preopCADEval - Perioperative Evaluation and Treatment of...

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Unformatted text preview: Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery Surgery November 4, 2003 November Thomas Vrobel, M.D. Antonio Cooper, M.D. with thanks to Robert Finkelhor, M.D. Perioperative MI Perioperative Scope of the Problem • 27 M noncardiac operations/year • 8 M with known CAD or risk with factors factors • CAD leading cause of nonsurgical CAD postoperative death postoperative Perioperative MI Perioperative Scope of the Problem • 50,000 perioperative MI (~0.2% of 50,000 surgeries) surgeries) • 30-50% mortality with MI • 1 M cardiac complications (~4%) cardiac • $20 billion added cost to surgery Perioperative MI Perioperative Mechanisms • Unstable plaque • Catecholamines – pain – anemia • BP swings – pain – anemia/hypovolemia Post MI Noncardiac Surgery Risk Noncardiac Mortality % 40 30 30 1970s 1980s 20 15 10 0 6 2 <3 3 to 6 5 >6 Months post MI Goldman Criteria Goldman • • • • Recent MI (<6 mos) Unstable angina CHF Abdominal or Abdominal thoracic surgery thoracic • Severe AS • Emergent surgery • Age >70 • Rhythm other than Rhythm sinus sinus • S3 • Other Other medical/metabolic problems problems Cardiac Risk Stratification Proposals Proposals • Goldman • Detsky • Eagle • ASA Revised Cardiac Risk Index Revised Independent Predictors Lee et al. Circ 1999;100:1043. • High risk surgery • History of ischemic heart disease • History of CHF • History of CVA • Diabetes requiring insulin • Cr>2.0 mg/dl Revised Cardiac Risk Index Revised Lee et al. Circ 1999;100:1043. ROC Curves Validation Set, n=1422 Sensitivity 1 0.8 Goldman (0.70) 0.6 Detsky (0.58) ASA (0.71) 0.4 Revised (0.81) 0.2 0 1 0.5 Specificity 0 Revised Cardiac Risk Index Revised Major Cardiac Complications* (n=4315) 9.6 10 8 % 6 5 4 2 0 0.5 0 1.2 1 2 >2 Risk Factors *Cardiac death, MI, pulmonary edema, arrhythmic arrest, heart block Lee et al. Circ 1999;100:1043. Revised Cardiac Risk Index Revised Lee et al. Circ 1999;100:1043. Mortality By Surgical Type Number of Risk Factors 14 12 10 % 0 1 2 >2 8 6 4 2 0 Other* Other Vascular AAA * Thoracic, Abdominal, Orthopedic, etc. Perioperative Cardiac Mortality with CABG with 15 N=1001 10 % 14 5 Hertzer, Ann Surg 1984;199:223. Hertzer, + CAB 1.5 Severe CAD Severe CAD CAD 3.6 Compensated 1.8 Mod CAD 1.5 Nl Cors 0 5.3 Preoperative Testing Preoperative Positive Predictive Value MI or Death MI 20 18.6 14.8 15 13.1 % 10 5 0 Stress ECG Dipyramidamole Tl Dobutamine Echo Eagle et al. JACC 1996;27:910. Preoperative Testing Preoperative Negative Predictive Value Freedom from MI or Death Freedom 100 99.4 98.6 96.3 95 % 90 85 80 Stress ECG Dipyramadole Tl Dobutamine Echo Eagle et al. JACC 1996;27:910. Functional Capacity Functional Metabolic Equivalents (METs) Metabolic • Low (< 4 METs) – increased surgical risk • • Eating Intermediate (4-10 METs) Dressing Walking around the house Excellent (> 10 METs) Dishwashing Postoperative Mortality Postoperative Preoperative Hemoglobin Adjusted Odds Ratio 20 15 CVD No CVD 10 5 0 6 7 8 9 10 11 Hemoglobin g/dl Carson et al. Lancet 1996;348:1055. 12 Perioperative Cardiac Mortality with CABG with 15 N=1001 10 % 14 5 Hertzer, Ann Surg 1984;199:223. Hertzer, + CAB 1.5 Severe CAD Severe CAD CAD 3.6 Compensated 1.8 Mod CAD 1.5 Nl Cors 0 5.3 Proven Indications for CABG Proven • Significant left main disease • 3 V CAD and LV dysfunction • 2 V CAD with proximal LAD CAD involvement involvement • Intractable ischemia Perioperative Cardiac Events with PTCA with 40 30 20 34 10 Post PTCA + D ob Echo Hi gh Ri sk 3 5 2.4 8 Intermed. Ri sk 0.6 Low Ri sk 0 18 - Dob Echo % Death and Nonfatal MI Vascular Patients Khot UN, Ellis SG. ACC Current J Rev 2001;10:57. PROBLEMS WITH PREOP CORONARY INTERVENTIONS INTERVENTIONS No proven benefit May not treat the “culprit” Delays surgery versus higher coronary risk PTCA : only few days but higher PTCA restenosis risk restenosis Stent : two to six weeks Postoperative Mortality Reduction Postoperative Beta-Blockers 25 21 20 14 15 10 10 8 5 0 3 0 Placebo Atenolol Mangano, et al. NEMJ 1996;335:1713. 