MORNING REPORT Travante Cartwright M.D. August 31 st , 2010

1. MORNING REPORT Travante Cartwright M.D. August 31st, 2010

2. CC: “my eye doctor said I needed to see you” 67 yo male presents to outpatient office for pre-op evaluation • No exertional CP, DOE, SOB, palpitations, dizziness, LH, chest pressure • No orthopnea, PND • No LE edema • Exercises three times weekly for 30-45min using exercise bike: no related cardiovascular complaints; plays singles tennis • Compliant with medications; BP controlled at home

3. Past Medical History • Hypertension • Mixed Hyperlipidemia • CAD s/p MI 2002 with BMS to pLCX • “borderline” diabetic • Asthma • Remote history of GI Bleed • Anemia

4. Social History • Retired accountant • Lives with wife • Has 3 adult healthy children • Occasional EtoH; Approx 2 per week • No tobacco • No illicit drugs • Actively exercises

5. Review of Systems • Positive • Nasal congestion • Constipation • Otherwise all systems negative

6. Medications • Metoprolol 25 every 12 hours (twice daily) • Aspirin 81mg • Lisinopril 10mg daily • Pravastatin 80mg daily • Lovaza 1000mg every 12 hours (twice daily) • Iron sulfate 325mg every 8 hours (three times daily)

7. Physical Exam T 97.3F BP 128/74 HR 71 RR 14 Gen: NAD, AAOx3, Non-focal Head: NCAT Neck: Supple; No JVD; Carotid upstrokes 2+ B/L without evidence of bruit Heart: Undisplaced and normal PMI Normal S1S2, Regular Rate No appreciated murmurs/rubs/gallops Lungs: Clear to ascultation B/L; No W/R/R Heart: S1S2, RRR, No M/R/G appreciated Abdomen: Soft, Non-tender, Non-distended, Bowel sounds present No appreciable abdominal pulsations or bruits Extremities: No LE edema; Distal pulses intact (Radial, DP, PT)

8. Lab Data 137 104 21 Ca 9.2 109 Mg 2.2 4.1 23 1.0 Phos 4.5 12.9 8.0 313 34.1

9. Data Cont’d • EKG: NSR at 67 beats per minute with poor precordial R wave progression and nonspecific T wave abnormalities; similar to EKG November 2009 • Nuclear Stress Test performed on June 15, 2009: patient obtained stage IV of Bruce protocol achieving 12 METS of metabolic activity, reaching 112% of maximal predicted heart rate and showed no perfusion abnormalities • Echocardiogram (6/09): Mild global left ventricular dysfunction with an EF of 50-55%, moderate RV dilatation with mild RV dysfunction in the presence of a normal estimated right ventricular systolic pressure. No valvular abnormalities. He had no major valvular abnormalities.

10. “Cardiac Clearance” • Truly a misnomer • Actually pre-operative risk stratification to reduce risk of cardiac complications of non-cardiac surgery • You cannot “clear a patient” from cardiac risk, the goal is to reduce cardiac risks

11. The Facts • Patients undergoing MAJOR non-cardiac surgery have risk of CV morbidity and mortality • Peri-operative complications have declined over the past 25-30 years as a result of improved surgical techniques and anesthesia but peri-operative cardiac complications remain a significant problem • Europe: 40 million surgical procedures are performed annually; post-operative myocardial infarction rate of ~1% (400,000) and a CV mortality rate of 0.33% (133,000).

