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Anaesthesia for non-cardiac surgery in patients with heart failure Daniela Filipescu, MD, PhD, DEAA Associate Professor of Anaesthesia & Intensive Care Medicine Department of Cardiac Anaesthesia & Intensive Care Medicine II Emergency Institute for Cardiovascular Diseases Bucharest, Romania CEEA Kosice 12014 Conflict of interest ? EuSOS European Surgical Outcomes Study Lancet 2012; 380:1059-1065 EuSOS Cohort 46539 Total2012; Mortality 1682 (4%) Lancet 380:1059-1065 19 million major procedures in Europe 42%of complications and death due to cardiac complications Approx 319000 deaths caused by perioperative cardiac complications Heart failure - definition • An abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues, despite normal filling pressures (or only at the expense of increased filling pressures). McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Stages of heart failure (HF) Valchanov KP & Arrowsmith JE. EJA 2012 29(3):121-128 HF - Epidemiology √ 2% of the adult population experience HF in developed countries √ 6-10% in those > 65 years √ Chance of developing HF in a lifetime is 1 in 5 individuals √ 25 % increase in HF prevalence by 2030 √ HF is seen in up to 10% of non-cardiac surgical patients √ HF is noted 1 in 8 death certificates √ 30-day mortality 10% √ 1-year mortality 24-33% √ 80% of the HF death occur in individuals aged > 65 Mebazaa A et al. Circulation 2014;130; 410-418 Maile MD et al. Anesth Analg 2014;119: 522-532 Beattie WS & Wijeysundera DN. Anesth Analg 2014;119: 506-508 Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145 HEART FAILURE 15,000,000 26,000,000 6,000,000 Perioperative outcome in HF patients elective emergency urgent Control CAD HF Hernandez AF et al. JACC 2004;44:1446 Perioperative outcome 38 000 patients 1. patients with HF or AF are at substantially higher risk of postoperative mortality than patients with CAD, and this risk is higher than previously appreciated by perioperative cardiac risk prediction models 2. patients with HF undergoing routine minor surgical procedures are not low risk (4% risk of mortality within 30 days of purportedly minor outpatient surgical procedures, such as a colonoscopies, bronchoscopies, and cystoscopies) 3. mortality rates are particularly high for those patients undergoing surgery within 4 weeks of an incident diagnosis of HF or AF and further highlighted by the risk carried by a recent HF rehospitalization on postoperative mortality. Van Diepen S et al. Circulation 2011; 124:289-296 Perioperative outcome Unadjusted 30-day perioperative mortality (blue), rehospitalization (red), and cardiac rehospitalization (green). van Diepen S et al. Circulation. 2011;124:289-296 Myocardial infarction, mortality and noncardiac complications after noncardiac surgery in preoperative HF patients Maile MD et al. Anesth Analg 2014;119: 522-532 Myocardial infarction, mortality and noncardiac complications after noncardiac surgery in preoperative HF patients Maile MD et al. Anesth Analg 2014;119: 522-532 Acute vs chronic Left-sided vs rightsided HF-PEF vs HF-REF Heart failure Systolic vs diastolic High CO vs Low CO Preserved vs. reduced ejection fraction HF Classification I. Heart Failure with Reduced Ejection Fraction (HFrEF) II. Heart Failure with Preserved Ejection Fraction (HFpEF) Ejection Fraction ≤40% Description Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date. ≥50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF. b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients. Left ventricular function and long-term survival after vascular surgery Flu W-I et al. Anesthesiology 2010; 112(6):1316-1324. McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Rapid change in HF signs and symptoms Pulmonary and systemic congestion Urgent need for therapy Acute heart failure Gheorghiade M, J Am Coll Cardiol 2009 Clinical scenarios in AHF syndrome • CS 1. Dyspnea and/or congestion with elevated SBP (>140mmHg) • CS 2. Dyspnea and/or congestion with normal SBP (100-140 mmHg) • CS 3. Dyspnea and/or congestion with low SBP (<100 mmHg) • CS 4. Dyspnea and/or congestion with signs of ACS • CS 5. Isolated right ventricular failure Mebazza A, Gheoghiade M et al. Crit Care Med 2008;S129 Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Steps to preoperative evaluation • Patient Risk Factors Clinical predictors Functional capacity Revised Cardiac Risk Index 4315 patients, > 50 years old Major elective noncardiac surgery Six independent risk factors High risk surgery