Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Perioperative Cardiovascular Evaluation SooJoong Kim, MD, PhD. Department of Cardiology, Internal Medicine, Kyunghee University Medical Center 30 million pt. with surgery : CAD or risk factors in 1/3 One million op. complicated by adverse C-V events high risk populations(vascular op.) : periop. MI in 34% (mortality rate 25%) Perioperative cardiac evaluation What is the risk of cardiac complications during & after surgery? How can that risk be reduced or eliminated ? Role of Medical Consultant Preoperative assessment Identification of modifiable risk factors Optimization of the condition of pt. for op. Prompt, Precise, & Thorough Written recommendation – overlooked Communication & timely follow-up Accurate Clinical criteria : significant predictors of adverse cardiac outcomes Efficient Each clinical variable adds independent & useful information to overall risk assessment Timely So as not to unnecessary delays in decision to perform or postpone the planned surgery Accurate stratification of patients into lower and higher risk groups Risk evaluation Are there interventions to reduce risk ? Do these interventions expose the patient to potential harm or cause unnecessary delays in surgery ? Does the benefit of the intervention justify the risks ? Availability of effective interventions Ix. for further cardiac testing & tx. : Same as in non-op. setting timing is dependent on the urgency of noncardiac surgery the patient’s risk factors Specific surgical considerations. Preoperative testing should be limited to circumstances in which the results will affect treatment and outcomes. Perioperative evaluation Patient-specific Procedure-oriented Time-focused Cardiovascular risk assessment Preop. evaluation : focus on C-V system Cardiac events : primary cause of death after op. Thorough examination for occult CAD Optimization of existing CAD Op. performed safely, even in significant cardiac disease Cardiovascular risk assessment Significant postop. cardiac events Unstable angina MI Pulmonary edema Serious arrhythmias (VT, VF) Cardiovascular risk assessment Goldman & colleagues Nine risk factor index (Hx, P/Ex, ECG, activity level, Lab, type of op.) Mangano & Goldman Five independent preop. clinical predictors of postop. myocardial ischemia HTN, ECG-LVH, DM, CAD, digoxin use Jeffrey & colleagues / Zeldin Underestimation of risk of C-V events in major abdominal aortic op. Overestimation of cardiac Cx. in high risk pt. Cardiovascular risk assessment Six independent predictors of cardiac complications high-risk surgery (procedures with a 5% or higher risk of cardiac complications, such as vascular and prolonged intraperitoneal or intrathoracic operations) history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin preoperative serum creatinine > 2.0 mg/dL. rates of major cardiac complications 0, 1, 2, or 3+ criteria 0.5%, 1.3%, 4%, and 9%, Lee TH, et al. Circulation 1999;100:1043 – 1049. Cardiovascular risk assessment ACC/AHA Consensus 1. Clinical markers or predictors (pt.-specific) Angina, previous MI, CHF, DM major, intermediate, minor groups 2. Level of functional capacity 4 MET poor functional capacity : a/w cardiac event after op. 3. Surgery specific risks Cardiovascular risk assessment Clinical predictors of periop. C-V risk Major clinical predictors 1. Unstable coronary syndromes Acute (< 7D) or recent(7~30) myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina (Canadian class III or IV) 2. Decompensated heart failure 3. Significant arrhythmias 4. High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Cardiovascular risk assessment Clinical predictors of periop. C-V risk Intermediate clinical predictors 1. Mild angina pectoris (Canadian class I or II) 2. Previous myocardial infarction by history or pathological Q waves (>1M) 3. Compensated or prior heart failure 4. Diabetes mellitus (particularly insulin-dependent) 5. Renal insufficiency (> 2mg/dL) Cardiovascular risk assessment Clinical predictors of periop. C-V risk Minor clinical predictors 1. Advanced age 2. Abnormal ECG (LVH, LBBB, ST-T abnormalities) 3. Rhythm other than sinus (e.g., atrial fibrillation) 4. Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) 5. History of stroke 6. Uncontrolled systemic hypertension Cardiovascular risk assessment Level of functional capacity 4 MET Perioperative cardiac and long-term risks increased in patients < 4-MET Cardiovascular risk assessment Surgery specific risks Cardiac risk > 5% Cardiac risk 1~5% Cardiac risk < 1% Cardiovascular risk assessment Surgery specific risks ACC/AHA Guidelines (<2 yr) ACC/AHA Guidelines ACC/AHA Guidelines ACC/AHA Guidelines Preoperative evaluation Hx. taking & physical examination Lab. & specialized testing ECG : arrhythmia, high-degree AVB, LVH a/w adverse outcome Recent MI (<1M) Unstable angina CHF or S3 aggressive preoperative medical tx. (pul. edema risk : x5) Severe valvular disease (AS) stroke, MI, arrhythmia, acute HF Preoperative evaluation Duration & severity of DM & HTN, stroke Hx. adverse perioperative cardiac events DBP > 100 mmHg should be controlled before op. Advanced age : indirect marker of surgical cardiac risk Role of specialized testing Ambulatory ECG : assess of silent ischemia : assess of arrhythmia Echocardiography : assess of LV resting fx. Performed when HF suspected : assessment of valvular heart dis. Exercise or pharmacologic stress testing with imaging : detection of occult CAD : estimate of functional capacity Expensive, subjective(interpreter-dependent) Stress ECG with imaging reliable tool for CAD & functional capacity evaluation Role of specialized testing Stress testing False (+) : female, >50 yrs & in LVH cases False (-) : taking BB or CCB 201-Tl : specific & good (-) predictive value Coronary angiography Reserved for pt at high risk & should be done only if angioplasty or CABG is considered Perioperative management HTN Valvular heart disease Myocardial disease Arrhythmia ICD Medical tx Beta blocker Alpha agonist Calcium antagonist Nitrate Statin CABG or PCI Postoperative management Myocardial ischemia Arrhythmia CHF Postoperative management Myocardial ischemia Silent, non-Q infarction Peak incidence at POD #2~ #3 ECG at baseline, postop(immediate), POD #3 in high risk pts. Cardiac marker if clinically suspected or abnormal ECG Postoperative management Postop. Arrhythmia Usually transitory VPC : tx only if sustained or hemodynamically significant Postoperative management CHF Excessive vol. administration, HTN, exacerbation of preexisting ventricular dysfunction Unexplained pul. edema suspicion of silent MI Postoperative management Cardiovascular drugs Aspirin Discontinue 7 days before operation; restart 2 days after operation Beta blockers Continue, to prevent withdrawal; useful for postoperative adrenergic hyperactivity Clonidine HCl Continue, to avoid rebound hypertension Warfarin sodium, except when used for artificial valves Discontinue 3-5 days before operation; restart when patient resumes oral intake Warfarin therapy for prosthetic valves Thrombosis risk is higher in patient with mitral valve than with aortic valve. ACCP gives three options for perioperative anticoagulation: · Stop warfarin several days preoperatively and proceed to surgery once INR is at a safe level for operation; restart shortly after operation · Decrease dosing to keep INR low during procedure · Stop warfarin and start heparin preoperatively; stop heparin 2-4 hr preoperatively; proceed to surgery once INR is safe for operation; restart heparin postoperatively when safe; restart warfarin postoperatively when safe Postoperative management Prophylaxis for infective endocarditis For dental, respiratory, gastrointestinal, or genitourinary tract procedures or other situations when bacteremia is a risk Pacemaker management (consult technical consultant of pacemaker manufacturer, if needed) Temporarily program pacemaker to fixed-rate mode to avoid temporary pacemaker inhibition by electrocautery-induced electromagnetic interference; limit length and frequency of use of electrocautery, particularly near pacemaker site Safeguard with automatic implantable cardioverter-defibrillator Best to switch off temporarily during surgery; electrocautery may interfere with function Drug use in patient with transplanted heart (due to denervation, resting heart rate is increased but response to stress is blunted) Supersensitivity to adenosine (Adenocard), normally responds to beta blockers and calcium channel blockers, does not respond to atropine sulfate or digoxin (Lanoxicaps, Lanoxin)