Preoperative Cardiac Evaluation Jonathan Hastie January 31, 2006 Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions.
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Preoperative Cardiac Evaluation Jonathan Hastie January 31, 2006 Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Case vignette • Mr Y is a 77 year old white male with a history of hypertension, coronary artery disease, and hypercholesterolemia. • He presents to the emergency department with a three week history of worsening dyspnea and generalized weakness. • In the E.D., he was found to have a large, rightsided pleural effusion Case vignette, cont. • Pus was aspirated on thoracentesis. Cardiothoracic surgery was consulted, and the patient was scheduled the following day for a thoracotomy and decortication. • Immediately post-op, the patient arrived in the I.C.U. where he was noted to have STsegment elevations. Case vignette, cont. • He was taken emergently for coronary angiography where two stents were placed. Case vignette, cont. • On returning from the cath lab, the patient had a v. fibrillation arrest and was resuscitated. • The remainder of his hospital stay was complicated by cardiogenic shock which gradually improved. He had a G.I. work-up since the empyema grew G.I. tract flora. • After his colonoscopy, the patient had a significant lower G.I. bleed. He was still on aspirin and Plavix for his coronary stents. Surgery in the United States • 25 million patients undergo noncardiac surgery yearly – 50,000 suffer perioperative myocardial infarction – >50% of 40,000 perioperative deaths are due to cardiac events Surgery in the United States The Ether-dome Massachusetts General Hospital Boston, MA Cardiovascular disease in the United States • 71,000,000 American adults with some form of cardiovasular disease – Hypertension: 65,000,000 – Coronary artery disease: 13,200,000 – Heart failure: 5,000,000 – Stroke: 5,500,000 Source: americanheart.org, website of the American Heart Association Cardiovascular disease in the United States • Mortality – CVD accounts for 37% of all deaths in the US – Since 1900, CVD has been the number one killer in the U.S. every year save one. – 2,500 Americans die from CVD daily. – Perioperative cardiac morbidity primarily related to ischemia, heart failure, or arrhythmias. Cardiovascular disease in the United States • Overheard on my cardiology elective: “The heart is simple. In fact, the A.S.C.A.S. II trial recently showed that there are really only three kinds of problems: ischemia, congestive heart failure, and arrythmias.” Cardiac risks of noncardiac surgery 1. Some types identify patients at higher risk for concomitant cardiac disease. -Vascular surgery 2. Cardiac stress inherent to surgery -Fluctuations in heart rate, blood pressure, intravascular volume, oxygenation -Anesthetic technique -Pain -Emergent procedures The role of the consultant • Evaluate the patient’s current medical status • Provide clinical risk profile • Recommend management of cardiac risk over • the entire perioperative period Treat modifiable risk factors Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery ACC/AHA 2002 The role of the consultant • Surgery and medicine – “I think of surgery as a pill that I might prescribe. Hypertension? Prescribe a betablocker. Cholecystitis? Prescribe surgery.” – M.A., UTSW medicine resident The role of the consultant • Surgery and medicine – “I think general surgeons are the best doctors in the hospital. I mean, they do everything that internists do, and they operate.” – R.L. UTSW surgery resident Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery • Developed by the American College of • • • Cardiology and the American Heart Association Revised in 2002 Largely based on observational or retrospective studies Few randomized prospective studies Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Risk Assessment Preoperative Cardiac Evaluation I. Significance of the preoperative cardiac evaluation II. Risk assessment -Fundamental clinical evaluation -Clinical predictors of increased risk -Surgery-specific risks -Preoperative evaluation algorithm -Preoperative testing III. IV. V. Therapeutic interventions Perioperative surveillance Summary Assessing the situation • Determine the urgency for surgery • Options to consider (as a team) – – – – – – Forgo surgery Modify the surgical procedure Delay case (for further testing or patient optimization) Perioperative medical therapy Perioperative monitoring Modification of the location of care Fundamental clinical evaluation • History – Angina – History of myocardial infarction – Heart failure symptoms – Symptomatic arrhythmias – Pacemaker or ICD – Comorbid diseases Fundamental clinical evaluation • Functional status 1-4 METs Activities of Daily Living Walk on level ground Light housework 4-10 METs Climb stairs Heavy housework Recreational activities Strenuous sports Fundamental clinical evaluation 1-4 METs Activities of Daily Living Walk on level ground Light housework 4-10 METs Climb stairs Heavy housework Recreational activities Strenuous sports 15 METs Intern on single intern team Fundamental clinical evaluation • Physical examination – Uncontrolled hypertension – General appearance – Signs of CHF and valvular disease – Presence of ICD/pacemaker Fundamental clinical evaluation • Electrocardiogram – Class I: recent chest pain in a moderate-risk patient undergoing moderate-risk procedure – Class IIa: Asymptomatic person with diabetes – Class IIb • Prior CABG or PTCA • Asymptomatic male >45 or female >55 with at least two risk factors • Prior admit for cardiac causes – Class III: Routine test for asymptomatic patients with low-risk procedures Consult etiquette • Overheard on my ICU month: “Did they really just consult pulmonary without getting a chest x-ray?!?” Assessing the patient • Minor predictors – Advanced age – Abnormal ECG – Rhythm other than sinus – Low functional capacity – Uncontrolled hypertension Assessing the patient • Intermediate predictors – Mild angina