12. The Facts Cont’d • Per the World Health Organization the epidemic of CV disease will both increase and shift to developing countries from developed nations • 1 in 4 individuals in the second half of the 21st century will be > 65 years of age • Patient in their 80s and 90s are routinely undergoing surgery and studies have shown that the rate of cardiac events increased with advancing age, independent of other clinical variables in patients with myocardial perfusion abnormalities during stress scintigraphy

13. Initial Pre-Operative Evaluation • Clinician must integrate information from the history, PE, electrocardiogram in order to develop an initial estimate of peri-operative cardiac risk • The American College of Cardiology/American Heart Association (ACC/AHA) determined three elements that should be assessed for peri-operative CV evaluation for non-cardiac surgery to stratify risk:

14. Three elements: 1. Patient Risk • Patient Specific Variables aka Patient Risks • Major predictors that may lead to delay/cancellation unless emergent • Unstable coronary syndromes • Unstable angina • Severe angina • Recent MI • Decompensated heart failure • Class IV • Worsening or new onset HF • Significant arrhythmias • High grade AV Block • Symptomatic ventricular arrhythmias / Supraventricular arrhythmia with vent rate >100 / new Ventricular Tachycardia • Symptomatic bradycardia • Severe heart valve disease (Aortic Stenosis / Symptomatic Mitral Stenosis) • Other Clinical predictors that warrant assessment • Hx of Ischemic Heart dz, Cerebrovascular disease, compensated HF, DM, Renal Insufficiency • Minor risks: Age > 70, Abnormal EKG, non-sinus rhythm, uncontrolled htn

15. Patient’s Risk

16. Three elements: 2. The Procedure • Surgery Specific Risk • High Risk (reported risk of cardiac death or non-fatal MI often) • Aortic / Vascular / Peripheral Artery Surgery • Intermediate Risk (reported risk of cardiac death or non-fatal MI 1 to 5 percent) • CEA / Head and Neck Surgery • Intraperitoneal and Intrathoracic Surgery • Orthopedic and Prostate Surgery • Low Risk (reported risk of cardiac death or non-fatal MI less than 1 percent) • Ambulatory/ Endoscopic / Superficial Procedures • Cataract and Breast Surgery

18. Three elements: 3. Exercise Capacity • Functional Capacity: patients with good functional status have lower risk of complications • 1 MET = 3.5 mL O2 uptake/kg per min = resting O2 uptake while sitting • Takes care of self; eat, dress, use toilet = 1 MET • Walk up flight of steps or hill = 4 METs • “Heavy” house work eg scrubbing floors, lifting or moving heavy furniture = 4 – 10 METs • Strenuous sports eg swimming, singles tennis, football, basketball = > 10 METs **Peri-op and long term risk is increased in patients unable to achieve 4 METs**

20. History • Detailed history of patient’s symptoms, clinical course and exercise tolerance • Previous coronary heart disease • Symptoms of angina • Symptoms of heart failure • Aortic stenosis • Hypertension • Peripheral artery disease

21. Physical Exam • BP measurement both arms • Analysis of carotid artery and jugular venous pulsations • Auscultation of the lungs • Precordial palpation and cardiac auscultation • Abdominal palpation • Examination of extremities for edema and vascular integrity ** assess for HF, murmurs (especially AS) **

22. EKG • Resting EKG as Q waves, ST elevation or depressions are associated with increased peri-operative cardiac complications • 12 lead EKG is reasonable in all obese patients who have at least one risk factor: • Diabetes • Hyperlipidemia • Hypertension • Tobacco • Poor exercise tolerance

23. ACC/AHA guidelines recommend peri-operative 12-lead EKG in the following patients:

24. Labs / Studies • CXR if clinically indicated or has underlying pulmonary disease • Lab work as needed – eg concerns for Anemia

25. Cardiac Risk Indices • Goldman Risk Index • Revised Cardiac Risk Index • Detsky Modified Risk Index • Eagle Criteria • Flesher-Eagle Criteria

26. Revised Cardiac Risk Index

27. Non Invasive Cardiac Testing • Stress testing has high negative predictive value (90 to 100 percent) but low positive predictive value (6-67 percent) • Exercise is the preferred stress • Pharmacological stress testing can be used in patients who cannot exercise • DECREASE-II Trial • 770 patients with intermediate risk (one to two RCRI risk factors) • Major Vascular Surgery: AAA or PAD • Randomly assigned to pharmacologic stress testing or no testing • All patients received perioperative beta blockade with goal HR 60-65 • Incidence of primary end point of cardiac death or non fatal MI at 30 days was similar: 1.8 vs 2.3 percent, Odds ratio 0.78, 95% CI • END RESULT: preoperative stress testing can be safely omitted in intermediate risk patients who have stable or no clinical coronary disease, where beta blockade has achieved tight HR control

28. Green bars:non invasive stress testing no recommended Orange bars: consider testing if it will change management Red bar: class IIa recommendation for non invasive stress testing ACC/AHA = American College of Cardiology/American Heart Association. Data from Fleisher et al..