6 Months 1 Year 2 Years Postoperative Cardiac Events In High Risk Patients High Beta-Blockade 25 20 % 17 17 15 Cardiac Death Non-fatal MI 10 5 0 3.4 Placebo Placebo n=53 0 Bisoprolol Bisoprolol n=59 Poldermans et al. NEJM 1999;341:1789. BETA-BLOCKERS BETA-BLOCKERS UNKNOWN FACTORS What is the optimal dose? How frequent are complications? Who should receive therapy? Are all beta blockers effective? When should they be started? How long should they be used? Are Alpha-Blockers also effective? Statin Use and Perioperative Death Statin • Patients: PV surgery 1991-2000 • Study Type: retrospective case-controlled Study – 160 deaths (5.6% of total) 160 – 2:1 survivors: non-survivors 2:1 • Vascular death: 104 (65% cases) • Statin use: Statin – 8% cases vs 25% controls (p<0.001) – odds ratio 0.22, (95% CI 0.10-0.47) Poldermans et al. Circ 2003;107:1848. Minor Clinical Predictors Minor • Advanced age • Abnormal ECG • Rhythm other than sinus • History of CVA • Uncontrolled HTN In-Hospital Mortality In-Hospital Perioperative PA Catheter 1994 Randomized High Risk Surgical Patients 1994 Favors PA Catheter Favors Standard Care Overall NYHA I or II or III or IV III -10 0 % Difference +10 Sandham et al. NEJM 2003;348:5. Major Clinical Predictors • Acute or recent MI (< one month) • Unstable or severe angina • Large ischemic burden (stress testing) • Decompensated CHF • Significant arrhythmias Intermediate Clinical Predictors Predictors • Remote MI ( >1 month) • Stable angina • Compensated CHF • Creatinine ≥ 2.0 Creatinine • Diabetes Surgery Specific Risk Surgery High (>5% Mortality) • Emergent (esp. in the elderly) • Aortic • Peripheral vascular Surgery Specific Risk Surgery Intermediate (1-5% Mortality) • Intraperitoneal /intrathoracic • Orthopedic • Head & neck • Carotid endarterectomy Surgery Specific Risk Surgery Low (<1% Mortality) • Endoscopic (cholecystectomy, Endoscopic arthroplasty, urologic, etc.) arthroplasty, • Breast • Skin • Cataracts Functional Capacity Functional Metabolic Equivalents (METs) Metabolic • Low (< 4 METs) – increased surgical risk • Intermediate (4-10 METs) • Excellent (> 10 METs) Functional Capacity Functional Metabolic Equivalents (METs) Metabolic • Climbing a flight of stairs Low (< 4 METs) Level walking at 4 mph Scrubbing floors – increased surgical risk Moving heavy furniture Golf • Intermediate (4-10 METs) • Excellent (> 10 METs) Functional Capacity Functional Metabolic Equivalents (METs) Metabolic • Low (< 4 METs) Swimming – increased surgical risk • Singles tennis Basketball Intermediate (4-10 METs) • Excellent (> 10 METs) Operative Risk Stratification Operative Surgical Urgency emergent OR Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53. Operative Risk Stratification Operative Surgical Urgency urgent or elective OR no Prior (<5 years) Prior revascularization revascularization yes Recurrent signs/symptoms yes no Further Risk Stratification Operative Risk Stratification Operative Clinical Predictors Major Intermediate Minor/none Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53. Operative Risk Stratification Operative Clinical Predictors Major Intermediate Minor/none Postpone Surgery? Medical Rx