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Preoperative Assessment of the Cardiac Patient for Non-cardiac Surgery John R. Butterly, M.D. Dartmouth-Hitchcock Issues Overview of ischemic heart disease General considerations Predictors – Clinical – Procedural – Anesthetic – Operative Clinical assessment of risk Disease specific states – CAD, hypertension, CHF, valvular Preoperative therapy Dartmouth-Hitchcock Bottom Line Indications for evaluation/intervention are the same as in the general population Pre-operative evaluation should be seen as an opportunity to provide recommendations for care over the long-term as well as the immediate, peri-operative period Intervention is rarely necessary to lower the risk of non-cardiac surgery Dartmouth-Hitchcock Overview of Ischemic Heart Disease Anatomy Physiology – coronary – left ventricular – patient Dartmouth-Hitchcock Etiology of Ischemia Supply – – – – blood O2 carrying capacity cardiac output systemic vascular resistance coronary resistance (Poiseuille) coronary resistance ~ 1/R4 Demand – Major determinants of MVO2 » systolic work heart rate blood pressure (afterload) duration of systole » ventricular wall tension (LaPlace) T = PR » contractility » myocardial mass Dartmouth-Hitchcock Ischemia vs Infarction Implications of demand related problem vs supply related problem – stability – biology » endothelial function » plaque rupture/thrombosis Dartmouth-Hitchcock General Considerations A substantial proportion of all deaths in most series of non-cardiac operations arise from cardiovascular complications. Stresses to cardiovascular system – decrease in myocardial contractility & respiration – fluctuations in temperature, afterload, preload, blood volume, & autonomic nervous system output Dartmouth-Hitchcock General Considerations Possible complications of anesthesia & surgery may impose additional burdens – – – – hemorrhage infection pulmonary embolism myocardial infarction Dartmouth-Hitchcock Anesthetic Considerations Factors influencing cardiovascular function – direct effect of anesthetic agent on heart – indirect effects mediated through the autonomic nervous system – level of ventilation » hypoxia » hypercarbia » acidosis Dartmouth-Hitchcock Anesthetic Agents General – inhalation – intravenous – muscle relaxants Spinal/Epidural – hemodynamic consideration The skill & experience of the anesthesiologist, including the ability to monitor hemodynamics & respond quickly, are far more important than the specific agent used. Dartmouth-Hitchcock Case Study Fragilina Moribundi is a 93 yo, pleasantly demented woman who presents to your office speaking fluent diabinase. She is referred for pre-operative cardiac evaluation prior to her planned cataract surgery. She has a history of a systolic murmur, and is s/p IMI in the distant past. Her history is contributory only in the absence of sx’s suggestive of active ischemia or LV dysfunction Her exam is remarkable for findings c/w severe aortic stenosis Her EKG shows findings c/w OIMI Dartmouth-Hitchcock Case Study Appropriate actions/evaluation would include – stress testing with imaging to risk stratify and rule out active ischemia Dartmouth-Hitchcock Case Study Appropriate actions/evaluation would include – stress testing with imaging to risk stratify and rule out active ischemia – echocardiography to evaluate the severity of the aortic stenosis and baseline LV function Dartmouth-Hitchcock Case Study Appropriate actions/evaluation would include – stress testing with imaging to risk stratify and rule out active ischemia – echocardiography to evaluate the severity of the aortic stenosis and baseline LV function – cardiac catheterization with an eye towards balloon valvuloplasty, if severe aortic stenosis is confirmed, as a bridge to get her through the proposed surgery Dartmouth-Hitchcock Case Study Appropriate actions/evaluation would include – stress testing with imaging to risk stratify and rule out active ischemia – echocardiography to evaluate the severity of the aortic stenosis and baseline LV function – cardiac catheterization with an eye towards balloon valvuloplasty, if severe aortic stenosis is confirmed, as a bridge to get her through the proposed surgery – a discussion with the PCP re: the indications for the proposed surgery, and clearance for same with appropriate precautions Dartmouth-Hitchcock Case Study Mrs. Moribundi does well with her cataract extraction, but 