Yatish Preop Clearance Final - Copy

8/7/2019 Yatish Preop Clearance Final - Copy

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Ultimate Goal

Quality of care and serving the

patients best interests.


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Goals

Understand how to estimate peri-operative CV

risk

Know when to perform stress testingpreoperatively

Learn how to reduce risk perioperatively in

those at higher risk


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55 Years old man with history of hypertension & CAD but

asymptomatic runs for 30 minutes daily, needs inguinal

hernia repair. You are consulted to clear him for surgery.

1) Order Nuclear stress test to evaluate

CAD.

2) Order Regular stress test

3) Order Cardiac catheterization

4) Clear for surgery


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Inflammatory

State

Hypercoagulable

StateStress

State

Hypoxic

State

Triggers

Surgical Trauma

Anesthesia/analgesia

Surgical Trauma


Surgical Trauma


Intubation/extubation

Pain

Hypothermia

Bleeding/anemiaFasting


Hypothermia

Bleeding/anemia

TNF-

IL-1

IL-6

CRP

PAI-1

Factor VII

Platelet reactivity

antithrombin III

catecholamine and

cortisol levelsoxygen delivery

BP

HR

FFAs

relative insulin

deficiency

Coronary artery shear

stress

Plaque fissuring

Oxygen demand

Myocardial

Ischemia

Acute Coronary

Thrombus

Perioperative Myocardial Infarction

Plaque fissuring


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Overview

Risk Assessment

Preoperative Testing

Postoperative Management to Reduce Risk


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Approaches to Risk Assessment

1. ASA/Dripps

2. Goldman Multifactorial Index

3. Detsky Modified Index

4. Revised Risk Index

5. ACC/AHA Task Force

Recommendations

Quantitative

Strategic


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Dripps/ASA ClassificationClass Systemic Disturbance Mortality*

1 Healthy patient with no disease outside of the surgical

process


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Goldman Risk Index

Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac

risk in non-cardiac surgical procedures.N Engl J Med148:2120-2127, 1988.


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Goldman Risk Index

Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac

risk in non-cardiac surgical procedures.N Engl J Med148:2120-2127, 1988.


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J Am Coll Cardiol, 2007; 50:1707-1732

ACC/AHA Guidelines


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Stepwise Approach to the Pre-

operative Evaluation


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Stepwise Approach to Preoperative Cardiac Assessment

Need for emergencynoncardiac

surgery

Operating room

Evaluate and treat

per ACC/AHA

Guidelines

Vigilant perioperativeand postoperative

management

Consider

Operating Room

Low Risk

Surgery

Active

cardiac

conditions

No

Yes

Yes

No

Proceed with

planned surgery

Asymptomatic andgood functional

capacity

Yes

Proceed with

planned surgery

No

Yes

Manage based on

clinical risk factors

No


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Active Cardiac Conditions

Surgery

Acute or recent MI (7Acute or recent MI (7--30 d)30 d)

Unstable coronary syndromeUnstable coronary syndromeDecompensated CHFDecompensated CHF

Significant ArrhythmiasSignificant Arrhythmias

Severe Valvular DiseaseSevere Valvular Disease

High Risk:High Risk:


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surgery

Operating room

Evaluate and treat

per ACC/AHA

Guidelines


management

Consider

Operating Room

Low Risk

Surgery

Active

cardiac

conditions

No

Yes

Yes

No

Proceed with

planned surgery


capacity

Yes

Proceed with

planned surgery

No

Yes

Manage based on


No


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Low Risk Surgery Risk < 1%

Endoscopic procedures

Superficial procedure

Cataract surgery

Breast surgery


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Low Risk Situations

Reasonable to proceed with surgery

Low risk surgeryLow risk surgeryGood functional capacityGood functional capacity

No cardiac symptomsNo cardiac symptoms

No active cardiac conditionsNo active cardiac conditions

No clinical risk factorsNo clinical risk factors

Low Risk:Low Risk:


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Functional Capacity :

Metabolic Equivalents (METs)

1. Correlates with maximum

oxygen uptake on treadmill

testing

2. Demonstrated predictor of

future cardiac events

2. Poor functional capacity may

hide low threshold cardiac

symptoms


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What is basal O2 consumption

(Vo2)?1) 1.5 ml/kg/min2) 2.5 ml/kg/min

3) 3.5 ml/kg/min4) 4.5 ml/kg/min


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Duke Activity Status Index

1 MET Can you take care of yourself?

Eat, dress, or use the toilet?

Walk indoors around the house?

Walk a block or two on level

ground at 2-3 mph or 3.2-4.8km/h?

4 METs Do light work around the house

like dusting or washing clothes?

MET = metabolic equivalent

4 METs Climb a flight ofstairs or walk up a

hill?

Walk on level ground at 4 mph or

6.4 km/h?

