David W Kabel MD, FACC

 Shift of emphasis  From preoperative risk stratification and testing   To perioperative management of risk Prevention of major adverse cardiac events (MACE)  Challenge to previous guidelines  Stress testing   Revascularization Beta blocker therapy

    30 million+ non-cardiac surgeries in the US annually One third have known CAD or cardiac risk factors 500,000 considered high risk for cardiac complications Operative mortality is declining  Better preop risk stratification    Better perioperative management Less invasive procedures Mortality is declining for high risk procedures as well

Assessment of perioperative risk to guide the decision to proceed with or the choice of surgery Determination of the need for changes in management Identification of cardiovascular conditions that warrant long term management

       Shared decision making Patient preferences and goals

PCP

Surgeon Anesthesiologist Specialists as needed Requires considerable advanced planning in high risk patients with multi-system disease

 Previously determined as low medium or high risk  Now only 2 categories   Low risk-<1%    Cataracts Dermatologic and minor cosmetic Require no preop evaluation High risk-1% or greater  Further workup depends on type of operation and patient characteristics

       One point for each risk factor Known ischemic heart disease Heart failure (current or past history) History of CVA or TIA Insulin dependent diabetes Creatinine> 2.0

High risk surgery-”Suprainguinal vascular, intraperitoneal, or intrathoracic surgery”

 Points  0  1  2  3+ Cardiac complications 0.4% 0.9% 7% 11% % 10 2

 Data from 525 hospitals and 1 million patients to develop this  Considers type of surgery by CPT code  Multiple patient factors are considered  www.riskcalculator.facs.org

 These surgeries usually require no additional preoperative cardiac evaluation  Breast        Dental Endocrine Eye Gynecology Reconstructive Minor orthopedic(arthroscopy) Minor urologic(cystoscopy)

 Aortic surgery-(Open procedures)  Major peripheral vascular  Not high risk because of the nature of the procedure  Almost all patients have multiple risk factors

     Known CAD Previous revascularization   Bypass PCI-When and what was done?-Bare metal vs DES Exertional symptoms Previous cardiac evaluation  When, and what did it show?

Exercise tolerance   Most important predictor of perioperative outcome Determines ability to increase O2 delivery perioperatively

 Functional Capacity of 4 METS confers low risk status  Can’t be evaluated in patients with mobility problems  Orthopedic procedures, especially joint replacement   COPD PAD with claudication    Very high risk population Known vascular disease AAA repair represents highest risk

      Signs of heart failure  Rales    JVD Edema S3 Tachycardia-Is patient in atrial fibrillation?

Bradycardia-Heart block, SSS Murmur of aortic stenosis Pulmonary findings-Wheezes Any of these findings necessitate further workup

     Unstable coronary syndromes Decompensated heart failure Arrhythmias  Ventricular tachycardia   AV block and sick sinus Uncontrolled atrial fibrillation or flutter Severe valvular disease  Especially aortic stenosis These patients need further evaluation prior to noncardiac surgery

 Class III or IV symptoms  Poor exercise tolerance  Indications for stress testing or cath are same as for those not undergoing noncardiac surgery  Patients with chronic stable angina (Class II) do not require preoperative stress testing

 Greater perioperative risk than ischemia  Should have EF measured  BNP may have prognostic significance if normal  Optimize therapy prior to surgery  Beta blockers and possibly ACEIs and ARBs should be continued perioperatively

   Severe aortic stenosis     AVA <1.0 cm2 or mean AV gradient >40 mm Hg, even in absence of symptoms Should have AVR prior to noncardiac surgery, preferably with a tissue prosthesis TAVR for high risk patients New guidelines suggest that asymptomatic patients with severe AS may have surgery  Requires hemodynamic monitoring postop Severe mitral stenosis  Can usually be treated with balloon valvuloplasty Regurgitant lesions are well tolerated in the absence of previous heart failure if LV function is normal