pectoris (class 1 or 2) – Prior MI – Compensated or prior heart failure – Diabetes mellitus – Renal insufficiency Assessing the patient • Major predictors – Acute or recent MI – Unstable or severe angina – Decompensated heart failure – High-grade A-V block – Severe valvular disease – Arrhythmias Surgery-specific risks • Two factors – Type of surgery – Degree of hemodynamic stress Surgery-specific risks • Low risk surgeries (<1% cardiac risk) – Endoscopic procedures – Superficial biopsies – Cataracts – Breast surgery Surgery-specific risks • Intermediate risk (<5% cardiac risk) – Intraperitoneal and intrathoracic – Carotid endarterectomy – Head and neck – Orthopedic – Prostate Surgery-specific risks • High risk (>5% cardiac risk) – Emergency major operations • Especially in the elderly – Aortic or major vascular surgery – Extensive operations with large volume shifts or blood loss. Preoperative evaluation algorithm “The Road Not Taken” by Robert Frost Preoperative evaluation algorithm • Emergent surgery to O.R. • Coronary revascularization within five years, no symptoms to O.R. • Recurrent symptoms after revascularization*, or no cardiac work-up, then evaluate – Clinical predictors – Functional status – Surgical risks Preoperative evaluation algorithm • For patients with major clinical predictors undergoing non-emergent noncardiac surgery, consider delaying the surgery. – Medical management – Risk factor modification – Consider coronary angiography Preoperative evaluation algorithm • Major predictors – Acute or recent MI – Unstable or severe angina – Decompensated heart failure – High-grade A-V block – Severe valvular disease – Arrhythmias Preoperative evaluation algorithm • For patients with intermediate clinical predictors, evaluate functional status. • Low functional status (<4 METs) may merit further testing. • Moderate to good functional status (>4 mets) promps us to look at the procedure itself. Preoperative evaluation algorithm • Intermediate predictors – Mild angina pectoris (class 1 or 2) – Prior MI – Compensated or prior heart failure – Diabetes mellitus – Renal insufficiency Preoperative evaluation algorithm • For patients with minor clinical predictors, evaluate functional status. • Moderate to good functional status indicates lowest cardiac risk for all procedures. • Poor functional status should prompt us to evaluate the surgical procedure. – High risk procedures may merit further testing. Preoperative evaluation algorithm • Minor predictors – – – – – Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity Uncontrolled hypertension Preoperative evaluation algorithm • Consider noninvasive testing if two or more are present: – Intermediate clinical predictors – Poor functional capacity – High surgical risk procedure Preoperative testing • Resting echocardiogram • Stress testing – Exercise stress test – Chemical stress test • Coronary angiography Resting echocardiogram • Has not been found to be a predictor of perioperative ischemic events • Recommended in patients with current or poorly controlled heart failure • Not recommended as a routine test of left ventricular function in patients without prior heart failure. Stress testing • Most useful in patients who have intermediate clinical predictors and poor functional capacity. • Useful in patients at risk for CAD • Prove myocardial ischemia before revascularization Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Coronary angiography • Pre-op indications are similar to “regular” indications – High risk of adverse outcome based on noninvasive tests Bypass Grafting • Indications for CABG before noncardiac surgery are identical to standard indications for CABG – Left main disease – Three vessel disease Perioperative Medical Therapy • Paucity of data • Two randomized, placebo-controlled trials of perioperative beta blockers – Reduced perioperative cardiac events – Improved 6-month survival • Beta-bocker indications – High cardiac risk patients undergoing vascular surgery – Prior usage for controling angina, symptomatic arrhythmias, or hypertension Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Perioperative surveillance • Poorly studied • Consider… – Pulmonary Artery Catheters – Intraoperative and post-op STmonitoring – Surveillance for Perioperative MI • Repeat EKG’s • Cardiac enzymes Preoperative Cardiac Evaluation I. II. III. IV. V. Significance of the preoperative cardiac evaluation Risk assessment Therapeutic interventions Perioperative surveillance Summary Questions Summary 1. Urgency for surgery? 2. Recent coronary revascularization 3. 4. 5. 6. without symptoms? Recent coronary evaluation? Major clinical predictors? Intermediate clinical predictors? Poor functional capacity & high-risk surgery? Critique • Should severe valvular stenosis be a major clinical • • • • predictor? Do the ACC/AHA guidelines send too many people to testing? Does a single intermediate predictor carry as much weight as multiple intermediate predictors? Gender effect If patients undergo pre-op revascularization… – Is the combined risk less than surgery alone? – Does revascularization significantly lower the cardiac risk? – Does recovery time unduly delay surgery? References • ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for • • • • • • • Noncardiac Surgery. “ACC/AHA Guideline Update for Perioperative CV evaluation for Noncardiac surgery.” Anesthesia & Analgesia, Volume 94(5), May 2002. “Beta-blockers and Reduction of Cardiac Events in Noncardiac Surgery:Clinical Applications” JAMA Volume 287(11) 20 March 2002. “Critical Review of the ACC/AHA Algorithm for Stratifying Cardiac Patients for Noncardiac Surgery.” International Anesthesiology Clinics Volume 39(4), Fall 2001. “Perioperative Evaluation and Managements of Patients with known or suspected CV disease…” Hurst’s The Heart McGraw-Hill, 11th edition, New York, 2004. “Preoperative Assessment of the Patient with Cardiac Disease” Refresher Courses in Anesthesiology Volume 33(1) 2005. www.americanheart.org www.acc.org Questions