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Peri-operative adverse cardiac events Identifying at risk patients and mitigating risk Dr Simon Arnett / Dr Steven Sutcliffe Terminology MACE Major adverse cardiac event = acute coronary syndrome, need for urgent revascularisation, malignant arrhythmia. Type I MI Raised troponin due to thrombotic occlusion of coronary artery (ACS). Type II MI Supply / demand mismatch secondary to a stenotic vessel with ischaemia in times of increased demand. How to diagnose a MACE Includes both the standard ACS definition Suggestive clinical history Raised biomarkers ECG changes And Raised biomarkers in the absence of ECG changes or symptoms, in the absence of an alternative cause of elevated biomarkers. The criteria are laxer in perioperative patients because: Pts are sedated/under anaesthesia at the time of maximum hemodynamic stress, therefore insensate to symptoms. Pts are given liberal analgesia post op, again masking clinical manifestations 65% of MACE events are missed due to the above factors. 1|Page Incidence of MACE In high risk surgeries occurs in 5% of all pts undergoing noncardiac surgery. 1/3 of all peri-operative deaths are due to MACE. Majority occur within T+ 48hrs post-surgery. Risk Factors for peri-operative MACE General medical factors Age >75 Male sex CKD Known macrovascular disease; established coronary artery disease, peripheral vascular disease, cerebrovascular disease DM Poor baseline exertional tolerance (<4 METS) Cardiac conditions Heart failure (particularly decompensated) AF Hypertension Severe Aortic Stenosis There are several risk stratification tools: RCRI (AKA Lee index) ACS-NSQIP MICA However, these tools were validated in nonemergent surgical scenarios, underestimate risk in surgical emergencies. 2|Page When should surgery be delayed prior to a cardiac assessment? Recent ACS event Severe angina Decompensated heart failure Significant arrhythmia - AV blocks – severe type I, Mobitz type II, CHB - Symptomatic non-sustained VT - new SVT with rapid ventricular responses >100 - Symptomatic bradycardia Severe (symptomatic) valvular disease – symptomatic aortic or mitral disease Which surgeries carry the highest risk of MACE? Highest risk (quoted risk of peri-operative MACE ~5%) is associated with vascular surgery - Aortic repair - Any major vascular surgery - Peripheral vascular surgery e.g. fem-pop bypass Higher risk also associated with open intra-thoracic and intra-abdominal surgery 3|Page What peri-operative events are risk factors for MACE? Recent Hx factors; Recent acute life-threatening insults (e.g. AAA rupture) Recent ACS event Recent coronary artery stent (6/12) Recent stroke (3/12) Acute trauma Urgent or emergency surgery How much risk is too much risk? Same philosophy as general approach to ACS/IHD presentations; <1% risk of peri-operative MACE – no further testing warranted >1% risk of perioperative MACE – pts should be investigated prior to surgical procedure What perioperative events can exacerbate MACE? Hypotension, Tachycardia, hypoxaemia Significant haemorrhage Pain +++ Mitigating risk of MACE 1. Aspirin - Aspirin as a secondary prevention measure can be discontinued 5-7 days prior to surgery (this does increase risk, and should be joint decision between medical and surgical teams) - Aspirin should not be commenced prior to surgery as a primary prevention measure - no benefit in MACE, increased major bleeding risk (POISE-2) 2. Statins - Those on statins should continue - Pts at high risk of perioperative MACE (DM, PVD, carotid artery disease, AAA, CKD) should be commenced on high dose statin as soon as possible 3. Beta-Blockers - DECREASE trial (Poldermans et al) – decreased mortality and peri-operative MACE event rate → Author of same subsequently convicted of fraud and publication has been withdrawn 4|Page Is there a role for Anticoagulation? Pts previously on thromboprophylaxis Requirement for bridging anticoagulation depends on thromboembolism risk. Low risk No requirement for bridging after cessation of oral anticoagulation preop. High risk DO require bridging anticoagulation. High risk includes stroke 3/12, mechanical valves, high risk CHADS2, VTE 3/12, previous thromboembolism with interruption, recent coronary stent. If the risk elevation is transient (i.e. recent stroke, VTE) – where possible, delay surgery until risk decreases. Certain procedures do not require discontinuation of anticoagulation – dental, cutaneous, cardiac implantation, cardiac catheter ablation. Generally, less requirement for bridging with use of NOACs due to rapid onset/offset compared to warfarin. Ceasing and Recommencing Anticoagulation Anticoagulant Stop prior Restart Warfarin Five days prior Check INR day before, if >1.5 → low dose vit K 12-24 hrs post surg if no complications Dabigatran (thrombin) Normal renal function – 2 days Impaired renal function – 4 days Within 24 hrs, but delay 2-3 days if high risk bleeding Rivaroxaban, apixaban (Xa) ~2 days, less for low risk, more for high risk bleeding Within 24 hrs, but delay 2-3 days if high risk bleeding Learning Points Perioperative MACE is common, and commonly missed. There are well defined risk factors, and risk calculation tools available, but be mindful of limitations. Be careful with post procedure hypotension, tachycardia, hypoxaemia, significant haemorrhage, pain +++ Statins are almost always a good idea. Aspirin is problematic peri-procedurally. Beta blockers were once thought to be mainstay, now known to be problematic. 5|Page Suggested Reading 6|Page Devereaux et al 2014 Aspirin in pts undergoing noncardiac surgery NEJM 370: 1494-1503 Devereaux 2015 Cardiac complications in patients undergoing major noncardiac surgery NEJM 373: 2258-2269 Auebach 2008 Changing the practice of perioperative cardioprotection Circ Cardiovasc Qual Outcomes 1:58-61