  Chronic atrial fibrillation and flutter  Control ventricular rate with beta blockers   Determine if bridging with Lovenox is necessary Some procedures can be done without stopping anticoagulants Newly diagnosed atrial fibrillation     Control ventricular rate, preferably with beta blockers Proceed with surgery Institute anticoagulation and specific anti-arrhythmic therapy postoperatively Medical or electrical cardioversion postoperatively

   Mobitz I   Review medications No need for pacing if asymptomatic, proceed with surgery Mobitz II and 3 rd degree block   Review medications If reversible causes not present, permanent pacemaker indicated before surgery Sick sinus syndrome     Review medications If asymptomatic, proceed with surgery If symptomatic, permanent pacemaker indicated May be useful to walk patient and observe HR response

    May lead to adverse outcomes Appropriate in selected patients  High risk surgery   Poor exercise tolerance Symptoms of possible ischemia  Exertional chest pain, tightness, heaviness  DOE Routine stress imaging in asymptomatic patients is poor at identifying patients who will have adverse outcomes Preoperative revascularization does not affect outcomes

     BARI trial No improvement in outcomes vs medical treatment of angina preoperatively Increased operative mortality if PCI within 12 days before surgery Similar outcomes for PCI vs Bypass Results duplicated in several trials

  No benefit in several studies  CASS  CARP CASS registry   High risk vascular surgery patients randomized to CABG vs medical treatment Medical rx-2.4% mortality   CABG-0.9% mortality BUT PREOP BYPASS HAD 1.4% MORTALITY, MAKING MEDICAL AND CABG ARMS EQUIVALENT

     Stress imaging is poor in identifying patients with adverse outcomes Angiography not always good at detecting disease  Less occlusive plaque is often the most unstable In autopsy studies, the infarct vessel was often not the most stenotic on previous cath Surgery and anesthesia can cause plaque disruption and hyper-coaguable states In nonsurgical populations revascularization has no benefit over medical treatment in stable patients

 Delayed surgery  Anticoagulation and antiplatelet issues  Morbidity and mortality inherent in the revascularization procedure  Cost effectiveness

 I-Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective  IIa- Weight of evidence is in favor of usefulness or efficacy  IIb-Usefulness or efficacy is less well established by evidence or opinion  III-Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful

 Beta blockers  Statins  ACEIs, ARBs  Aspirin  ADP receptor antagonists(antiplatelet drugs)

 Continue beta blocker therapy in patients receiving Rx for angina, arrhythmias, hypertension or other Class I indications  Level of evidence-B

 Management of beta blockers postop should be guided by clinical circumstances, independent of when the drug was started  May require temporary discontinuation due to hypotension, bradycardia, or other conditions  LOE-B

    Patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification testing (LOE C) Patients with 3+ RCRI risk factors (LOE B) Patients with compelling long-term indications for beta blocker therapy but no other RCRI risk factors (LOE B) Initiate beta blocker therapy long enough in advance to assess safety and tolerability (LOE B)

 Patients with absolute contraindications to beta blocker therapy  Risks outweigh benefits  Do not start on the day before or the day of surgery (LOE B)

 Little evidence to support >30 day timeline  Can be started 2-7 days before  Optimal dosing and timing not defined  Elevated perioperative stroke risk  However, incidence of MACE much higher than stoke.

 Initiate 2-7 or up to 30 days prior to surgery  Titrate to resting pulse rate of 60-80  Titrate to blood pressure of 130/80 or less  Avoid hypotension

     Cardioprotective effects in perioperative period  Improves endothelial morphology and function  Plaque stabilization Discontinuation of chronic therapy preoperatively is associated with adverse outcomes May benefit even started the day before surgery Start therapy in high risk patients 7-30 days before procedure-Class I, level B Do not discontinue statin therapy preoperatively-Class I, level C

 LV dysfunction  Continue for high risk surgery-Class I, level C  Consider continuing for low risk surgery-Class IIa, level C   Hypertension-Consider transient discontinuation to avoid hypotension-Class IIb, level C Recommendations based on low level of evidence

