CCS Perioperative Guidelines When to order a BNP and What ... · CCS Perioperative Guidelines . When to order a BNP and What to do with a Positive Troponin . Dr. Vikas Tandon. Associate

CCS Perioperative Guidelines When to order a BNP and What to do with a

Positive Troponin

Dr. Vikas TandonAssociate Professor, Cardiology

McMaster UniversityNovember 1, 2017

Canadian Society of Internal MedicineAnnual Meeting 2017

Toronto, ON

CSIM Annual Meeting 2017Conflict Disclosures

I have the following conflicts to declare:

Company/Organization Details

Advisory Board or equivalent X X

Speakers bureau member X X

Payment from a commercial organization. (including gifts or other consideration or ‘in kind’ compensation)

X X

Grant(s) or an honorarium X X

Patent for a product referred to or marketed by a commercial organization. X X

Investments in a pharmaceutical organization, medical devices company or communications firm.

X X

Participating or participated in a clinical trial McMaster University Participated in periop research studies

including VISION, POISE-2, MANAGE

CSIM Annual Meeting 2017

The following presentation represents the views of the speakerat the time of the presentation. This information is meant foreducational purposes, and should not replace other sources

of information or your medical judgment.

Learning Objectives:• Understand the importance of perioperative risk assessment • Review the utility of current risk stratification tools • Examine the utility of BNP/nt-pro-BNP in the preoperative setting • Understand the significance of the postoperative troponin elevation and develop an approach to management

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• 72 y/o F with significant OA• Referred for upcoming total knee arthroplasty• Cardiac risk factors

• DM, HTN, Chol, previous NSTEMI 2003

• Otherwise asymptomatic, N vitals, N labs• Meds: ASA, Atorvastatin, Coversyl, Bisoprolol• OR date – July 19, 2016

Case – Mrs. B.W.

• What should be done next?1. Send for cath2. Take pt straight to the OR, no other consult

required3. Cancel surgery – too high risk4. Consider for a perioperative consult by

medicine and/or cardiology teams

Case – Mrs. B.W.

Is the preoperative consult useful?

• Worldwide >200,000,000 major noncardiac surgical procedures annually

• 1:20 suffer myocardial injury/infarction or cardiac arrest/death within 30 days

• Perioperative cardiac complications account for ≥1/3 of perioperative deaths

Scope of problem


Yes!

1. Patients: – ethical obligation to patients to give accurate

risk assessment for informed decision making

2. Physicians:– Gauge CV risk to guide management– Further testing if needed– Instructions re: medications– Postop monitoring– Shared care model


1. Clear estimation of risk

2. Clear recommendation re: further testing

3. Clear recommendations for medications

4. Clear direction as to degree of post op monitoring– i.e. ward bed w tele vs CCU/ICU/Step down bed, trops

5. Clear communication of who will do what

Good Pre-op Consults Specify:

• RCRI – most validated; simplest to use– CAD, stroke, CHF, DM, high risk surgery, Creatinine– Does not take into account emergency surgeries– underestimates cardiac risk by 50%

•NSQIP – likely superior to RCRI– Requires an online calculator– Underestimates risk as routine troponin screening not

done

•All risk scores – will underestimate in >40% pts– Limited mobility so pts won’t manifest symptoms

Risk Scores

CCS Recommendation

When evaluating cardiac risk, we suggest clinicians use RCRI over other available

clinical risk prediction scores

Conditional recommendationlow-quality evidence

Variables Pts

Hx of IHD 1

Hx of CHF 1

Hx of CVD 1

Insulin for diabetes 1

Crt >177 µmol/L 1

High-risk surgery 1

Total RCRI points

Risk of MI, cardiacarrest, or death 30 days after surgery

95% CI

0 3.9% 2.8%-5.4%

1 6.0% 4.9%-7.4%

2 10.1% 8.1%-12.6%

≥3 15.0% 11.1%-20.0%

* based on high-quality external validation studies

Revised Cardiac Risk Index

• Current guidelines:– Pts with low functional capacity– Pts with risk of MI/death ≥ 1%– When result will change management

• Stress Nuclear and Stress Echo most common– 9% of adults ≥ age 40 with int/high risk tested

Is Non-Invasive Testing Useful?

• Several studies, mostly small sample size and small number of events

• Low quality of evidence– most retrospective, few reported risk adjusted associations

• No study adequately assessed incremental value of stress tests over well-established perioperative cardiac risk factors (e.g., RCRI)

Pharmacological stress echocardiography and radionuclide imaging

CCS RecommendationsWe recommend against performing preoperative exercise stress test,

pharmacological stress echocardiography,

or preoperative radionuclide imaging to enhance perioperative cardiac risk

estimation

Is Cardiac CT Angiography Useful?