2 months later presents to the ER with evidence for total bowel obstruction and free air under the diaphragm. You are emergently consulted by the general surgeons who want to take her to the OR. Appropriate actions include: – emergency echocardiogram to evaluate status of valve and ventricle Dartmouth-Hitchcock Case Study Mrs. Moribundi does well with her cataract extraction, but 2 months later presents to the ER with evidence for total bowel obstruction and free air under the diaphragm. You are emergently consulted by the general surgeons who want to take her to the OR. Appropriate actions include: – emergency echocardiogram to evaluate status of valve and ventricle – trip to the cath lab for emergency balloon valvuloplasty Dartmouth-Hitchcock Case Study Mrs. Moribundi does well with her cataract extraction, but 2 months later presents to the ER with evidence for total bowel obstruction and free air under the diaphragm. You are emergently consulted by the general surgeons who want to take her to the OR. Appropriate actions include: – emergency echocardiogram to evaluate status of valve and ventricle – trip to the cath lab for emergency balloon valvuloplasty – trip to the cath lab for IABP placement prior to surgery Dartmouth-Hitchcock Case Study Mrs. Moribundi does well with her cataract extraction, but 2 months later presents to the ER with evidence for total bowel obstruction and free air under the diaphragm. You are emergently consulted by the general surgeons who want to take her to the OR. Appropriate actions include: – emergency echocardiogram to evaluate status of valve and ventricle – trip to the cath lab for emergency balloon valvuloplasty – trip to the cath lab for IABP placement prior to surgery – discussion with anesthesia re: optimal peri-operative management/hemodynamic monitoring Dartmouth-Hitchcock The Operation Type – in general, surgical mortality is 25-50% higher in patients with underlying cardiovascular conditions compared to patients with normal cardiac function. – ophthalmologic surgery & TURP almost always safe – highest cardiovascular complication rates seen in vascular surgery » AAA aortic cross-clamping, major fluid & electrolyte shifts » carotid / peripheral surgery co-existing CAD, clinical underestimation of severity Dartmouth-Hitchcock The Operation Duration – correlation is general and mostly related to type of operation – exceptions » operative time prolonged due to complication » operation > 5 hours Dartmouth-Hitchcock Cardiac Risk for Noncardiac Surgical Procedures High – – – – (reported cardiac risk > 5%) emergent major operations, esp. in elderly aortic and other major vascular procedures peripheral vascular procedures anticipated prolonged procedure with large fluid shift/blood loss Dartmouth-Hitchcock Cardiac Risk for Noncardiac Surgical Procedures Intermediate – – – – – (reported cardiac risk < 5%) carotid endarterectomy head and neck intraperitoneal & intrathoracic orthopedic prostate Dartmouth-Hitchcock Cardiac Risk for Noncardiac Surgical Procedures Low – – – – (reported cardiac risk < 1%) endoscopic procedures superficial procedure cataract breast Dartmouth-Hitchcock Case Study Mr. A. Jean Jacques is a 58 year old gentleman referred for pre-operative evaluation because of one isolated PVC seen on a pre-op EKG. He is scheduled for nephrectomy for a renal mass the following morning He has no cardiac history of which he is aware. His only risk factor is that of a history of 3 years of smoking in college. Dartmouth-Hitchcock Case Study He considers himself fit, and is proud of being in good physical condition. He plays full court basketball on Saturdays, and wins. He climbed Mount Washington in October and was pleased that a few of his sons friends could not keep up with him. He denies dyspnea or chest discomfort, and his exam is remarkable in that he looks fit and has a resting pulse of 52 on no medications. Dartmouth-Hitchcock Case Study Appropriate next steps include – routine stress testing to risk stratify and rule out occult ischemia Dartmouth-Hitchcock Case Study Appropriate next steps include – routine stress testing to risk stratify and rule out occult ischemia – 24 hour Holter monitor to evaluate burden of ventricular ectopy Dartmouth-Hitchcock Case Study Appropriate next steps include – routine stress testing to risk stratify and rule out occult ischemia – 24 hour Holter monitor to evaluate burden of ventricular ectopy – echocardiogram to rule out unsuspected LV dysfunction Dartmouth-Hitchcock Case Study Appropriate next steps include – routine stress testing to risk stratify and rule out occult ischemia – 24 hour Holter monitor to evaluate burden of ventricular ectopy – echocardiogram to rule out unsuspected LV dysfunction – clear for surgery with no recommendations for further cardiac evaluation Dartmouth-Hitchcock Clinical Assessment History – Single most important part of evaluation to determine level of cardiovascular risk » Identify presence of cardiac condition » Evaluate severity, stability » Identify risk factors, co-morbid conditions » Determination of individual functional capacity Taking a history for angina Dartmouth-Hitchcock The asymptomatic patient Silent ischemia – “active” silent ischemia » Type I - absence of any sx despite the presence of CAD & provocable ischemia (defective anginal warning system) » Type II - sx’s generally present, but patient also has silent episodes – “passive” silent ischemia » sedentary patient » patient limited for other reasons Dartmouth-Hitchcock Functional Capacity 1 MET 4 – – – – – Climb a flight of stairs, walk up hill? – Walk on level at 4 mph? – Run a short distance? – Heavy housework – Golf, bowling, dancing, doubles tennis – Swimming, singles tennis football, basketball, skiing Can you take care of self? Eat, dress, use toilet? Walk indoors in house? Walk a block or two on level at 2-3 mph? – Do light housework like dusting or dishes? METs 4 METs >10 METs Dartmouth-Hitchcock Clinical Assessment Physical – – – – examination general appearance evidence for CHF evidence for PVD heart sounds, murmur Dartmouth-Hitchcock Clinical Assessment Co-morbid – – – – conditions pulmonary diabetes mellitus * renal impairment hematologic disorders Dartmouth-Hitchcock Clinical Assessment Ancillary studies – CBC, PT/PTT, blood chemistry (electrolytes, BUN, creatinine) – ECG – CXR ?? Dartmouth-Hitchcock Case Study Alvin Falfa is a 63 yo dairy farmer from the Northeast Kingdom. He was discharged from North Country Hospital 3 weeks ago having sustained an uncomplicated, non-Q MI. He has been slowly increasing his activity and is asx. He was incidently found to have an iron deficiency anemia during his hospitalization, and this was felt to be the cause of his MI. Further w/u revealed a large, fungating mass in his cecum, biopsy positive for adenoCa. He is referred for pre-op evaluation prior to his right hemicolectomy which is scheduled for tomorrow morning. Dartmouth-Hitchcock Case Study Initial appropriate actions include: – postponement of the scheduled surgery Dartmouth-Hitchcock Case Study Initial appropriate actions include: – postponement of the scheduled surgery – stress testing for risk stratification and to determine whether or not there is inducible ischemia Dartmouth-Hitchcock Case Study Initial appropriate actions include: – postponement of the scheduled surgery – stress testing for risk stratification and to determine whether or not there is inducible ischemia – echocardiography to evaluate LV function Dartmouth-Hitchcock Case Study Initial appropriate actions include: – postponement of the scheduled surgery – stress testing for risk stratification and to determine whether or not there is inducible ischemia – echocardiography to evaluate LV function – cardiac catheterization with an eye towards intervention prior to abdominal surgery Dartmouth-Hitchcock Case Study Initial appropriate actions include: – postponement of the scheduled surgery – stress testing for risk stratification and to determine whether or not there is inducible ischemia – echocardiography to evaluate LV function – cardiac catheterization with an eye towards intervention prior to abdominal surgery – clearance for surgery after a discussion with anesthesia about appropriate peri-operative management/hemodynamic monitoring Dartmouth-Hitchcock Clinical Predictors of Risk Major – Unstable coronary syndromes » recent MI with evidence for ischemia » unstable or severe angina (Canadian class III or IV) – Decompensated CHF – Significant arrhythmia » high grade AV block » symptomatic ventricular arrhythmia (with organic disease) » supraventricular arrhythmia with uncontrolled rate – Severe valvular disease Dartmouth-Hitchcock Clinical Predictors of Risk Intermediate – – – – – Mild angina pectoris (Canadian class I or II) Prior MI by history or pathological Q waves Compensated