Download So What`s Wrong with Vascular Surgery Anyway??

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!!