Run a short distance?Do heavy work around the house

likescrubbing floors orlifting or

moving heavy objects?

Participate in moderate

recreational activitieslike golf,

bowling, dancing, doubles tennis,

or throwing a baseball or football?

10 METs Participate in strenuoussportslike

swimming, singles tennis, football,

baseball, orskiing?

Resting or basal O2 consumption(Vo2) of a 70 kg, 40 yrs old man is

3.5 mL per kg per min, or 1 MET.


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Clinical Risk Factors

Known Ischemic Heart Disease

Compensated or Prior Heart Failure

Diabetes Renal Insufficiency

Cerebrovascular disease


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surgery

Operating room

Evaluate and treat

per ACC/AHA

Guidelines


management

Consider

Operating Room

Low Risk

Surgery

Active

cardiac

conditions

No

Yes

Yes

No

Proceed with

planned surgery


capacity

Yes

Proceed with

planned surgery

No

Yes

Manage based on


No


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Clinical Risk Factors

History of heart diseaseHistory of heart disease

Compensated or prior CHFCompensated or prior CHF

Cerebrovascular diseaseCerebrovascular disease

Diabetes MellitusDiabetes Mellitus

Renal InsufficiencyRenal Insufficiency

Proceed CautiouslyProceed Cautiously


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Manage based on


3 or more clinical

risk factors*

1 or 2 clinical

risk factors*

No clinical

risk factors*

Vascular

Surgery

Intermediate

risk surgery

Vascular

Surgery

Intermediate

risk surgery

Proceed with

planned surgery

Proceed with planned surgery with HR control

or consider non-invasive testingConsider Testing

*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal

insufficiency, cerebrovascular disease

Asymptomatic but

poor/unknown functional

capacity


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Intermediate Risk Surgery Risk < 5%

Carotid endarterectomy

Endovascular AAA repair

Head and neck

Intraperitoneal and intrathoracic

Orthopedic

Prostate


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High Risk Surgery Risk > 5%

Emergent major operations (3-5 times more risk)

Aortic and other major vascular

Peripheral vascular

Anticipated prolonged or associated with large fluid

shifts and/or blood loss


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Overview

Risk Assessment


Postoperative Management to Reduce Risk


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Most preoperative testing assesses for

presence of obstructive CAD and NOT

plaque vulnerability which truly predicts

the risk.

Unfortunately we have no way of

predicting this.


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ACC/AHA Recommendations

Echocardiography:

Dyspnea of unknown origin (Class IIa)

Current or hx of HF and no echo in 12 months

(Class IIa)

12 Lead ECG

Vascular surgery and 1 CRF (class I)

CRFs and intermediate risk surgery (class I)

All vascular surgery (class IIa)


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ACC/AHA Recommendations

Treadmill stress testing

High cardiac risk conditions

3 CRFs, poor functional capacity & vascular

surgery (class IIa)

Nuclear stress testing


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Which test to choose?

Most ambulatory

patients

Abnormal resting

ECG (dig, LVH)

LBBBUnable to exercise

Treadmill Stress Test

Exercise

echo or sestamibi

DSE

Adenosine sestamibi

dipyridamole sestamibi


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Preoperative TestingNegative Predictive Value

96.3

98.699.4

80

85

90

95

100

%

St ECG Dipyramadole Tl Dobutamine Echo

Freedom from MI or DeathFreedom from MI or Death

Eagle et al. JACC 1996;27:910.Eagle et al. JACC 1996;27:910.


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Whenever feasible, an exercise stress test is best

choice

Dipyridamole or adenosine perfusion scan andDSE are reasonable choices if:

unable to exercise

BBB or other resting ECG abnormality

Avoid dipyridamole and adenosine scan ifbronchspasm

Avoid DSE if serious arrhythmias or severe

hypertension

Caveats


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Overview

Risk Assessment


Perioperative Management to Reduce Risk


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60 yrs old man with history of CAD, HTN, DM & Creatinine of

2.5 showed small I W ischemia on nuclear stress test at 10

METS & asymptomatic, needs to have prostatectomy for Ca.

How would you treat?

1) Cardiac cath & PCI as indicated.

2) Cancel surgery & request other Rx option.3) BB with heart rate control perioperative.

4) Give nitrates & CCB & proceed with surgery.


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Perioperative Nitrates?

0

5

10

15

20

25

30

35

Percen

I

che

c

Preop Induc on Inc on E erg. PostOp

ontrol

TNG

Dodds, et al. Anesth. Analg. 1993;76:705-13


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Perioperative Management

Revascularization

Beta blockers

Statins Alpha-2 agonists

Calcium channel blockers


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Revascularization

5859 vets screened prior

to vascular surgery;4669

excluded

510 randomized to: Revascularization (258)

99 CABG

141 PCI

18 not revascularized

252 no revascularization

9 revascularized

143 medical rx

McFalls, et al. NEJM 2004;351:2795-2804


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Intervention is rarely necessary to simply lower

the risk of surgery.