• Prospective cohort study– 12 centers in 8 countries

• Evaluated whether preop CCTA enhances perioperative risk prediction in 955 at-risk patients

• Physicians were blinded unless LM detected• Systematic Postop Trop monitoring• Primary outcome - CV death and nonfatal MI

– 74 patients (7.7%) within 30 days of surgery

VISION CCTA

• Although CCTA findings improve risk estimation – for patients who will suffer periop CV death or

MI

• CCTA findings are more than 5 X as likely to lead to inappropriate overestimation of risk – among patients who will not suffer these

outcomes

Interpretation of VISION CCTA results

CCS Recommendation

We recommend against performing preoperative coronary CT angiography to

enhance perioperative cardiac risk estimation Strong recommendation,

moderate-quality evidence

Biomarkers – NT pro-BNP

Individual data M-A of 2179 patients

• 235 suffered death or MI within 30 days after noncardiac surgery

• Preop NT-proBNP ≥300 ng/l or BNP ≥92 ng/l strongest independent preop predictor of death/MI– OR, 3.40; 95% CI, 2.57-4.47

• Compared to preop clinical model preop natriuretic peptide improved risk estimation among patients who did and did not suffer primary outcome

• In sample of 1000 patients overall absolute NRI is 155 patients

Test result Risk estimate

95% CI

NT-proBNP <300 ng/L or BNP <92 mg/L 4.9% 3.9% - 6.1%

NT-proBNP value ≥300 ng/L or BNP ≥92 mg/L 21.8% 19.0% - 24.8%

Risk of death or MI at 30 days after noncardiac surgery, based on patient’s preoperative NT-proBNP or BNP

– compared to RCRI, preop NT-proBNP/BNP results improved risk classification in 155 patients in 1000 patient sample

– based on risk categories <5%, 5-10%, >10-15%, >15%

NT-proBNP/BNP

• Compared to imaging, NT pro-BNP– More accurate– Less expensive– Convenient and faster due to availability of

point of care NT pro-BNP assays– due to cost differential b/w NT pro-BNP and

consult may have role in determining who needs preop consult

Biomarkers – NT pro-BNP

We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance

perioperative cardiac risk estimation in patients ≥65 years of age, 45 to 64 years of age with

significant cardiovascular disease, or who have RCRI score ≥1

Strong recommendation, moderate-quality evidence

CCS Recommendation

x



• Otherwise asymptomatic, N vitals, N labs• Meds: ASA, Atorvastatin, Coversyl, Bisoprolol• OR date – July 19, 2016

Case – Mrs. B.W.

x

Troponin monitoring

• POISE Trial (8351 patients)

• 65% of patients suffering perioperative MI do not experience ischemic symptoms

• Presence or absence of signs/symptoms doesnot change risk 30-day mortality– symptomatic MI: aOR 4.76 (95% CI, 2.68-8.43)– asymptomatic MI: aOR 4.00 (95% CI, 2.65-6.06)

VISION Study (Botto 2014)• Prospective international cohort study • 15,065 in-hospital noncardiac surgery patients • TnT measured postop days 1,2,3

• MINS Criteria TnT ≥ 0.03 ng/ml due to myocardial ischemia– death at 30 days: MINS - 9.8%, No MINS - 1.1%

• 84% MINS asymptomatic– undetected without troponin monitoring

• Asymptomatic perioperative TnT elevations adjudicated as myocardial injuries due to ischemia – that did not fulfill Universal Definition of MI –were also associated with increased risk of 30-day mortality– aHR, 3.30; 95% CI, 2.26–4.81

RecommendationWe recommend obtaining daily troponin

measurements for 48 to 72 hours after noncardiacsurgery in patients with baseline risk >5%* for

cardiovascular death or nonfatal MI at 30 days after surgery


* Patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥1, age 45 to 64 years with significant cardiovascular disease, or age ≥65 years

Approach to MINS• Look for and correct physiological

abnormalities – hypoxia, hypotension, tachycardia (if BP adequate),

Hb if <70

• If no signs of bleeding initiate ASA 81 mg daily

• Initiate or intensify Statin therapy

Postoperative management of complications

• ASA and statin in patients suffering myocardial injury after noncardiac surgery

• Prospective cohort study

• 415 noncardiac surgery patients who suffered postop MI

• ASA and statin at discharge reduced 30-day mortality– ASA : aOR 0.54 (95% CI, 0.29-0.99)– Statin: aOR 0.26 (95% CI, 0.13-0.54)

RecommendationsWe recommend initiation of long-term ASA and statin in patients who suffer myocardial injury or myocardial

infarction after noncardiac surgery




• Otherwise asymptomatic, N vitals, N labs• Meds: ASA, Atorvastatin, Coversyl, Bisoprolol

• Follow up – 1, 6, 12, (18, 24) months

Case – Mrs. B.W.