AAA, vascular,thoracic, abdominal, ortho History ischemic heart disease History CHF History cerebrovascular disease Preoperative insulin use Preoperative serum Cr > 2.0 mg/dl Lee, Circulation 1999 Revised Cardiac Risk Index Revised cardiac risk index Incidence of cardiac events 0 points 0.4% 1 point 0.9% 2 points 7% ≥3 points 11% Lee, Circulation 1999 Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery Clinical Perspective by Prateek K. Gupta, Himani Gupta, Abhishek Sundaram, Manu Kaushik, Xiang Fang, Weldon J. Miller, Dennis J. Esterbrooks, Claire B. Hunter, Iraklis I. Pipinos, Jason M. Johanning, Thomas G. Lynch, R. Armour Forse, Syed M. Mohiuddin, and Aryan N. Mooss American College of Surgeons National Surgical Quality Improvement Program (NSQIP) MICA model Circulation 2011;124(4):381-387 Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Functional capacity Can you … 1 MET Can you … Can you … 4 MET Can you … Take care of yourself ? Eat, dress, use the toilet ? Climb 2 flights of stairs or walk uphill Walk indoors around the house ? Run a short distance Walk 100 m on level ground, at 35km/h Do heavy work around the house (scrubbing floors, lifting, moving heavy furniture Participating in strenuous sports like tennis, swimming, football, basketball, skiing? >10 MET 4 MET 1 MET: the oxygen consumption (VO2) of a 70 kg, 40 y.o. man at rest…3.5 cc/kg/min Steps to preoperative evaluation 1. Patient Risk Factors 2. Surgical Risk Factors Surgical risk Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Domi et al. International Archives of Medicine 2014 Steps to preoperative evaluation 1. Patient Risk Factors 2. Surgical Risk Factors 3. Preoperative Testing Who & How Heart failure Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Natriuretic peptides Preoperative NT-pro- BNP > 1740 pg/ml was associated with a 6.9-fold univariate relative risk for in-hospital major cardiac events Farzi S et al. Br J Anaesth 2013;110:554-560 Postoperative BNP& NT-pro- BNP are independently associated with increased risk of mortality, myocardial infarction and cardiac failure at 30 days and more than 180 days after surgery Postoperative natriuretic peptides measurement enhanced risk stratification for the composite outcomes of death or nonfatal MI 30 days and at least 180 days after noncardiac surgery as compared with a preoperative measurement alone Rodseth RN et al. Anesthesiology 2013;119:270-283 Rodseth RN et al. J Am Coll Cardiol 2013 McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Steps to preoperative evaluation 1. Patient Risk Factors 2. Surgical Risk Factors 3. Preoperative Testing 4. Perioperative Management Risk reduction strategies • In patients with newly discovered heart failure, if possible, non-cardiac surgery should be postponed so it can be performed under optimal medical therapy, in a stable patient. Heart failure Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Beta-blockers Anti-platelet drugs Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517573 1. Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. 2. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. 3. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). 4. Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns Pay attention to your drugs! Anesthesia and heart failure Preoperative evaluation and optimization Adequate monitoring Volemic and transfusion strategies Quality anesthesia Standard monitoring • 2/3 lead ECG (leads II and V5 are standard of care but adding V4 gives best sensitivity for ischemia) • Pulse oximetry, capnography • Invasive arterial pressure monitoring • Right heart catheterization in selected cases Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573 Intraoperative hypotension Bijker et al, Anesthesiology 2012 Complex monitoring- cardiac output and volume responsiveness Pulsecontour/transpulmonary thermodilution Transoesophageal echocardiography Pulmonary artery catheter Neuraxial anesthesia versus general anesthesia Forest plots for mortality 0 to 30 days Guay J et al. Anesthesia & Analgesia. 119(3):716-725, September 2014 Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517573 Principles of anaesthetic management Principles of anaesthetic management Principles of anaesthetic management Postoperative risk stratification Surgical Apgar score Surgical Apgar score 10 7 Adjusted complication rate 3% 9.1% <5 32.9% Haynes AB et al, Surgery, 2011 Perioperative acute heart failure (AHF) A significant diagnostic and therapeutic challenge Clinical scenarios: • Pulmonary oedema • Left/right/biventricular congestive HF •Cardiogenic shock Clinical signs Echocardiography Plasma biomarkers . Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145 Perioperative HF triggers Hypertension Tachyarrhythmias Anemia Hyper-coagulability Inapropiate fluid management Pain Surgical stress Myocardial ischaemia Acute valve diseases Pulmonary emboli Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145 McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Therapeutic approach of AHF McMurray JJV et al. European Heart Journal 2012;33:1787-1847 McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Tacon CL et al. Intensive Care Med 2012;38:359-367 Effects of inotropic therapy Groban L et al.Anesthesia & Analgesia. 103(3):557-575, September 2006. Pharmacological effects of levosimendan Enantiomer of {[4-(1,4,5,6-tetrahydro-4-methyl-6-oxo3-pyridazinyl)phenyl]hydrazono}propanedinitrile. a) increased cardiac contractility mediated by calcium sensitisation of troponin C b) vasodilation through the opening of potassium channels on the sarcolemma of smooth muscle cells in the vasculature c) cardioprotection through the opening of mitochondrial potassium channels in the cardiomyocytes Nieminen MS, et al. Heart, Lung and Vessels. 2013; 5(4): 227-245 Why is calcium sensitisation a better approach? Contraction % cell shortening Control Other inotrope, e.g. dobutamine Levosimendan 15 0 Calcium transient O2 demand not increased [Ca2+]i 0.35 O2 demand; arrhythmias 0.20 500 ms Lancaster M & Cook S. Eur J Pharmacol 1997:97 Effects of levosimendan on mortality and hospitalization A meta-analysis of randomized controlled studies Data from 5,480 patients in 45 clinical trials (1999-2010) Landoni G, et al. Crit Care Med 2012;40:634–646 Effects of levosimendan on mortality Global 17.4 vs.23.3% Cardiac surgery 5.8 vs. 12.9 % Levosimendan in patients taking betablockers 1.5 Change in cardiac output + 1.0 - p=0.01 0.5 0 0 Change in PCWP Patients on -blockers do not have lessened levosimendan effects, as is the case with dobutamine. Dobutamine Although -blockers interfere with the action of a -agonist (dobutamine), there is no such effect with levosimendan because it acts as a calcium sensitiser. + Levosimendan -2 -4 • - p=0.03 • -6 -8 Follath F et al. Lancet 2002:196 Invasive monitoring Intra-arterial line Insertion of an intra-arterial line should only be considered in patients with persistent HF and a low systolic blood pressure despite treatment. Pulmonary artery catheterization Right heart catheterization does not have a general role in the management of AHF, but may help in the treatment of a minority of selected patients with acute (and chronic) HF Pulmonary artery catheterization should only be considered in patients: (i) who are refractory to pharmacological treatment; (ii) who are persistently hypotensive; (iii) in whom LV filling pressure is uncertain; (iv) who are being considered for cardiac surgery. McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Mechanical support Intra-aortic balloon pump Percutaneous cadiopulmonary bypass system Mechanical assist devices Percuaneous assist devices Intraaortic balloon support for myocardial infarction with cardiogenic shock IABP-SHOCK II trial 300 patients in the IABP group 298 in the control group Mortality at 30 days: 39.7% vs. 41.3% Thiele H et al. NEJM 2012;367:1287-96 Options for mechanical circulatory support McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Ultrafiltration Conflicting evidence regarding efficacy Can be done in the ward, on a peripheral vein Is reserved for refractory congestion • Peristent pulmonary oedema • Severe hyponatremia • Resistance to diuretics McMurray JJV et al. European Heart Journal 2012;33:1787-1847 Bart B. N Engl J Med 2012 Approach to perioperative heart failure Develop differential diagnosis for cause, treat repairable lesions. Initiate resuscitation measures: maximize oxygenation/ventilation, control postoperative pain/tachycardia, correct acid-base and electrolyte abnormalities. Evaluate and optimize preload, afterload, contractility, heart rate and rythm • Preload- volume load vs. diuresis based on evaluation of volume status • Afterload- if high, consider dilation with nytroglicerine, sodium nitroprusside; if low consider augmentation with norepinephrine • Contractility - use inotropic agents • Establish stable heart rate and rhythm Use mechanical assistance for patients refractory to above measures. Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145 Take home message Management …