What is Cardiology Clearance?

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future What is Cardiology Clearance? Sheilah Bernard, MD, FACC Director, Cardiac Amb Services Boston University School of Medicine May 19, 2006 9:30-10:00am

2. Eight Steps to Best Possible Outcome • Assess the patient’s clinical features • Evaluate functional status • Consider the patient’s surgery-specific risk • Decide if further noninvasive evaluation is needed • Decide when to recommend invasive evaluation • Optimize medical therapy • Perform appropriate perioperative surveillance • Design maximal long-term therapy

3. AHA/ACC Practice Guidelines Perioperative CV Evaluation for Noncardiac Surgery 2002, Eagle K et al. www.acc.org or www.americanheart.org

4. Fleisher: N Engl J Med, Volume 345(23).December 6, 2001.1677-1682

5. Implementing Guidelines • Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI) • Resources: ETT 88%47%; Cath 24%11%; revascularization 25%2% • Costs: $1087$171 • Effect was sustained 2 years after guideline implementation Froelich JB, J Vasc Surgery 2002 36L758-63

6. B&W Preadmission Testing Center (PATC) and last minute Cardiology consults for: Dudley JC et al, AM HEART J 1996;131:245-9.

7. Sources of “last-minute” cardiology consults

8. Improved survival with atenolol after noncardiac surgery

9. 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 Lindenauer, P. K. et al. N Engl J Med 2005;353:349-361

10. Beta blocker guidelines

11. Limitations in the perioperative beta blocker literature • Most trials inadequately powered • Few randomized trials of medical therapy have been performed • Few randomized trials have examined titration to effect (e.g. target heart rate) • Few randomized trials have examined the role of perioperative beta blocker therapy • Studies to determine role in intermediate and low risk populations are lacking. • Optimal beta blocker • No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom)

12. Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804

13. Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804

14. ?CABG/PCI before major elective vascular surgery? NO • In conclusion, this multicenter, randomized trial shows thatcoronary-artery revascularization before elective vascular surgerydoes not alter long-term survival. • Although the study was notpowered to detect a beneficial effect in the short term, therealso appears to have been no reduction in the number of postoperativemyocardial infarctions, deaths, or days in the hospital. • Onthe basis of these data, coronary-artery revascularization beforeelective vascular surgery among patients with stable cardiacsymptoms cannot be recommended.

15. Kaplan-Meier Survival Curves to One Year Sandham, J. et al. N Engl J Med 2003;348:5-14

16. The Statins for Risk Reduction in Surgery (StaRRS) study • Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece • 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization • 157 complications occurred • 9.9% statin vs 16.5% non-statin O’Neil-Callahan et al JACC 2005; 336-42

17. The Statins for Risk Reduction in Surgery (StaRRS) study

18. Optimization before the OR • Pacing/ICD “Electrical” issues • Turn off ICD/magnet for VVI pacing • Valvular “Coagulation” issues • Reverse, hold or bridge warfarin • SBE prophylaxis • Myocardial “CHF” issues • PA catheter/CHF management • Coronary “ischemia” issues • Per AHA/ACC algorithm

19. Is patient high CV risk (>5%)? • Unstable coronary syndromes • Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing • Unstable or severe angina CC III or IV • Decompensated heart failure • Significant arrhythmia • High degree AV block • Symptomatic ventricular arrhythmias in the presence of underlying heart disease • Supraventricular arrhythmia with uncontrolled ventricular rate • Severe valvular disease

20. Special “surgeries”….

21. Hemodynamic changes with labor • Uterine contractions cause up to 500 cc autotransfusion • C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR) • Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change • HR, volume, CO normalize by 5-6 weeks postpartum

22. Hemodynamic changes with pregnancy

23. Classification of Valvular Heart Lesions according to Maternal, Fetal, & Neonatal Risk*

24. Areas in further need of research • Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness • Cost-effectiveness of the various methods of noninvasive testing • Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients • Establishment of optimal guidelines for selected patient subgroups, especially elderly • Establishment of monitoring guidelines in treatment decisions and outcomes

25. Aortic Stenosis

26. What is cardiology clearance? • Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management • Interdisciplinary management • Considerations in delivering the pregnant cardiac patient • Future operational strategies