Transcript Slide 1

Tamas Szabo, MD, PhD
Ralph H. Johnson VAMC
Medical University of South Carolina
South Carolina Society of Anesthesiologists Annual Meeting
June 5, 2010
1. Perioperative Cardiovascular Evaluation
2. Case Presentation
3. Update on Perioperative Beta Blockade
4. Patients with Stents
5. Cardiac Rhythm Management Devices
ACC/AHA Guidelines on
Perioperative Cardiovascular
Evaluation and Care for
Noncardiac Surgery
Born: 1996
Reborn: 2002
Revised: 2007
Major Predictors: Active Cardiac Conditions
Intermediate Predictors: Revised Cardiac Risk Index
Minor Predictors: their presence is not an indication for
further workup (but might lead to a higher suspicion of CAD)
Functional Capacity: increased emphasis
Able to exercise to a ≥ 4 MET level without symptoms:
Proceed with even high risk surgery without further testing
regardless of clinical risk factors.
Condition
Examples
Unstable coronary syndromes
Unstable / severe angina
Recent MI (1 week-1 month)
Decompensated HF (NYHA IV.)
Significant arrhythmias
Newly recognized ventricular tachycardia
Symptomatic ventricular arrhythmias
Symptomatic bradycardia
Supraventricular arrhythmias (>100/min)
Third degree AVB
Mobitz II. AVB
Severe valvular disease
Severe AS (AVA<1 cm2, mean gradient >40 mmHg
Symptomatic MS (DOE, HF, syncope)
Prediction of cardiac risk for stable patients undergoing
elective major noncardiac surgery.
•CAD (h/0 MI, NTG-use, CP, q-waves, +stress test)
•CHF (h/o pulmonary edema, PND)
•Cerebrovascular disease (stroke, TIA)
•Diabetes (on insulin)
•Creatinine > 2 mg/dl
Dutch dataset with 108,593 noncardiac operations.
1 point each for CAD, CHF, CVD, IDDM, Cr >2, High-risk surgery.
0.5% Total cardiovascular deaths 543 (0.5%).
Cardiovascular mortality (%)
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
1
2
3
Points assigned
4
Risk Stratification
Examples
Vascular (cardiac risk > 5%)
Aortic / Major vascular surgery
Peripheral vascular surgery
Intermediate (1-5%)
Intraabdominal / Intrathoracic surgery
Carotid endarterectomy
Head and neck surgery
Orthopedic / Urology cases
Low (<1%)
Ambulatory surgery
Endoscopic procedures
Cataracts
Breast surgery
80 yo male w/ after recent acute gallstone pancreatitis and cholecystitis
presents for laparoscopic cholecystectomy.
PMH: Ischemic cardiomyopathy, dual-chamber PM for AVB (2008), 2
vessel CABG (1980), 4 vessel CABG (1994), HTN, Hyperlipidemia,
COPD.
Functional capacity: 4 METs, but recently becoming less active 2 to SOB.
Abnormal stress test (12/2009): inducible anterior apical and inferior
ischemia, EF: 40%.
A. Call in sick or cancel the case.
B. Bite the bullet and do the case.
C. Call cardiology for further workup and to interrogate the PM.
A. Repeat stress-test .
B. Cardiac cath.
C. Interrogation of the pacemaker.
A. Nothing fancy.
B. Preinduction A-line, CVP, PAC, TEE, external pacer-pads.
C. Preinduction A-line, aggressive beta-blockade, ext. pacer-pads.
8331 patients undergoing noncardiac surgery
Metoprolol 100 mg or Placebo 2-4 hours preop and 6 hours postop
Metoprolol 200 mg or Placebo 18 hours postop for 30 days
Primary end point: composite of cardiovascular death, MI, and
nonfatal cardiac arrest
Fewer Metoprolol patients reached the primary end point (5.8%
vs. 6.9%, p<0.04) or had an MI (4.2% vs. 5.7%, p<0.0017).
More Metoprolol patients died (p=0.03), had a stroke (p=0.0053),
developed significant hypotension (p<0.0001) and bradycardia
(p<0.0001).
The usual initial daily dose of Metoprolol is 25-100 mg for HTN
Poise Pts could receive up to 400 mg on the first day
1066 intermediate-risk patients undergoing noncardiac surgery
4 groups: Bisoprolol, Fluvastatin, both or nothing.
Primary end point: composite of cardiac death and nonfatal MI.