Conclusions1. Current clinical risk scores underestimate risk in substantial

proportion of patients – Revised risk estimations for RCRI in new CCS guidelines– Non-invasive testing probably adds little– CCTA has net overall effect of putting more patients in wrong risk

category

2. NT pro-BNP is more accurate, convenient, faster, and less expensive than non-invasive testing

3. Troponin are strong independent predictor of 30-day mortality after noncardiac surgery

– 85% of MINS patients asymptomatic (4TH gen trop)– Up to 93% asymptomatic with hs-trops

4. ASA and Statins reduce 30 day mortality in patients with MINS

CSIM Annual Meeting 2017

Special thanks to Dr. PJ Devereaux• Scientific Leader, Perioperative Research

Group, PHRI, McMaster University• VISION, POISE 1, POISE 2• MANAGE, HIP ATTACK, VISION 2, POISE 3

• Co-Chair, CCS Perioperative Guidelines

Comments and Questions

M-A of dipyridamole stress perfusion prior to vascular surgery


Baseline risk = 7%


Baseline risk = 7%


Baseline risk = 7%


Baseline risk = 7%


Baseline risk = 7%


Baseline risk = 7%

• Limitations:– Small studies, few events, clinicians not blinded– Almost half used a retrospective design– No evaluation independent prognostic value– Few systematically monitored for MI– None reporting net absolute reclassification

Is Non-Invasive Testing Useful?

Net Absolute Reclassification Index

• how well a new model reclassifies subjects -either appropriately or inappropriately - as compared to an old model

• i.e. comparison of old model vs. old model + 1 new element

• RCRI alone vs. RCRI + non invasive test

Is Cardiac CT Angiography Useful?

VISION CCTA• Prospective cohort study

– 12 centers in 8 countries

• Evaluated whether preop CCTA enhances perioperative risk prediction in 955 at-risk patients

• Physicians were blinded unless LM detected• Systematic Postop Trop monitoring• Primary outcome - CV death and nonfatal MI

– 74 patients (7.7%) within 30 days of surgery

Model with CCTA and RCRI - C=0.66# of

PatientsHR 95% CI P

RCRI scores012 ≥3

32040717850

1.001.39 (0.74-2.61)1.88 (0.94-3.79)4.02 (1.80-8.98)

0.005-

0.3000.076

<0.001CCTA findingsNormalNon-obstObstructiveExtensive obst

81371357146

1.001.51 (0.45-5.10)2.05 (0.62-6.74)

3.76 (1.12-12.62)

0.014-

0.5090.2380.032

Model with CCTA and RCRI - C=0.66# of

PatientsHR 95% CI P

RCRI scores012 ≥3

32040717850

1.001.39 (0.74-2.61)1.88 (0.94-3.79)4.02 (1.80-8.98)

0.005-

0.3000.076

<0.001CCTA findingsNormalNon-obstObstructiveExtensive obst

81371357146

1.001.51 (0.45-5.10)2.05 (0.62-6.74)

3.76 (1.12-12.62)

0.014-

0.5090.2380.032

NRI for those who had event: 21.6% 95% CI 10.4-32.9) p<0.001NRI for those who did not have event: -10.7% (-13.9- -7.5) p<0.001 Overall NRI: 11% (-0.73, 22.64), p=0.066

Net reclassification indexModels for 30 day probability of CV death and MI

Model that included CCTA findingsPatients who had

an eventPatients who did not have

an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29

17 pts appropriately reclassified1 pt inappropriately reclassfiedNet = 17-1 =16




an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29





an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29





an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29





an event

RCRI only

<5% 5-15% >15% <5% 5-15% >15%

<5% 5 10 0 191 114 05-15% 0 41 7 47 453 37>15% 0 1 10 0 10 29

17 pts appropriately reclassified 57 pts appropriately reclassified1 pt inappropriately reclassfied 151 pts inapprop. reclassifiedNet = 17-1 = 16 Net = 57-151 = -94

Interpretation of VISION CCTA results

• Although CCTA findings improve risk estimation – for patients who will suffer periop CV death or

MI

• CCTA findings are more than 5 X as likely to lead to inappropriate overestimation of risk – among patients who will not suffer these

outcomes

CCS Recommendation

We recommend against performing preoperative coronary CT angiography to

enhance perioperative cardiac risk estimation Strong recommendation,

moderate-quality evidence

Documents

CCS Perioperative Guidelines When to order a BNP and What ... · CCS Perioperative Guidelines . When to order a BNP and What to do with a Positive Troponin . Dr. Vikas Tandon. Associate