Revascularization (surgery or PCI) should be

considered only if standard indications arepresent.


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PCI before anticipated surgery

Acute MI

High Risk ACS

High risk anatomy

Stent and continued

Dual-antiplatelet rx

Bleeding risk of

anticipated surgery

Balloon

angioplasty

Bare-metal

stent

Drug-eluting

stent

14 to 29Days

30 365Days

> 365Days

Low

Not low


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Timing of Surgery After PCI

Balloon

angioplasty

Bare-metal

stent

Drug-eluting

stent

< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days

DelaySurgery

with ASADelay Delay

Surgery

with ASA

Surgery

with ASA


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Revascularization

Beta blockers




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Postoperative Mortality ReductionBeta-Blockers

8

14

21

0

3

10

0

5

10

15

20

25

Pl ce Ate l l

6 t

1 Ye r

2 Ye r

200 pts undergoing

non-cardiac surgery

Random assignmentto:

IV followed by oral

atenolol or

Placebo

Double-blind follow-up over 2 years

Mangano, et al. NEMJ 199 ;335:1713.

Mortality


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Postoperative Cardiac Events In HighRisk Patients

Bisoprolol n=59Placebo n=53

Poldermans et al. NEJM 1999;341:1789.Poldermans et al. NEJM 1999;341:1789.

173 patients

undergoing vascularsurgery with positive

DSE

Randomized to BB

1 week pre-op or

placeboFollowed for 30

days

1 7 1 7

3 .45

1 0

1 5

0

25

P l ac e bo B i s opr o l o l

B e ta B loc ad e

ardiac ea t

N o n a ta l M


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Perioperative Beta Blockers

AHA/ACC Recommendations: 2006 UpdateBeta blockers required in recent past to control symptoms of angina orpatients with symptomatic arrhythmias or hypertension

Patients at high cardiac risk owing to the finding of ischemia on

preoperative testing who are undergoing vascular surgeryPatients undergoing vascular surgery and with identified CAD

Vascular surgery and multiple cardiac risk factors

Moderate or high risk surgery and multiple cardiac risk factors

Key Point: if known or suspected CAD and

undergoing moderate or high risk surgery, use a

beta blocker!


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Revascularization

Beta blockers




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Perioperative Statins?

100 patients pre-op before

vascular surgery

Random assignment:

Atorvastatin 20 mg

Placebo

Started 30 days preoperatively

Follow-up 6 month

Endpoint:

Cardiac death Non-fatal MI

USA

Stroke

J Vasc. Surgery 2004;39:967


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Perioperative Statins

Hindler, et al. Anesthesiology 2006;105:1260-72


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Perioperative Statins

44% reduction in mortality after all types of

surgery.

59 % after vascular surgery alone

Hindler, et al. Anesthesiology 2006;105:1260-72


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Revascularization

Beta blockers




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Perioperative Alpha-2 Agonists

Clonidine prophylaxis in patients with or at

risk of CAD undergoing noncardiac surgery

reduced perioperative ischemia significantly.

(P=0.01) & mortality up to 2 yrs was also

reduced (P=0.035)

Wallace et al (PDBT)


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Revascularization

Beta blockers




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Preoperative Hgb and Mortality

0

2

4

6

8

10

12

14

R

e

tive

Ris

r

taity

6.0-6.9 .0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 >12

Pre He in

N

Carson, et al. Lancet. 1996;348:1055-60

Study of Untreated Anemia


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Perioperative Hypothermia

1 4

6 3

2 4

7 9

0

1

2

3

4

5

6

7

8

C

ar

iac

or

i

it

y

(

ercent)

Mor i ity V

Nor other ia Hy other ia

300 pts undergoing

general surgery

Randomized,

double blinded

assignment to

routine care or

supplementalwarming

Frank SM JAMA 1997;227(14)


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Inflammatory

State

Hypercoagulable

StateStress

State

Hypoxic

State

Triggers

Surgical Trauma


Surgical Trauma


Surgical Trauma


Intubation/extubation

Pain

Hypothermia

Bleeding/anemiaFasting


Hypothermia

Bleeding/anemia

TNF-

IL-1

IL-6

CRP

PAI-1

Factor VII

Platelet reactivity

antithrombin III

catecholamine and

cortisol levelsoxygen delivery

BP

HR

FFAs

relative insulin

deficiency

Coronary artery shear

stress

Plaque fissuring

Oxygen demand

Myocardial

Ischemia

Acute Coronary

Thrombus

Perioperative Myocardial Infarction

Plaque fissuring


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Key Point:

Beta blocker if able

Limit hypothermia Aggressive post-operative pain control

Avoid significant anemia

Avoid Sympathetic Stimulation in those at Risk!


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THANK YOU

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Yatish Preop Clearance Final - Copy