and Risk Factor Optimization Coronary Angiography Operative Risk Stratification Operative Clinical Predictors Major Intermediate Minor/none < 4 METs > 4 METs Stress Testing Surgical Procedural Risk High Intermediate or Low OR Operative Risk Stratification Operative Clinical Predictors Major Intermediate Minor/none < 4 METs Surgical Procedural Risk Intermediate or Low OR > 4 METs Operative Risk Stratification Operative Clinical Predictors Major Intermediate Minor/none < 4 METs Stress Testing High Surgical Procedural Risk Operative Risk Stratification Operative Stress Testing Summary Minor Intermediate Major Medical Risk Surgery Specific Risk Low OR Stress test Intermediate High Functional capacity <4 METs: stress test Optimize RF and/or further eval. Prevention of Perioperative MI Prevention Goals • Identify severe or symptom limiting Identify CAD - risk stratification CAD • Minimize risk from CAD (standard Minimize Rx of CAD) Rx Perioperative Issues Perioperative • Risk stratification History, physical, ECG, lab tests • Minimize risk Selective stress testing Clinically indicated catheterization • Monitoring • Treating complications Perioperative Issues Perioperative • Risk stratification • Minimize risk β -blockers • Monitoring anemia Correct Risk directed PCI Clinically indicated • Treating complicationsCABG Perioperative MI Perioperative Risk Predictors • Severity of underlying CAD Severity – clinical markers • Type of surgery Type – hemodynamic stress and duration • Functional capacity Diabetes and Coronary Mortality Mortality 7 Year Incidence Fatal and Nonfatal MI 1373 Nondiabetic 50 1059 Diabetic 45 40 % 30 20 20.2 18.8 10 0 3.5 Prior MI Alone DM Alone Both Neither Haffner et al. NEJM 1998;339:229. Preop Stress Testing Preop Basic Principles • Same indications as with the non-preop Same patient patient • Without standard indications for stress Without testing - intermediate cardiac risk testing • How will the results will change How management? management? Preoperative Imaging Testing Preoperative • Higher risk with ischemia versus scar • Graded risk with ischemia by severity Graded and extent and • LBBB special case (adenosine Tl) Postoperative Mortality Postoperative Preoperative Hemoglobin % M ortality 40 30 20 n=1958 10 0 6 7 8 9 10 11 12 Hemaglobin g/dl Carson et al. Lancet 1996;348:1055. >12 Postoperative Mortality Postoperative Operative Fall in Hemoglobin Adjusted Odds Ratio Cardiovascular Disease 250 200 <2 2 to 4 >4 150 100 50 0 6 7 8 9 10 Hemoglobin g/dl 11 12 Role of Preoperative Echo Role Halm et al. Ann Int Med 1996;125:433. • Not an independent predictor • Only for standard indications – murmur/valvular disease – atrial fibrillation/flutter – dyspnea/CHF/cardiomyopathy – unstable angina Role of Preoperative Echo Role Rohde LE, et al. Am J Cardiol 2001;87:505. • Clues to order echo: – Prior CHF or MI – Evidence of valvular heart disease • Predictive utility only for Revised Predictive Cardiac Risk Index III and IV Cardiac Perioperative MI Prevention Perioperative Transesophageal Echo (TEE) • Detects new wall motion Detects abnormalities abnormalities • Labor intensive • Interpreter expertise • Expensive • No objective evidence of benefit Perioperative MI Prevention Perioperative Swan-Ganz Catheterization • Early detection of altered filling Early pressures pressures • Expertise in interpreting and Expertise troubleshooting troubleshooting • Presumed benefit: – high risk cardiac patients (AS, MS, CHF) – surgery with likely major fluid shifts Perioperative MI Prevention Perioperative Nitroglycerin • Reduces myocardial ischemia – arterial and venodilator – reduces ventricular preload • Hypotension can exacerbate Hypotension ischemia ischemia • No proven benefit in prophylaxis Diagnosing Perioperative MI Diagnosing • Often without typical angina • 2/3 present with ST depression • CK-MB/Troponins • ECG/Troponin (high risk patients) – – q 8 h first 24 hrs then next 2 days Treatment of Postoperative MI Treatment • Aggressive medical Rx: • ST depressionAntiplatelet Rx – (non ST elevation) – medical Rx with locker β blocker medical b appropriate diagnostic – Statin testing testing – ACEI • ST elevation – Correct anemia – acute intervention (emergent PCI or CABG) acute • Further noninvasive assessment as bleeding risk warrants as • Appropriate revascularization Treatment of Postoperative MI Treatment • ST depression – medical Rx with appropriate diagnostic medical testing testing • ST elevation – acute intervention (emergent PCI or CABG) acute as bleeding risk warrants as Postoperative MI Postoperative Immediate Invasive Strategy • 48 patients 1.6 ± 1.9 days post surgery 48 – intraabominal 14, ortho 11, vascular 11, intraabominal misc. 12 • ST elevation MI in 33 (75%) ST • Shock in 21(44%) • Cardiac arrest in 12 (25%) Berger PB, et al. Am J Cardiol 2001;87:1100-2. Postoperative MI Immediiate Invasive Strategy • Intervention: – 41 PTCA – 2 CABG – 4 medical – 1 died in cath. • Results: – Survival in 31 Survival (65%) (65%) – Post arrest 9/12 Post (75%) (75%) – Post shock 11/21 Post (52%) (52%) Berger PB, et al. Am J Cardiol 2001;87:1100-2. Clinical Case History History • 46 y/o male smoker • T3-4 diskectomy and laminectomy T3-4 for herniated disc for • Post ectopy v. tach v.fib defib Clinical Case Clinical Hospital Course • Echo: LVEF 40% Echo: • Cath: 100% proximal LAD, Cath: • PTCA without anticoagulation • IABP • Beta-blockade, ACEI Clinical Case Clinical Hospital Course • Repeat cath day 10: reocclusion of Repeat LAD, 50% OM1, 65% prox RCA LAD, • Repeat PCA with stent • D/C meds: – lisinopril – metropolol – ASA and ticlopidine Perioperative MI Perioperative Treatment Limitations • Few randomized studies concerning Few treatment to prevent MI treatment • No studies specifically on treating No perioperative MIs perioperative Thrombolysis of Acute MI Thrombolysis • Reduces mortality from 10-15% to 710% • Indicated for: – ST elevation – <12 hrs. from onset • Contraindicated for: – excessive bleeding risk Acute MI Mortality Acute ISIS-2. Lancet 1988;2:349. 30 day Mortality 14 13.5 12 10.1 10 % 10.4 7.8 8 6 4 2 0 Placebo Strepto. ASA Both Placebo Strepto. ASA Both Acute MI Revascularization Acute Gusto IIb Angioplasty Substudy 10 8 % 6 7 5.7 6 4.4 4 2.3 2 0 t-PA (n=573) PTCA (n=565) 0.2 Death (Re) MI 30 Day Endpoints Stroke Optimizing Patency After PTCA PTCA • Heparin • Glycoprotein IIb/IIIa inhibitor • IABP • Stents IABP After Primary PTCA IABP Stone et al. JACC 1997;29:1459. 10 8 8 6.2 6 % 4 6.7 5.5 4.3 P=0.03 2.4 3.1 2 0 No IABP (n=226) Death Reinfarction Reocclusion 0 Stroke IABP (n=211) Clinical Markers of Severe CAD CAD • Major – recent MI – unstable or severe angina – uncompensated CHF Clinical Markers of Severe CAD CAD • Intermediate – less severe from “major” – DM • Minor – – – advanced age abnormal ECG poor functional capacity Preoperative Revascularization Preoperative Risk Guidelines • Standard indications for Standard revascularization revascularization • Noncardiac surgery risk > 5% • Cardiac revascularization risk < 3% ...
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This note was uploaded on 12/16/2011 for the course BIOLOGY 101 taught by Professor Mr.wallace during the Fall '11 term at Montgomery College.

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