or prior CHF Diabetes mellitus Renal insufficiency (creatinine > 2) Dartmouth-Hitchcock Clinical Predictors of Risk Minor – – – – – – Advanced age abnormal ECG (LVH, LBBB, ST-T change) Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension Dartmouth-Hitchcock Determination of need for further cardiac testing Urgency of surgery Intermediate predictor of risk Recent Recent Major – functional capacity – risk level of surgery revascularization coronary evaluation predictor of risk Minor or no predictor of risk – functional capacity – risk level of surgery Dartmouth-Hitchcock Disease-Specific Approaches Coronary Artery Disease Hypertension Congestive Heart Failure/Cardiomyopathy Valvular Heart Disease Arrhythmias & Conduction Defects Pulmonary Vascular Disease Dartmouth-Hitchcock Case Study Hiram Wrisck is a 72 yo gentleman referred for evaluation prior to AAA. He describes himself as active, but his wife rolls her eyes behind his back when he says this. He has a positive history of hypertension and adult onset diabetes that recently became insulin dependent, but no history to suggest angina. A stress test done prior to his visit with you demonstrated 1.5mm ST depression in leads II, V4-6 at 4 METS (100 bpm) Dartmouth-Hitchcock Case Study Physical exam shows him to be an obese 72 year old man looking older than his stated age. He weighs 285#, pulse is 96 with frequent extra-systoles, BP 140/90 in right arm, 190/105 in left arm. The rest of the exam is remarkable for a II/VI SEM at the LSB, bilateral carotid and femoral bruits, and absent pedal pulses. Dartmouth-Hitchcock Case Study Appropriate next steps include – Repeat stress as a DSE to try to get a heart rate response closer to 85% PMHR Dartmouth-Hitchcock Case Study Appropriate next steps include – Repeat stress as a DSE to try to get a heart rate response closer to 85% PMHR – Cardiac catheterization with a low threshold for percutaneous or surgical revascularization if anatomically appropriate Dartmouth-Hitchcock Case Study Appropriate next steps include – Repeat stress as a DSE to try to get a heart rate response closer to 85% PMHR – Cardiac catheterization with a low threshold for percutaneous or surgical revascularization if anatomically appropriate – Recommend intra-operative SG line and i.v. TNG Dartmouth-Hitchcock Case Study Appropriate next steps include – Repeat stress as a DSE to try to get a heart rate response closer to 85% PMHR – Cardiac catheterization with a low threshold for percutaneous or surgical revascularization if anatomically appropriate – Recommend intra-operative SG line and i.v. TNG – Fully review the medical record in hopes that Andy Torkelson has previously seen him at some point in time Dartmouth-Hitchcock Coronary Artery Disease Clinically apparent vs occult disease – past history – active symptoms – “active” vs “passive” silent ischemia Issues to be addressed – ischemic threshold – amount of myocardium in jeopardy – left ventricular function Dartmouth-Hitchcock Coronary Artery Disease Risk assessment based on stress testing High risk – ischemia induced at low level (< 4 METs, heart rate < 100 or < 70% age predicted) with: » ST depression > 0.1 mV » ST elevation > 0.1 mV in noninfarct lead » five or more abnormal leads » persistent ischemic response > 3 minutes post exercise » typical angina – thallium Dartmouth-Hitchcock Coronary Artery Disease Risk assessment based on stress testing Intermediate risk – ischemia induced at moderate level (4-6 METs, heart rate 100-130 or 70-85% age predicted with: » ST depression > 0.1 mV » typical angina » persistent ischemic response >1-3 minutes post exercise » three to four abnormal leads Dartmouth-Hitchcock Coronary Artery Disease Risk assessment based on stress testing Low risk – no ischemia or ischemia at high level (> 7 METs, heart rate > 130 or >85% age predicted with: » ST depression > 0.1 mV » typical angina » one to two abnormal leads Dartmouth-Hitchcock Coronary Artery Disease Indications for Coronary Angiography Class I: patients with suspected or proven CAD » high risk results from noninvasive testing » angina pectoris refractory to medical therapy » unstable angina » nondiagnostic/equivocal test results in high risk pt. Class II: » intermediate risk results from noninvasive testing » nondiagnostic/equivocal test results in intermediate risk pt. » urgent non-cardiac surgery in convalescent period post-MI » perioperative MI Dartmouth-Hitchcock