Bisoprolol was started 30 days before surgery and was titrated to
a HR 50-70/min. It was continued until 30 days postop.
The Bisoprolol group had a lower incidence of cardiac death and
nonfatal MI (2.1% vs. 6.0%, p=0.002). Ischemic stroke rate was
not significantly different between the groups.
770 intermediate-risk patients undergoing vascular surgery
Patients were randomly assigned to cardiac stress testing or no testing.
All Pts received beta blockers titrated to a resting HR 60-65/min.
Pts assigned to no testing had a similar incidence of cardiac events as
those assigned to testing (1.8% vs. 2.3%, p=ns). Pts with a HR<65/min
had lower risk than the rest (1.3% vs. 5.2%, p=0.003).
“Cardiac testing can safely be omitted in intermediate-risk patients,
provided that beta-blockers aiming at tight heart rate control are
prescribed.”
Beta blockers should be continued in patients undergoing surgery
who are receiving beta blockers for treatment of conditions with
ACC/AHF Class I guideline indications for the drugs. (Class I)
Several Class II recommendations exist for Pts undergoing vascular
or intermediate-risk surgeries with multiple clinical risk factors.
Initiation well before a planned procedure with careful titration to
achieve adequate HR-control (60-80/min) while avoiding frank
bradycardia and hypotension is also suggested.
Routine administration, particularly higher fixed-dose regimens
begun on the day of surgery, cannot be advocated (POISE).
Coronary Stents ≠ less perioperative problems and complications
A,B: 8/2005 LAD PCI with DES
Stopped Plavix in 5/2006
C,D : 8/2006 MI 2 to LAD stent occlusion
Emergent balloon dilatation
E,F : platelets, fibrin and inflammatory cells
(neutrophils and eosinophils) in the thrombus
Upcoming surgery
Abrupt discontinuation of antiplatelet drugs
Rebound effect
Increased platelet adhesion/aggregation/TXA2
Prothrombotic/proinflammatory state (surgery)
Incomplete stent endothelialization
Perioperative stent thrombosis
STEMI (20-65% mortality)
899 patients undergoing noncardiac surgery after BMS placement.
5.2% experienced MACEs (STEMI, NSTEMI, stent thromboses,
repeat revascularizations and deaths).
The risk of MACEs after NCS was found to be the highest within
30 days of PCI w/ BMS (10.5%), and lowest after 90 days (2.8%).
Bleeding complications were not associated with antiplatelet
therapy.
520 patients undergoing noncardiac surgery after DES placement.
5.4% experienced MACEs (STEMI, NSTEMI, stent thromboses,
repeat revascularizations and deaths).
The rate of MACEs did not change significantly with time after
placement. Bleeding complications were few and were not
associated with antiplatelet therapy.
Bare-metal stents
Drug-eluting stents
Major Adverse Cardiac Events (%)
12
10
8
6
4
2
0
0
3
6
9
12
15
18
21
Time from stent until surgery (months)
24
Scotland-wide retrospective cohort study.
1953 patients were treated with DES (n=570) or BMS (n=1383) and
subsequently underwent noncardiac surgery.
There were no differences in in-hospital mortality or MI between
the 2 groups, however perioperative death and ischemic cardiac
events occurred more frequently when noncardiac surgery was
performed within 42 days of stent implantation. Mortality
between 6 weeks – 1 year was still 4x higher than beyond 1 year.
<42 days 42 days – > 1 year
1 year
P
Death
5.1%
0.9%
0.2%
<0.0001
MI
8.5%
0.7%
0.6%
<0.0001
All stents
Balloon angioplasty > 14 days
Bare-metal stent > 30-45 days
Drug-eluting stent > 365 days
Elective surgeries should be delayed to meet the above time-limits.
D/C-d antiplatelet drugs:
risk for perioperative stent thrombosis,
MI and death
Continued plavix and aspirin:
potential for surgical bleeding
Current ACC/AHA recommendations for the prevention of stent
thrombosis after coronary stent implantation state that patients
should be treated with clopidogrel 75 mg and aspirin 325 mg for one
month after bare-metal stent implantation, 3-6 months (ideally 12
months) after DES implantation if they are not at high risk for
bleeding.
However, these recommendations were based on the antiplatelet
regimen used in trials to obtain FDA approval in low-risk patients
with low-risk lesions. DES are now being used high-risk lesions.
