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Pre-operative Cardiovascular Evaluation: Guidelines and More Eric A. Brody MD, FACC Medical Director, NA Cardiology and Medical Services Associate Professor of Clinical Medicine University of Arizona Medical Center Objectives • Review Algorithm for Pre-op risk assessment for current guidelines • Define the roles of the cardiac/medical consultant for the non-cardiac surgery patient • Discuss “clearance” • Review the 10 commandments of the cardiac/medical consultant Mechanisms of Perioperative MI • Unique postoperative conditions lend themselves to AMI – Volume loss/Fluid Shifts – Anemia – Anxiety/Pain – Tachycardia – Temperature fluctuations – Coagulation cascade MVO2 Shear Stresses Excess Catechols Platelet Activation What Causes Perioperative MI? Surgery Patient Underlying CAD Volume Shifts Hypertension Anemia Tachycardia Medication withdrawal Anxiety/Pain Temperature fluctuation Hemostasis Acidosis Myocardial Infarction Treatment of Peri-operative MI Antithrombotic Therapy UFH/LMWH Anti-thrombins Thrombolysis Antiplatelet Therapy Medical Therapy Beta Blockers Interventional Therapy PCI/Stent Ca+ Channel. Blockers ACE inhibitors/ARB ASA GP2b3a Thienopyridines Role of the Medical Consultant • Identify co-morbidities which may complicate surgery • Airway/anaesthesia issues • Functional status of the patient • Clarify pre-op medications • Peri-procedural cardiac risk What is “Cleared”? Questions to answer. • Patients condition is optimized prior to surgery?? • Benefits outweigh risk of surgery?? • OK to proceed?? • Medical Legal considerations removed??? What is “Cleared”? • My preference- one of 2 options – “Patient is considered ______________ (low, moderate or high) risk for peri-op cardiovascular complications based on current ACC/AHA guidelines” -” My recommendations for perioperative care include…..” -”Patient requires additional testing to better clarify perioperative cardiac risk.” http://www.americanheart.org/ ACC/AHA Perioperative Guidelines Updates: October 2007 • Last revision: 2002 • Significant changes to previous guidelines • Dramatic change in perioperative evaluation algorithm. JACC 2007: vol. 50 (17) 2007 Update Perioperative Guidelines Algorithm Step 1 Need for Emergency noncardiac Surgery? No Step 2 Yes Operating Room Perioperative Surveillance and postop. Risk stratification. Risk Factor management Perioperative Guidelines Algorithm Step 2 Active Cardiac Conditions Yes Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Active Cardiac Conditions: Patients require evaluation and treatment before noncardiac surgery • Unstable Coronary Syndromes • Decompensated CHF • Significant Arrhythmias • Severe Valvular Heart disease Unstable or Severe Angina (class III or IV) or recent MI >7 days but < one month Active Cardiac Conditions: Patients require evaluation and treatment before noncardiac surgery • Unstable Coronary Syndromes • Decompensated CHF • Significant Arrhythmias • Severe Valvular Heart disease Significant Arrhythmias • High grade AV block • Mobitz II AVB • Third degree AVB • Symptomatic Vent. Arrhythmias/Bradycardia • SVT/Afib with uncontrolled rate (>100/min) Active Cardiac Conditions: Patients require evaluation and treatment before noncardiac surgery • Unstable Coronary Syndromes • Decompensated CHF • Significant Arrhythmias • Severe Valvular Heart disease Severe Valvular Heart disease • Severe Aortic Stenosis • Critical Mitral Stenosis Perioperative Guidelines Algorithm Step 2 Active Cardiac Conditions No Step 3 Yes Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Perioperative Guidelines Algorithm Step 3 Low Risk noncardiac Surgery? Yes Low Risk Surgeries Proceed with planned surgery • • • • Endoscopic Superficial Breast Most ambulatory surgeries • Cataracts/ocular Perioperative Guidelines Algorithm Step 3 Low Risk non-cardiac Surgery? No Step 4 Proceed with planned surgery Perioperative Guidelines Algorithm Step 4 Good Functional Capacity without symptoms (>4 mets) Yes Proceed with planned surgery Assessing Functional Capacity ADL’s Eat, Dress or Toilet 1 Met Walk Indoors Walk 1-2 blocks, level ground Light House Work 4 