Coronary Artery Disease Indications for Coronary Angiography Class III: » low risk surgery in pt. with known CAD & low risk testing » screening for CAD » asx pt. after revascularization with exercise capacity > 7 METs » mild, stable angina with good LV function, low risk testing » patient not candidate for revascularization Dartmouth-Hitchcock Other disease states Hypertension – not independent risk factor – implications for intraoperative lability – rational for preoperative control Congestive heart failure/Cardiomyopathy – confers risk independently – etiology key to risk assessment/treatment Dartmouth-Hitchcock Other disease states Congestive Heart Failure/Cardiomyopathy » systolic vs diastolic dysfunction » hypertrophic cardiomyopathy Valvular heart disease » aortic stenosis » mitral stenosis » regurgitant (volume overload) lesions » antibiotic prophylaxis / anticoagulation Dartmouth-Hitchcock Other disease states Arrhythmias & conduction defects » important as markers for underlying disease » therapy aimed to correct or avoid ischemia or hemodynamic embarrassment » high grade AV block - to pace or not to pace Pulmonary vascular disease » little objective data available » sensitivity to hypoxia » implication in presence of pre-existing shunts Dartmouth-Hitchcock Supplemental Preoperative Evaluation Resting left ventricular function » methodology » when is it good to be over 40? » indications for testing Stress testing » exercise » nonexercise persantine thallium dobutamine stress echocardiography Dartmouth-Hitchcock Preoperative Therapy Surgical revascularization CASS registry Foster et al Ann Thorac Surg 1986;41:42-50 » 1600 pts. underwent noncardiac operations, 113 (7%) vascular » mortality rates 0.5% without angiographic evidence advanced CAD 0.9% with prior CABG 2.4% with significant CAD (70% stenosis) but no prior revascularization p=ns p=.009 European Coronary Surgery Study Group Lancet 1982;2:1173-80 » survival rates, 58 pts. with PVD randomized to CABG or medical Rx p=.02 85% with CABG 57% with medical Rx Dartmouth-Hitchcock Preoperative Therapy Surgical revascularization Cleveland Clinic series Ann Surg. 1984;199:223-233 » 1001 pts. scheduled for elective vascular surgery » mortality rates 5.3% + 1.5% for CABG group (6.8%) 1.4% in group with normal coronaries 1.8% in group with mild to moderate CAD 3.6% in group with advanced, compensated CAD 14% in group with severe, uncorrected CAD » 5 year survival 72% in pts. who underwent CABG 43% in pts. in whom CABG indicated but not performed p=.001 Dartmouth-Hitchcock Preoperative Therapy Surgical revascularization Indications – – – – for preoperative CABG left main stenosis with acceptable risk 3VD with LV dysfunction 2VD with severe, proximal LAD disease coronary ischemia refractory to medical management ACC/AHA Task Force JACC 1991;17:543-589 Dartmouth-Hitchcock Preoperative Therapy Catheter based revascularization Mayo Clinic series Mayo Clin Proc. 1992;67:15-21 » 50 pt. series, high risk group 10% required urgent CABG perioperative MI rate 5.6% mortality rate 1.9% Timing » restenosis » recoil/thrombosis New technologies Dartmouth-Hitchcock Preoperative Therapy Medical therapy Author Procedure n Control Drug Coriat carotid 45 TNG 0.5 TNG 1.0 mcg/kg/m mcg/kg/m placebo TNG 0.9 Anesth 1984 Dodds noncardiac 45 Anesth Analg 1993 Godet Anesth 1988 32%/30% 4%/0% 30 placebo diltiazem 3mcg/kg/m 73%/4% 0/0 AAA 83 casecontrol metoprolol 50 mg p.o. _____ 18%/3% vascular 200 2.4/5 episodes _____ noncardiac 128 Am J Surg 1989 Stone 0/0 vascular Circ 1987 Pasternak 64%/17% mcg/kg/m Anesth 1987 Pasternak Ischemia MI control/drug control/drug unblinded metoprolol 50 mg p.o. placebo p.o. beta blocker 28%/2% 0/0 Dartmouth-Hitchcock Preoperative Therapy Valve surgery » general considerations » balloon valvuloplasty » stenotic vs regurgitant lesions Arrhythmia/Conduction Devices » ICD’s » pacemakers Dartmouth-Hitchcock Tools Vs Toys Pulmonary artery catheters Transesophageal Intra-aortic echocardiography balloon counterpulsation Dartmouth-Hitchcock Summary Overview of ischemic heart disease General considerations Predictors – Clinical – Procedural – Anesthetic – Operative Clinical assessment of risk Disease specific states – CAD, hypertension, CHF, valvular Preoperative therapy Dartmouth-Hitchcock Conclusions Judgement/Experience/Skill Medical care: a point in time vs continuum Teamwork Dartmouth-Hitchcock Dartmouth-Hitchcock