% CI 0.10-0.47) Poldermans et al. Circ 2003;107:1848.

  25. Minor Clinical Predictors • Advanced age • Abnormal ECG • Rhythm other than sinus • History of CVA • Uncontrolled HTN

  26. In-Hospital MortalityPerioperative PA Catheter 1994 Randomized High Risk Surgical Patients Favors PA Catheter Favors Standard Care Overall NYHA I or II III or IV 0 -10 +10 % Difference Sandham et al. NEJM 2003;348:5.

  27. Major Clinical Predictors • Acute or recent MI (< one month) • Unstable or severe angina • Large ischemic burden (stress testing) • Decompensated CHF • Significant arrhythmias

  28. Intermediate Clinical Predictors • Remote MI ( >1 month) • Stable angina • Compensated CHF • Creatinine  2.0 • Diabetes

  29. Surgery Specific RiskHigh (>5% Mortality) • Emergent (esp. in the elderly) • Aortic • Peripheral vascular

  30. Surgery Specific RiskIntermediate (1-5% Mortality) • Intraperitoneal /intrathoracic • Orthopedic • Head & neck • Carotid endarterectomy

  31. Surgery Specific RiskLow (<1% Mortality) • Endoscopic (cholecystectomy, arthroplasty, urologic, etc.) • Breast • Skin • Cataracts

  32. Functional CapacityMetabolic Equivalents (METs) • Low (< 4 METs) • increased surgical risk • Intermediate (4-10 METs) • Excellent (> 10 METs)

  33. Functional CapacityMetabolic Equivalents (METs) • Low (< 4 METs) • increased surgical risk • Intermediate (4-10 METs) • Excellent (> 10 METs) Climbing a flight of stairs Level walking at 4 mph Scrubbing floors Moving heavy furniture Golf

  34. Functional CapacityMetabolic Equivalents (METs) • Low (< 4 METs) • increased surgical risk • Intermediate (4-10 METs) • Excellent (> 10 METs) Swimming Singles tennis Basketball

  35. Operative Risk Stratification Surgical Urgency emergent OR Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53.

  36. Operative Risk Stratification Surgical Urgency urgent or elective Prior (<5 years) revascularization OR no no yes Further Risk Stratification yes Recurrent signs/symptoms

  37. Operative Risk Stratification Clinical Predictors Major Intermediate Minor/none Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53.

  38. Operative Risk Stratification Clinical Predictors Major Intermediate Minor/none Postpone Surgery? Medical Rx and Risk Factor Optimization Coronary Angiography

  39. Operative Risk Stratification Clinical Predictors Major Intermediate Minor/none < 4 METs > 4 METs Stress Testing Surgical Procedural Risk High Intermediate or Low OR

  40. Operative Risk Stratification Clinical Predictors Major Intermediate Minor/none < 4 METs > 4 METs Surgical Procedural Risk Intermediate or Low OR

  41. Operative Risk Stratification Clinical Predictors Major Intermediate Minor/none < 4 METs Stress Testing Surgical Procedural Risk High

  42. Operative Risk StratificationStress Testing Summary Surgery Specific Risk Low Intermediate High Medical Risk Minor Intermediate Major OR Functional capacity <4 METs: stress test Stress test Optimize RF and/or further eval.

  43. Prevention of Perioperative MIGoals • Identify severe or symptom limiting CAD - risk stratification • Minimize risk from CAD (standard Rx of CAD)

  44. Perioperative Issues • Risk stratification • Minimize risk • Monitoring • Treating complications History, physical, ECG, lab tests Selective stress testing Clinically indicated catheterization

  45. Perioperative Issues • Risk stratification • Minimize risk • Monitoring • Treating complications -blockers Correct anemia Risk directed PCI Clinically indicated CABG

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