mets Assessing Functional Capacity Climb 1 flight stairs or walk uphill 4 mets Heavy Housework Walk 4 mph Run a short distance Moderate sports Strenuous Sports >10 mets Assessing Functional Capacity Another Way to look at This!! • No Clinical Risk Factors and Low or intermediate risk surgeries with good functional capacity may proceed directly to the OR. Perioperative Guidelines Algorithm Step 4 Good Functional Capacity without symptoms (>4 mets) No or Unknown Step 5 Yes Proceed with planned surgery Clinical Risk Factors Step 5 • • • • • Ischemic Heart Disease Compensated or Prior CHF DM (insulin requiring) Renal Insufficiency (creat. >2.0) Cerebrovascular Disease Lee et al. Circulation. 1999;100:1043- Percent Revised Cardiac Risk Index AAA Other Vascular Thoracic Abdominal Orthopedic Procedure Type Other Perioperative Guidelines Algorithm Step 5 No Clinical Risk Factors Proceed with planned surgery Perioperative Guidelines Algorithm Step 5 Class IIa, LOE B Intermediate Risk Surgery 1 or 2 Clinical Risk Factors Vascular Surgery Proceed to OR with HR control or Consider Non invasive testing Class IIb, LOE B Cardiac Risk Stratification: High Risk Procedures • Reported Cardiac Risk often >5% – Emergent major operations, particularly in elderly patients – Aortic and other major vascular – Peripheral vascular – Anticipated prolonged procedures with large fluid shifts or blood loss Cardiac Risk Stratification: Intermediate Risk Procedures • Reported cardiac risk generally <5% – Carotid endarterectomy – Major head and neck, especially for CA – Intraperitoneal and intrathoracic – Orthopedic, especially in elderly – Radical prostatectomy Perioperative Guidelines Algorithm Step 5 Intermediate Risk Surgery 3 or more Clinical Risk Factors Vascular Surgery Proceed to OR with HR control or consider Non invasive testing Consider Noninvasive testing Class IIa, LOE B TYPE of Surgery http://www.surgicalriskcalculator.com/miorcardiacarres On line tool to calculate patient and procedure specific risk for planned surgery ACC/AHA Perioperative Guidelines Updates: October 2007 Miscellaneous ACC/AHA Perioperative Guidelines Updates: October 2007 • Who Needs an ECG?? • Undergoing Vascular surgery (one or more clinical risk factors) Class I • Undergoing Vascular Surgery (no risk factors) IIa • Intermediate risk surgery with established CVD (CAD, PVD, Cerebrovascular disease) Class I • Intermediate Risk surgery with one or more clinical risk factors ACC/AHA Perioperative Guidelines Updates: October 2007 • Who Needs an ECG?? – CLASS III- ECG not needed in asymptomatic patients undergoing low risk surgical procedures. Recommendations for Statin Therapy ACC/AHA Perioperative Guidelines Updates: October 2007 • Class I- (LOE B) – Patients taking statins should be continued on this therapy at time of non-cardiac surgery Best Treatment of Perioperative MI Conclusions: Ways to Avoid Cardiac Complications • Know the Patient’s History – Prior MI or known CAD – Prior CHF and LVEF – Renal Failure/ baseline Creatinine – History of significant Valvular heart disease • Stenosis > regurgitation Conclusions: Ways to Avoid Cardiac Complications • Know what your surgeons and anesthesiologists did – Speak with them directly to coordinate perioperative care. – Blood loss/serial hematocrits – Fluid resuscitation – Check the post op orders yourself Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 • Our own insecurities – Long history of “clearance” performed by cardiologists • Changing the Culture – Surgeons – Anesthesiologists Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 • Getting the surgeons to listen to peri-operative recommendations – “You lost me at ‘Cleared’…..” – Importance of continuing statin therapy and beta blocker therapy in those already taking these medications Conclusions: Ways to Avoid Cardiac Complications • Know the patients’ medications – Continue Beta Blockers if on these preoperatively – Prophylactic beta blockade is not indicated in all patients Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 • The “Business” of stress testing and preoperative evalutation • Who’s going to pay? Preoperative Evaluation Keep it simple!!