There is no evidence that warfarin, antithrombotics, or glycoprotein
IIb/IIIa agents reduce the risk of stent thrombosis after
discontinuation of oral antiplatelet agents.
•Establish whether the patient has a CMRD.
•Define the type of CMRD.
•Have the device interrogated by cardiology.
•Determine dependency on pacing function of the CMRD.
•Determine whether EMI is likely to occur intraoperatively.
•Determine
whether reprogramming pacing function to
asynchronous mode or disabling rate responsive function is
advantageous.
•Suspend antitachycardia functions if present.
•Have temporary pacing and defibrillation equipment immediately
available.
Pacemaker/AICD response to EMI:
1.
2.
3.
4.
5.
Temporary or permanent resetting to a backup pacing mode.
Temporary or permanent inhibition of pacemaker output.
Increase in pacing rate (rate-responsive PMs).
AICD inappropriate shock.
Myocardial injury at the lead tip: failure to sense or capture.
Sources:
1.
2.
3.
4.
5.
6.
Electrocautery
Radiofrequency ablation
MRI (contraindicated!)
Radiation therapy
ESWL
ECT
Assure that the electrosurgical receiving plate (aka “ground patch”)
is positioned so that the current pathway does not pass through or
near the CMRD system.
Avoid the proximity of the cautery’s electrical field to the pulse
generator or leads.
Use short, intermittent or irregular bursts at the lowest energy levels.
Use bipolar electrocautery system or harmonic scalpel.
Pacemaker:
Pacing without sensing at a fixed rate (asynchronous modes: AOO,
VOO, DOO).
AICD:
Pacing capability is not affected.
The antitachycardia (shock) function will be temporarily disabled
and will become active once the magnet is removed.
OR
The shock function will first be suspended and then turned off.
For a patient with an AICD and magnet-disabled therapies:
Terminate all sources of EMI while magnet is removed.
Remove the magnet to activate the shock function.
Observe the patient and the monitors for appropriate device therapy.
External defibrillation:
Position defibrillation/cardioversion pads as far as possible from the
pulse generator (anterior-posterior application preferable).
Use clinically appropriate energy levels.
Medtronic (800) 633-8766
Vitatron
Guidant (800) 227-3422
CPI
Intermedics
St. Jude Medical (800) 722-3774
Ventritex
Pacesetter
Teletronics
Biotronik (800) 547-0394
ELA (800) 352-6466
1. Boersma E. Perioperative Cardiovascular Mortality in Noncardiac Surgery: Validation of the Lee cardiac Risk Index. Am J Med.
2005;118:1134-41
2. Caplan RA. Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents. Anesthesiology.
2009;110:22-3
3. Cruden NL. Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Nincardiac Surgery. Circ
Cardiovasc Interv. 2010 (Epub ahead of print)
4. Deveraux PJ. Effects of Extended-release Metoprolol Succinate in Patients Undergoing Non-cardiac Surgery (POISE trial): A
Randomized Controlled Trial. Lancet. 2008;371:1839-47
5. Dunkelgrun M. Bisoprolol and Fluvastatin for the Reduction of Perioperative Cardiac Mortality and Myocardial Infarction in
Intermediate-risk Patients Undergoing Noncardiovascular Surgery : A Randomized Controlled trial. Ann Surg. 2009;249:921-6
6. Fleischmann KE. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:2123-51
7. Fleisher LA. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report
of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation.
2007;116:418-500
8. Grines CL. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents.
Circulation. 2007;115:813-8
9. Lee TH. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation.
1999;100:1043-9
10. Nuttall GA. Time and Cardiac Risk of Surgery after Bare-metal Stent Percutaneous Coronary Intervention. Anesthesiology.
2008;109:588-95
11. Poldermans D. Should Major Vascular Surgery be Delayed because of Preoperative Cardiac Testing in Intermediate-risk Patients
Receiving Beta-blocker Therapy with Tight Heart-rate Control? J Am Coll Cardiol. 2006;48:964-9
12. Rabbitts JA. Cardiac Risk of Noncardiac Surgery after Percutaneous Coronary Intervention with Drug-eluting Stents.
Anesthesiology. 2008;109:596-604
13. Rade JJ. Noncardiac Surgery for Patients with Coronary Artery Stents. Anesthesiology. 2008;109:573-5
14. Zaidan JR. Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices:
Pacemakers and Implantable Cardioverter- Defibrillators. Anesthesiology. 2005;103:186-98