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Epidemiology of Noncardiac Surgery Dr. Mohammed Naser Overview • Important Decision points: – Urgent vs Elective Surgery – High risk surgery vs intermediate vs low -Active Cardiac Condition vs non-active Functional capacity on basis of pt ablility To perform certain activities The Search For High Risk Methods for Assessing Risk Pre-Operatively Is the surgery emergency PROCEED and manage post operatively according to AHA& ACC guidelines If the surgery emergency..?? Active/Major Cardiac Conditions • Unstable Coronary Conditions • Decompensated CHF • Significant arrhythmias (i.e. 3⁰HB, new Vtach) • Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)??????? Non-Active Cardiac Factors • Intermediate Risk • Hx of CHD • History of prior CHF • Hx of stroke • Diabetes • Renal insufficiency * Not associated with cardiac risk • • • • • Minor Risk* Age > 70 Abnormal ECG Nonsinus rhythm Uncontrolled systolic BP Six Independent predictors of cardiac risk 1) ischemic heart disease 2) congestive heart failure 3) cerebrovascular disease 4) high risk surgery (AAA, orthopedic sx) 5) pre-operative insulin tx for diabetes 6) preoperative creatinine for creat > 2 mg/dL Lee et al Functional capacity Functional Capacity • Functional status has shown to be a reliable periop and long-term predictor of cardiac events • MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest • Periop risk is increased if person cannot > 4 METS 1 MET 4 MET 10 MET The Trump Card: Functional Capacity • Perioperative cardiac risk is increased in patients unable to exercise 4 METs • Functional capacity can be estimated in the office – Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs – Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs – Swimming and singles tennis exceeds 10 METs Surgery Risk Type Type Cardiac risk examples High > 5% Aortic, peripheral vasc sx Intermediate risk 1-5% Intraperitoneal Intrathoracic Carotid End Head and neck Orthopedic Sx Prostate Sx Low <1% Endoscopic procedures Superficial Cataract Sx Breast Sx Ambulatory Sx Surgery-Specific Risk: High Risk* • Major emergency surgery • Vascular surgery including: aortic surgery, infra-inguinal bypass • Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5% Stepwise Approach • Step 1: Determine urgency of surgery • Step 2: Active cardiac condition?-→test • Step 3: Undergoing low-risk surgery? < 1%* • Step 4: Good functional capacity? * Combined morbidity and mortality < 1% even in high risk patients The Catheterization Questions to Ask Yourself • Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now? • Am I willing to send the patient to CABG? • Am I doing this just to know the anatomy? Is pre-op coronary revasc advantageous? • If high risk surgery and patient has active cardiac issue • Functional test and perfusion Imaging and if • L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op STENTS If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after If received DES.... – 1) postpone sx until > 12 months, – 2) do sx on both asa+clop – 3) do sx on single ap tx Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended Medical tx 1) beta blockers-if on keep them if not.... 2) Statins continue, ? Start -need randomized trials Other Issues • DVT/PE prophylaxis • Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B) • No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes • Routine troponin monitoring not recommended Surveillance for Perioperative Myocardial Infarction • ECGs –All intermediate and high-risk patients should get a post-op ECG. –As need for signs or symptoms of ischemia • Troponin / CK –In patients with signs or symptoms of ischemia –Do not do screening biomarkers High Risk Features • Severe obstructive or restrictive pulmonary disease • Diabetes • Renal impairment • Anemia, polycythemia, thrombocytosis PCI pre-op • ST-elevation MI • Unstable angina • Non ST elevation MI 2007 ACC/AHA Perioperative Guidelines Take Home Messages Take Home Messages • Unstable syndromes require management prior to surgery. Look for – Unstable angina – Signs of heart failure – Stenotic valve lesions – Ventricular arrhythmias • Functional tolerance is the best single predictor of outcome • Be very specific in your history (one step at at time, regular or slow pace, etc) • If patient on beta blockers & statins continue them, more trials to mandate them • PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.