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PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009

PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. What is the appropriate cardiac evaluation?. Case #1

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PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009

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  1. PreOperative Cardiac ClearanceGME Chief RetreatSeptember 2010August 5th, 2009 AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

  2. What is the appropriate cardiac evaluation? Case #1 A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

  3. Case #1Should this patient get a cardiac stress test? • Yes • No 10

  4. What is the appropriatecardiac evaluation? Case #2 An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

  5. Case #2Should this patient get a cardiac stress test? • Yes • No 10

  6. What is the appropriatecardiac evaluation? Case #3 A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

  7. Case #3Should this patient get a cardiac stress test? • Yes • No 10 Slide 7

  8. Cardiac PreOperative Evaluation AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation for Non-cardiac Surgery • Clinical Cardiac Risk Factors • Operative Risk • Functional Capacity Circulation (2007) 116:1971.

  9. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No OR = operating room

  10. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Active Cardiac Condition STEP 2

  11. CLINICAL RISK FACTOR ASSESSMENT • Major Risk Factors • Unstable coronary syndromes • Unstable/severe angina • Recent MI • Decompensated CHF • Significant arrhythmia • Severe valvular disease Circulation (2007) 116:1971.

  12. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No

  13. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Low-Risk Operation STEP 3

  14. OPERATION RISK STRATIFICATION Circulation (2007) 116:1971.

  15. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No

  16. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low Risk Operation STEP 3 OR No STEP 4 Functional Capacity  4 METs

  17. METABOLIC EQUIVALENTS Can you… Take care of yourself? Eat, dress, toilet? Walk a block or two at 3 mph? Do light work around the house like dusting or washing? Can you… Climb a flight of stairs? Walk at 4 mph? Do heavy housework (scrubbing, lifting)? Participate in strenuous sports (swim, football, ski)? 1 MET 4 METs 4 METs >10 METs Circulation (2007) 116:1971.

  18. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Consider OR Active Cardiac Condition Non-Invasive Stress Test / Treat STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR No/Unknown

  19. Circulation (2007) 116:1971. Yes Emergency Operation? STEP 1 OR No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors

  20. CLINICAL RISK FACTOR ASSESSMENT • Other Risk Factors • History of heart disease • Compensated prior CHF • Prior cerebrovascular disease • Diabetes mellitus • Renal insufficiency • Major Risk Factors • Unstable coronary syndromes • Unstable/severe angina • Recent MI • Decompensated CHF • Significant arrhythmia • Severe valvular disease Circulation (2007) 116:1971.

  21. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors OR

  22. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors 1. Proceed with planned surgery with HR control 2. Consider non-invasive testing OR

  23. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors Intermediate Risk Vascular Surgery Consider testing Consider treating 1. Proceed with planned surgery with heart rate control 2. Consider non-invasive testing OR

  24. Coronary Revascularization Prior to Surgery? Coronary Artery Revascularization Prophylaxis (CARP) Trial • 510 patients prior to major vascular surgery • ≥ 70% stenosis of 1 or more coronary arteries • Randomized to receive: • Revascularization prior to surgery • No revascularization prior to surgery NEJM (2004) 351:2795.

  25. Coronary Revascularization Prior to Surgery? Coronary Artery Revascularization Prophylaxis (CARP) Trial NEJM (2004) 351:2795.

  26. Coronary Revascularization Prior to Surgery? Coronary Artery Revascularization Prophylaxis (CARP) Trial NEJM (2004) 351:2795.

  27. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors Intermediate Risk Vascular Surgery Consider testing Consider treating 1. Proceed with planned surgery with heart rate control 2. Consider non-invasive testing OR Slide 27

  28. PeriOperative Beta-Blockade • Dosing 30 minutes prior and immediately post-op • IF HR  55 and SBP  100 AND no evidence of CHF, 3º heart block, bronchospasm • THEN • Atenolol 5 mg IV over 5 minutes • Wait for 5 minutes • If HR and SBP criteria still met, repeat dose once NEJM (1996) 335:1713.

  29. PostOperative Beta-Blockade • Intravenous (twice-daily dosing) • Same dosing as perioperative protocol • OR • Oral (once-daily dosing) • If HR  65 and SBP  100, then atenolol 100 mg • If HR  55 and SBP  100, then atenolol 50 mg • Continue until discharge or 7 days post-op NEJM (1996) 335:1713.

  30. Evidence for Beta-Blockade NEJM (1996) 335:1713.

  31. What is the appropriatecardiac evaluation? Case #1 revisited A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

  32. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors Intermediate Risk Vascular Surgery Consider testing Consider treating 1. Proceed with planned surgery with heart rate control 2. Consider non-invasive testing OR Slide 32

  33. What is the appropriatecardiac evaluation? Case #2 revisited An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

  34. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors Intermediate Risk Vascular Surgery Consider testing Consider treating 1. Proceed with planned surgery with heart rate control 2. Consider non-invasive testing OR Slide 34

  35. What is the appropriatecardiac evaluation? Case #3 revisited A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

  36. Circulation (2007) 116:1971. Yes Emergency Operation? OR STEP 1 No Yes Active Cardiac Condition Non-Invasive Stress Test / Treat Consider OR STEP 2 No Yes Low-Risk Operation STEP 3 OR No STEP 4 Yes Functional Capacity  4 METs OR STEP 5 No/Unknown  3 Clinical Risk Factors 1 or 2 Clinical Risk Factors No Clinical Risk Factors Intermediate Risk Vascular Surgery Consider testing Consider treating 1. Proceed with planned surgery with heart rate control 2. Consider non-invasive testing OR Slide 36

  37. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society

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