29. Cardiac Evaluation and Care Algorithm for Noncardiac Surgery Based on Active Clinical Conditions, Known Cardiovascular Disease, or Cardiac Risk for Patients 50 Years of Age or Greater American College of Cardiology Foundation, et al. J Am Coll Cardiol 2009;54:e13-e118

30. Revascularization • The vast majority of studies reveal poorer outcomes in patients who undergo surgery after revascularization • If PCI with stenting is indicated: Bare Metal Stent with approximate 30 day delay as opposed balloon angioplasty alone without stenting • Stopping Clopidogrel (Plavix) prematurely for surgery confers great risk

32. CARP Trial • Coronary Artery Revascularization Prophylaxis trial • Randomized comparison of pre-op revascularization (PCI or CABG) vs medical therapy in patients undergoing major vascular surgery with stable coronary disease • 5859 total patients; 1190 of which were of increased cardiac risk who then… • Underwent coronary angioplasty and 680 patients excluded because of Left Main disease, severely depressed LV dysfunction, severe AS or coronary anatomy not suitable for revascularization • 510 remained and were either revascularized or received medical RX

33. CARP Trial Cont’d • 49% of the 510 had RCRI > or = 2 and 13% had > or = 3 • 2/3 study had one or two vessel disease • Of those revascularized • 41% underwent CABG • 59% underwent PCI • RESULTS: • no differences in LVEF between two groups ie Medical RX vs Revascularization at 3 months • At 2.7 years all course mortality was not significantly different: 23% (med) vs 22% (RVN)

34. CARP TRIAL

35. Perioperative Beta Blockers • Previously thought to be beneficial for all patients • Now concerns are present especially in low risk patients • Recommendations: • If currently taking beta blockers – continue them (I/C) • If stress test revealed ischemia and will undergo vascular surgery – start them (I/B) • Those at higher risk who are undergoing intermediate or high risk procedures should probably receive beta blockade (IIa/B) • Goal: start ahead of time with target HR of approximately 60

36. Perioperative Beta Blockers Cont’d • POISE TRIAL: Lancet 2008 • >8300 patients for non-cardiac surgery (~42% vascular surgery) • Randomized: 100mg metoprolol ER vs placebo given two to four hours pre-op AND repeated zero to six hours post operatively THEN 200mg of metoprolol or placebo for 30 days • Endpoints: CV death, Non fatal MI, Non fatal cardiac arrest • Results: BB group had significant decrease in primary endpoints 5.8 vs 6.9 percent; driven primarily be decrease in MI BUT: • Total Mortality increased in BB group 3.1 vs 2.3 percent • Stroke increased in BB group 1.0 vs 0.5 percent

37. References • Fleisher LA, Beckman JA, Brown KA, et al 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade incorporated into the ACC/AHA 2007 Guidelines on perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery • Andreoli TE et al; Cecil Essentials of Medicine, 7th edition, Saunders Elsevier, Philadelphia 2007 • Bai J, Hashimoto J, Nakahara T, Suzuki T, Kubo A. Influence of ageing on perioperative cardiac risk in noncardiac surgery Age Ageing 2007;36:68-72 • Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) J Am Coll Cardiol 2007;50:e159-e241 • Iakovou, I et al. Incidence, Predictors, and Outcome of Thrombosis After Successful Implantation of Drug-Eluting Stents JAMA 2005; 293:2126-2130. • Kasper DL et al: Harrison’s principles of internal medicine (17th ed.). McGraw-Hill, New York 2008 • Mangano, DT, Goldman, L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333:1750 • POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839-1847