Preoperative Evaluation of Cardiac Patient for Noncardiac surgery

1. Preoperative Evaluation of Cardiac Patient for Noncardiac surgery Dr BalajiAsegaonkar MD,DNB (Anaesthesia) Consultant cardiac anaesthesiologist Ozone Anaesthesia Group, Aurangabad.

2. CASE 1 • 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD • ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTS • ON DUAL ANTIPLATELATE AGENTS • TO BE POSTED FOR TURP

3. CASE 2 • 70 YR MALE ,HYPERTENSIVE, DIABETIC & SEVERE OSTEOARTHRITIS. • SMOKER FOR LAST 30 YRS. • TO BE POSTED FOR TKR

4. CASE 3 • 80 YRS MALE, HT, IHD- POST PLASTY, • POOR EFFORT TOLERANCE • EF 25 % • TO BE POSTED FOR CATARACT

5. Let’s face it… • The surgical population is older, sicker, on more medications, and having more & more cardiac interventions. • There is a subset of your patients for whom the patient, the surgeon, or you may have questions about cardiovascular risk.

6. So what do you do? • Guess?…Argue?…Worry?…Refer everyone cardiological investigations • OR do a thorough, focused exam. • Followed by the individualized application of some authoritative guidelines… • …for evaluation, risk stratification, and management… • …and refer, delay, or cancel only when appropriate.

7. Authoritative guidelines…..? • Evidence based medicine. • Based on research findings, expert opinion, and consensus . • Cardiovascular authority, like American College of Cardiology/American Heart Association. • Anaesthesiology authority, like ASA.

8. Objectives: • How to approach cardiac Patients. • Risk stratification. • Modification of level of care. • Discuss standard recommendation.

9. focused approach……… • We are not cardiologists, We simply need to recognize when a cardiac condition might affect the patient’s response to anaesthesia, and what to do about it. We need to be: • Thorough enough to find all significant problems (sensitivity). • Focused enough to consider only significant problems (specificity).

10.  …and Stepwise Approach? • Thorough, focused cardiac evaluation • ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery (2007). • Indicated cardiac testing and consultation. • Optimization of cardiovascular function in relation to the demands of the surgery and the anaesthesia.

11. The courage is knowledge of how to fear what ought to be feared & how not to fear what ought not to be feared.

12. Applying Classification of Recommendations and Level of Evidence Level of Evidence:

13. So, let’s start with … • The Preop portion of the ACC/AHA Guidelines, which is based on your history and physical, plus indicated tests.

14. Guidelines : Stepwise approach • Need for surgery:Emergentvs Urgent/Elective. • Clinical Risk Predictors: (Major, Intermediate, Minor). • Functional capacity (Exercise tolerance).

15. ACC/AHA Guidelines: Preop • Surgical Risk Predictors: (High, Intermediate, Low) • Recent coronary revascularization or Evaluation.

16. Major Clinical Risk Predictors • Unstable Coronary Syndromes: • Recent MI (> 7 and < 30 days). • Unstable angina (Canadian Class III-IV). • Decompensated CHF. • Significant Dysrhythmias. • High-grade AV block. • Symptomatic ventricular dysrhythmias. • Supraventricular dysrhythmias with uncontrolled ventricular rate. • Severe Valve Disease.

17. Intermediate Clinical Risk Predictors • Mild angina (Canadian Class I - II). • Prior MI by history or pathological Q waves. • Compensated or prior CHF. • Diabetes, especially IDDM. • Renal Insufficiency (creatinine > 2mg%).

18. Minor Clinical Risk Predictors • Advanced age. • Abnormal ECG (LVH, LBBB, ST-T abnl). • Rhythm other than sinus (e.g. a-fib). • Low functional capacity (< 4 METs). • Hx CVA. • Uncontrolled HTN (>180 / >110).

19. Cardiac Functional Classification:Canadian Cardiovascular Society • No angina with ordinary physical activity . Angina with strenuous exertion. II. Slight limitation of ordinary activity. III. Marked limitation of ordinary activity. IV. Inability to carry on any physical activity without discomfort. Angina may be present at rest.

20. Functional Capacity = Exercise Tolerance • Major clinical risk predictors are sufficient alone to trigger further testing or intervention before pt posted for Sx. • Intermediate and minor clinical risk predictors are subject to a second step: • Evaluation of cardiovascular functional capacity, i.e., exercise tolerance.

21. Exercise Tolerance • Angina or anginal equivalents (DOE, palpitations, fatigue)= Ischemic threshold. • Point where metabolic demand > supply • Metabolic equivalent (MET): 1 MET = resting O2 consumption(VO2) = 3.5mL/kg/min • Functional capacity in METs: • Poor: < 4 • Mod: 4-7: > 4 is the “tipping point”. • Good: 7-10. • Excellent: > 10.

