Preoperative CardiacPreoperative Cardiac...

Preoperative CardiacPreoperative Cardiac Evaluation 2012Evaluation 2012

John E. Ellis MDUniversity of Pennsylvania (USA)y y ( )

johnellis1700@gmail.com

WHAT’S THE GOAL OF PREOPEVAL?

•Is patient in best possible shape?C th ti t b d b tt ?•Can the patient be made better?

•Risk assessment?Risk assessment?•Who should not have surgery?

What will kill the patient?p

•T i l l CAD•Triple vessel CAD•L ft i CAD•Left main CAD•A ti t i•Aortic stenosis

Anesthesiology 2010; 113:794 – 805

PERIOP CV EVAL 2012•Falling periop event rates make aggressive workup less rewardingaggressive workup less rewarding•What’s it worth to reduce complications 50%50%…

•From 10% to 5%? (NNT = 20)From 2% to 1%? (NNT = 100)•From 2% to 1%? (NNT = 100)

Who is at risk for perioperativemyocardial infarction?

What tools to use?What tools to use?• American Society of• American Society of

Anesthesiologists?• Charlson comorbidity?• Lee (Goldman) cardiac risk index?Lee (Goldman) cardiac risk index?• Eagle• F ilt ?• Frailty?

Pathophysiologic differences?Pathophysiologic differences?

•Different risk factors•Different risk factorsoSmokinggoObesity

Di b toDiabetesoSleep apneaoSleep apnea

“BEDSIDE” RISK FACTORS

Lee TH et al Circulation 1999

“BEDSIDE” RISKFACTORS

•High risk surgeryh/o ischemic heart disease•h/o ischemic heart disease

•h/o CHF•h/o CVAInsulin Rx•Insulin Rx

•Creatinine > 2.0 mg/dL

Lee TH et al Circulation 1999

By definition, patients undergoing AAA, thoracic, and abdominal procedures were excluded from class I.

Risk class predicts cardiovascular morbidity

Class 1: 0 riskClass 2: 1 risksClass 3: 2 risksClass 3: 2 risksClass 4: >3 risks

But that’s not allBut that s not all…Changing nature of cardiovascular

disease

Circulation 2011, 124:289-296: originally published online June 27, 2011

Circulation 2011, 124:289-296: originally published online June 27, 2011

Wh t b t h t i ?What about hypertension?

Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 6 (December), 2010: pp 927-930

Limitations of "traditional" evaluationevaluation

T d t f 1Tend to focus on 1 organ systemsystemOften the heartOften the heart

Yet surgical morbidityYet, surgical morbidity and mortality have ychanged

The Elderly PatientThe Elderly Patient

Aging DemographicsAging DemographicsLife RankLife expectancy

Rank

Australia 81.81 9thust a a 8 8 9t

Hong Kong 82.04 8th

New Zealand 80.59 23rd

https://www.cia.gov/library/publications/the‐world‐factbook/rankorder/2102rank.html

Functional status in elderlyFunctional status in elderly

http://www.nytimes.com/2012/08/25/sports/25iht-athlete25.html?_r=0

• Unintentional weight loss ≥10 pounds in lastyear.yea

• Decreased grip strength (weakness).• ExhaustionExhaustion.• Low physical activity.• Slowed walking speed (walk 15 feet)Slowed walking speed (walk 15 feet).

Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908

Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908

Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908

Who “needs” a stress test?Cardiology consultation?

LAURA C•55 yo F•s/p CVA MI CHF IDDM•s/p CVA, MI, CHF, IDDM•Gangrenous toesF di t l b d•Fem-distal bypass proposed

Does she need a stress test?

JOHN B•75 yo WM for iliac angioplasty•Cath, stented RCA s/p MI 2 years agoCat , ste ted C s/p yea s ago

•No symptoms since•Medical Rx

•ACE-I•Beta blocker•Statin•Aspirin

Does he need a stress test?

I will argueLaura C maybe needs a stress

test (or maybe straight to cardiac th)cath)

J h B d tJohn B does not

WHAT DOES STRESS TEST ADD?

•L’Italien et alROC (P ti•ROC curve areas (Prognostic accuracy)

•74% by clinical criteria•81% by clinical criteria + stress81% by clinical criteria stress tests

J Am Coll Cardiol. 1996 Mar 15;27(4):779-86.

It’s the history!It s the history!

Once again, history and physical more important than “specialized” testing

S SStep 1: Emergency Surgery

Proceed to surgery with medical risk reduction and perioperativerisk reduction and perioperativesurveillance

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

St 2 A ti C di C ditiStep 2: Active Cardiac Conditions• Unstable angina, recent MI• Decompensated CHF• Decompensated CHF• Significant arrhythmias• Severe valvular disease• Severe valvular disease

Postpone surgery until stabilized or corrected

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

or corrected

St 3 L Ri k S ( i k <1%)Step 3: Low Risk Surgery (risk <1%)• Superficial or endoscopic• Cataract or breast• Cataract or breast• Ambulatory

Proceed to surgery

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

St 4 F ti l C itStep 4: Functional Capacity• Good• > 4 METs• > 4 METs

o Can walk flight of stairs without symptomssymptoms

Proceed to surgery

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

Risk factors• DMCVA / TIA• CVA / TIA• CHF• CAD

• Cr > 2 0• Cr > 2.0

No risk factors: 1 2 risk factors AND >3 risk factors:No risk factors:

PROCEED TO

1-2 risk factors ANDvascular / intermed.

surgery:

>3 risk factors:

CONSIDER STRESS TESTINGPROCEED TO

SURGERY PROCEED TO SURGERY WITH

HR CONTROL

STRESS TESTINGIF IT WILL CHANGE

MANAGEMENT

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1

Ann Surg. 2012 Sep 7. [Epub ahead of print]

Ann Surg. 2012 Sep 7. [Epub ahead of print]

TABLE 5. Predictors of Preoperative Cardiac Stress Testing (N = 74,117)

Female

Year of surgery

Charlson comorbidity indexCharlson comorbidity index

Size of MSA

US region

Hospital size

Least in Pacific NW

Hospital size

MSA indicates metropolitan statistical area.All P < 0 05

Ann Surg. 2012 Sep 7. [Epub ahead of print]

All P < 0.05

J Clin Anesth. 2010 Sep;22(6):402-9

ConclusionsConclusions• Declining cardiac event rates change theDeclining cardiac event rates change the

value of preop testing• Preop evaluation should be guided by historyPreop evaluation should be guided by history• Other factors important besides CAD:

o Heart failureo Heart failureo Arrhythmiaso Valvular heart diseaseoo Fraility

• Stress tests are marginally useful to g yreclassify intermediate risk patients