PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009

PREOPERATIVE CARDIAC

CLEARANCE

GME CHIEF RETREATSEPTEMBER 2010AUGUST 5TH, 2009

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

WHAT IS THE APPROPRIATE CARDIAC EVALUATION?

Case #1

A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

Slide 2

Slide 3

CASE #1SHOULD THIS PATIENT GET A

CARDIAC STRESS TEST?

1. Yes2. No

1 2

0%0%

10

WHAT IS THE APPROPRIATECARDIAC EVALUATION?

Case #2

An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

Slide 4



1 2

0%0%

1. Yes2. No

10Slide 5


Case #3

A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

Slide 6



1 2

0%0%

1. Yes2. No

10 Slide 7

CARDIAC PREOPERATIVE EVALUATION

Circulation (2007) 116:1971.

AHA 2007 Guidelines on Perioperative

Cardiovascular Evaluation for Non-cardiac Surgery

Clinical Cardiac Risk Factors

Operative Risk

Functional Capacity

Slide 8

YesORSTEP 1

No

Emergency Operation?

Circulation (2007) 116:1971.

Slide 9

OR = operating room

YesORSTEP 1

No

Active Cardiac Condition


STEP 2

Circulation (2007) 116:1971.

Slide 10

CLINICAL RISK FACTOR ASSESSMENT

Slide 11Circulation (2007) 116:1971.

Major Risk Factors

• Unstable coronary syndromes

Unstable/severe angina

Recent MI

• Decompensated CHF

• Significant arrhythmia

• Severe valvular disease

YesORSTEP 1

No



Yes Non-Invasive Stress Test / Treat

Consider OR

No

STEP 2

Circulation (2007) 116:1971.

Slide 12

YesORSTEP 1

No




Consider OR

Low-Risk Operation

No

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 13

OPERATION RISK STRATIFICATION

Circulation (2007) 116:1971.

Anticipated Risk of Cardiac Events

ProcedureExamples

High risk >5% Aortic surgeryPeripheral vascular

Intermediate risk 1%–5% Abdominal/thoracic surgeryOrthopedic surgery

Low risk <1% Endoscopy, cataract, hernia, breast

Slide 14

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

No

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 15

YesORSTEP 1

No




Consider OR

Low Risk Operation

YesOR

No

Functional Capacity

4 METs

NoSTEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 16

METABOLIC EQUIVALENTS

Circulation (2007) 116:1971.

1 MET

4 METs

Can you…

Take care of yourself?

Eat, dress, toilet?

Walk a block or two at 3 mph?

Do light work around the house like dusting or washing?

4 METs

>10 METs

Can you…

Climb a flight of stairs?

Walk at 4 mph?

Do heavy housework (scrubbing, lifting)?

Participate in strenuous sports (swim, football, ski)?

Slide 17

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 18

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

1 or 2 Clinical Risk Factors

3 Clinical Risk

Factors

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 19

CLINICAL RISK FACTOR ASSESSMENT

Circulation (2007) 116:1971.

Major Risk Factors

• Unstable coronary

syndromes

Unstable/severe angina

Recent MI

• Decompensated CHF

• Significant arrhythmia

• Severe valvular disease

Other Risk Factors

• History of heart disease

• Compensated prior CHF

• Prior cerebrovascular disease

• Diabetes mellitus

• Renal insufficiency

Slide 20

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR


3 Clinical Risk

Factors

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 21

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR


1. Proceed with planned surgery with HR control

2. Consider non-invasive testing

3 Clinical Risk

Factors

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 22

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR


1. Proceed with planned surgery with heart rate control


3 Clinical Risk

Factors

Vascular Surgery Intermediate Risk

Consider testing

Consider treating

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 23

CORONARY REVASCULARIZATION PRIOR TO SURGERY?

Coronary Artery Revascularization Prophylaxis (CARP) Trial

NEJM (2004) 351:2795.

• 510 patients prior to major vascular surgery

• ≥ 70% stenosis of 1 or more coronary arteries

• Randomized to receive:

Revascularization prior to surgery

No revascularization prior to surgery

Slide 24



NEJM (2004) 351:2795.

Revascularization(n = 258)

Medical Management(n = 252)

MI, 30 days 12% 14% P = .37

Mortality, 2.7 yr 22% 23% P = .92

Slide 25



NEJM (2004) 351:2795.

Revascularization(n = 258)

Medical Management(n = 252)

MI, 30 days 12% 14% P = .37

Mortality, 2.7 yr 22% 23% P = .92

Days to surgery 54 18 P < .01

Slide 26

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR




3 Clinical Risk

Factors


Consider testing

Consider treating

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 27

PERIOPERATIVE BETA-BLOCKADE

NEJM (1996) 335:1713.

• Dosing 30 minutes prior and immediately post-op

• IF HR 55 and SBP 100 AND no evidence of CHF, 3º heart block, bronchospasm

THEN

1) Atenolol 5 mg IV over 5 minutes

2) Wait for 5 minutes

3) If HR and SBP criteria still met, repeat dose once

Slide 28

POSTOPERATIVE BETA-BLOCKADE

NEJM (1996) 335:1713.

• Intravenous (twice-daily dosing)

Same dosing as perioperative protocol

OR

• Oral (once-daily dosing)

If HR 65 and SBP 100, then atenolol 100 mg

If HR 55 and SBP 100, then atenolol 50 mg

Continue until discharge or 7 days post-op

Slide 29

EVIDENCE FOR BETA-BLOCKADE

NEJM (1996) 335:1713.

Beta-Blockade(n = 99)

Placebo(n = 101)

Mortality, 6 months 0% 8% P < .01

Mortality, 1 year 3% 14% P = .01

Mortality, 2 years 10% 21% P = .02

Slide 30


Case #1 revisited

A 71-year-old woman with no previous medical history is scheduled for a total knee arthroplasty. Her blood pressure is 167/93 mm Hg. She can walk only 1 block because of knee pain.

Slide 31

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

Yes OR

No

No/Unknown

No Clinical Risk

Factors

OR




3 Clinical Risk

Factors


Consider testing

Consider treating

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 32


Case #2 revisited

An 81-year-old man with a history of a heart attack, hypertension, and renal insufficiency is scheduled for an open lung resection. He is able to perform light housework only for short periods of time because he becomes short of breath.

Slide 33

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR




3 Clinical Risk

Factors


Consider testing

Consider treating

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

Slide 34


Case #3 revisited

A 68-year-old man with a history of diabetes, heart failure, stroke, and chronic renal insufficiency plans to undergo a resection of a left ear mass. He can climb half a flight of stairs, after which he becomes short of breath.

Slide 35

YesORSTEP 1

No




Consider OR

Low-Risk Operation

YesOR

No

Functional Capacity

4 METs

YesOR

No

No/Unknown

No Clinical Risk

Factors

OR




3 Clinical Risk

Factors


Consider testing

Consider treating

STEP 5

STEP 4

STEP 3

STEP 2

Circulation (2007) 116:1971.

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PreOperative Cardiac Clearance GME Chief Retreat September 2010 August 5th, 2009