22. Exercise Tolerance in METs • 1 MET: Eat, dress, use the toilet. • 2 METs: Household ambulation. • 3 METs: Light housework. Walk level ground 2-3 MPH. • 4 METs: Walk up one flight stairs. Walk level ground 4 MPH. • 4-10 METs: Run short distance. Scrub floors, move furniture. Moderate sports. • >10 METs: Strenuous sports.

23. Surgical Risk Predictors • High (> 5% Cardiac Death/MI).Emergent major operation, espec. in elderly, Aortic and other major vascular Sx Peripheral vascular,Prolonged procedure. • Intermediate (< 5%). Carotid endarterectomy, Head & neck Intraperitoneal, Intrathoracic, Prostate, Ortho • Low (< 1%). Endoscopic, Superficial, Cataract, Breast

25. Procedure Details : Angioplasty • Time since procedure. • Which artery. • Present medication. • Symptoms benefits. • Baseline ECG. • Which stents.

26. DRUG ELUTING STENT • ANTICACER DRUGS COATED. • SLOW RELEASE TILL 6 TO 8 MONTH. • NO ENDOTHELIAZATION. • LEAST CHANCE OF INSTENT THROMBOSIS • ANTIPLATELETS

27. Post plasty :Noncardiacsurgery

28. Treatment for patients requiring PCI who need subsequent surgery

29. Procedure Details : CABG • Time since procedure. • Which arteries grafted & Type of conduit. • Present medication. • Symptoms benefits. • Baseline ECG

30. Recommended stepwise approach • STEP 1: • How urgent noncardiac surgery is ? • p/o risk stratification & assessment done. • All these are Gr V cases.

31. Step 2 • Has Pt undergone coronary revascularisation in past 5 yrs ? • If yes & Pt has no s/s of cardiac problem – further detail cardiac testing not required.

32. Step 3 • If Pt has any coronary evaluation in past 2 yrs – revealing no significant CAD ,if there is no aggravations of s/s –no further testing is needed.

33. Step 4 • Does Pt have any major clinical predictors ? • Delay noncardiac surgery until problem has identified & treated.

34. Step 5 • If Pt have intermediate clinical predictors. • Consider functional capacity & surgery specific risks. • Decide accordingly weather further testing needed or not.

35. Step 6 • Pt with intermediate predictor & mod to excellent functional capacity can undergo intermediate Sx. • Pt with 2 or more intermediate predictor & poor functional capacity OR mod functional capacity but high risk Sx – further testing & evaluation needed.

36. Step 7 • Noncardiac Sx safe in Pt with minor clinical predictor & mod to excellent functional capacity. • Additional testing must for Pt with no clinical predictors but poor functional capacity & who are facing high risk Sx.

37. CASE 1 • 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD • ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTS • TO BE POSTED FOR TURP

38. CASE 2 • 70 YR FEMALE ,HYPERTENSIVE & SEVERE OSTEOARTHRITIS. • CABG DONE 2 YRS BACK ON ANTIPLATE, ANTI HT & STATINS • TO BE POSTED FOR TKR

39. CASE 3 • 80 YRS MALE, HT, IHD- POST PLASTY, • POOR EFFORT TOLERANCE • EF 25 % • TO BE POSTED FOR CATARACT

40. Thanks....!

43. Step 8 • In documented CAD , if risk of coronary interventions or CABG exceeds proposed noncardiac Sx & if such Sx improves long term prognosis of Pt – noncardiac Sx should be done.

48. Summary from ACC / AHA • Perioperative evaluation and mgmt of high-risk cardiac patients for noncardiac surgery requires careful teamwork and communication between patient, surgeon, anesthesiologist, physian or cardiologist. • Indications for cardiac testing and treatments are the same as in the non-operative setting, and should clearly affect patient management. • Factors include the urgency of surgery, patient-specific risk factors, and surgery-specific considerations.

49. Summary • For many patients, noncardiac surgery represents their first opportunity for assessment of short- and long-term cardiac risk. The consultant best serves the patient by making recommendations aimed at lowering the immediate perioperative cardiac risk, as well as assessing the need for postoperative risk stratification and interventions directed to modify cardic risk factors. • Future research should be directed at determining the value of routine prophylactic medical therapy vs. more extensive diagnostic testing and interventions.

50. Proposed Approach to the Management of Patients with Previous PCI Who Require Noncardiac Surgery Previous PCI Balloon Drug-eluting Bare-metal angioplasty stent stent <365 days >30- 45 days >365 days <30- 45 days >14 days Time since PCI <14 days Delay for elective or Proceed to the Delay for elective or Proceed to the nonurgent surgery operation room nonurgent surgery operating room with aspirin with aspirin PCI, percutaneous coronary intervention