    Aspirin for secondary prevention usually should not be discontinued in patients with previous stents 15 % of recurrent ACS in stable CAD patients due to discontinuing aspirin Increased risk of stroke Should only stop if expected bleeding risks and sequelae are greater than known risk of stopping    Intracranial or back surgery Posterior eye chamber Prostate

     Most often arises after PCI Premature discontinuation increases perioperative M&M without reducing risk of bleeding Elective surgeries should be postponed    PTCA-2-6 weeks Bare metal stent-30 days-The longer the better Drug eluting stents-12 months Emergency surgeries should be done on aspirin at least and preferably on dual antiplatelet therapy Exceptions are intracranial, intraspinal, and retinal surgery

     Defined on basis of EKG changes and troponin elevations 65% of MIs were asymptomatic 11% died within 30 days (58% of those within 48h) Troponin elevation >3x normal was independent risk factor in absence of symptoms or EKG findings Conclusion-At risk patients should be monitored for perioperative infarction with EKGs and enzymes for first three days postop

   Class I  Troponin level recommended if signs or symptoms of myocardial ischemia or MI (LOE A)  EKG recommended if Sx or signs of ischemia or MI(LOE B) Class IIb  Usefulness of troponin or EKG in high risk patients is uncertain without sx of signs of ischemia (LOE B) Class III  Routine screening with EKG or troponin in unselected patients without Sx or signs is not useful for guiding postoperative care

      1-Determine if the patient has had prior revascularization-When and what?

2-Has patient had a cardiac workup in the last several years?-What were the results?

3-Assess the patient’s functional capacity

4-Determine preoperative risk (RCRI or ACS risk calculator) 5-Determine the pretest probability of cardiac complications based on type of surgery and institutional experience 6-Assess whether stress testing will alter pretest probability of risk. Most of the time it will not.

    7-For elective surgery, determine if benefits outweigh perioperative risk.

8-Determine if there are opportunities to reduce cardiac complications by modifying preoperative or intraoperative care 9-Develop strategies to minimize perioperative risk, especially beta blockers and statins 10-Utilize careful postoperative monitoring to identify nonfatal cardiac events and modifiable risk factors to tailor long term therapy and follow up

 Tell the patient   Find out how badly the patient wants the surgery Emphasize that the risks may outweigh the benefits  Call the surgeon     How urgent is the operation?

Is there a less invasive alternative?

 Endovascular or laproscopic procedures Is the surgeon willing to operate with patient on antiplatelet drugs?

Don’t back down if you really think the risk is too high. Most surgeons do worry about operative mortality.

   Determine if there are risk factors that can be modified to reduce risk and allow surgery at a later date  Uncompensated heart failure     Uncontrolled diabetes Uncontrolled hypertension Arrhythmias COPD Get a consult

There is no reason to do an elective operation under less than optimal conditions

 Often no opportunity for preoperative assessment or risk reduction  Try to do risk stratification before OR  Postoperative monitoring for cardiac events becomes more important in this setting

 The most important clinical indicator of perioperative cardiovascular outcome is:  A-Previous revascularization  B-History of heart failure  C-Functional capacity  D-The type of surgical procedure

 A 74 y/o man is referred prior to THR. He has a history of previous bypass 10 years ago. He is asymptomatic but severely limited by his arthritis. As part of his preop evaluation he should have:  A-A treadmill GXT  B-Cardiac catheterization  C-Pharmacologic stress imaging  D-EKG

 The man in the previous question is on aspirin, lisinopril, and metformin. Prior to surgery his regimen should be changed as follows:  A-Add a long acting beta blocker  B-Stop aspirin  C-Add a statin  D-Make no changes

 A 68 y/o woman comes in for preop evaluation for colon resection for carcinoma. She has no symptoms. Her pulse is 110 and irregular, BP 120/74, and an EKG shows atrial fibrillation. She takes losartan and HCTZ. You should:  A-Clear for surgery  B-Start anticoagulation and postpone surgery until after cardioversion  C-Start beta blocker therapy and postpone surgery until resting pulse rate <80