The Patient with Cardiac Disease Who Undergoes Noncardiac Surgery How to Assess and Reduce Risk El manejo del paciente con enfermedad cardiaca, que require cirugia no cardiaca

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The Patient with Cardiac Disease Who Undergoes
Noncardiac Surgery How to Assess and Reduce
RiskEl manejo del paciente con enfermedad
cardiaca, que require cirugia no cardiaca

• Howard Weitz, M.D.
• February 2012

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ACC / AHA Guideline 2002Philosophy

• the concept of medical clearance for surgery
  is short sighted.
• Goals of the preoperative consult
• Evaluate current medical status
• Advise on disease management in the periop
  period.
• At times recommend preventive measures for
  future.
• Define your role in care (Co-manager?,
  subspecialty consultant?, etc)

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Case

• You have been asked to evaluate a 60 year old man
  for resection of a pulmonary nodule.
• Hx hypertension, hypercholesterolemia
• Smokes 2ppd many years.
• Does not exercise but climbs 1 flight stairs
  daily without difficulty
• Bp 120/70 HR 60
• Exam unremarkable.
• ECG Normal sinus rhythm. Within normal limits

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Case

• In an effort to aid in his preoperative
  evaluation you suggest
• A. Exercise ECG (no imaging)
• B. Exercise stress thallium
• C. Exercise echo
• D. Pharmacologic stress test
• E. None of the above

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October 23, 2007
400 new articles reviewed since 2002 guideline
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Key Elements of Risk Stratification

1. Emergency surgery
2. Active cardiac conditions
3. Low risk surgery
4. Functional capacity
5. Clinical risk factors
6. Will testing preop intervention change
   management ?

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Step 1
Step 1
Need for emergency noncardiac surgery?
YES
Perioperative surveillance and postoperative
risk stratification
Operating room
NO
Step 2
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Step 2
Step 2
Active cardiac conditions
Consider operating room
Evaluate and treat per ACC/AHA guidelines
YES
NO

• Active Cardiac Conditions
• Unstable coronary syndromes
• Unstable or severe angina
• Recent MI
• Decompensated HF
• Significant arrhythmias
• Severe valvular disease

Step 3
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Step 3
Step 3
Low risk surgery
Proceed with planned surgery
YES
NO
Step 4

• Low Risk Surgery
• Endoscopic procedures
• Superficial procedures
• Cataract surgery
• Breast surgery

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Step 4
Step 4
Good functional capacity (METS gt 4) without
symptoms
YES
Proceed with planned surgery
No or Unknown
Step 5
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Step 5
Step 5
Clinical Risk Factors

• History of ischemic heart disease
• History of compensated or prior HF
• History of cerebrovascular disease
• Diabetes
• Renal insufficiency

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Step 5
Step 5
Clinical Risk Factors (Isch HD, CHF hx, Cereb
vasc dx, DM, Cr gt2
3 or more
1 or 2
None
Vascular surgery
Intermediate Risk surgery
Proceed with planned surgery
Vascular or intermediate risk surgery
Consider testing if it will change management
Proceed with planned surgery with HR control or
consider Noninvasive testing if it will change
management
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Case

• In an effort to aid in his preoperative
  evaluation you suggest
• A. Exercise ECG (no imaging)
• B. Exercise stress thallium
• C. Exercise echo
• D. Pharmacologic stress test
• E. None of the above

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Case

• In an effort to aid in his preoperative
  evaluation you suggest
• A. Exercise ECG (no imaging)
• B. Exercise stress thallium
• C. Exercise echo
• D. Pharmacologic stress test
• E. None of the above

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National Surgical Quality Improvement
Database gt250 hospitals gt200,000
pts/year Predictors of perioperative (up to 30
day) MI, Arrest ASA Class Functional
status Age Serum Cr Type of surgery
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Problems - Limitations

• MI (one or more of the following)
• STEMI new LBBB, new Q waves
• Tn
• gt 3 times top normal

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Problems-Limitations

• HF not a predictor
• NSQIP database does not record
• Preop stress test
• Echo
• Arrhythmia history / occurrence
• Aortic valve disease
• Beta blocker use
• Remote history of CAD (except prior PTCA or CABG)

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• Risk Reduction Strategies
• Medications
• Anesthesia
• Monitoring
• Interventions

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Perioperative Beta BlockersWhat really is the
evidence?
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High risk
N Engl J Med 19993411789-94
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In the absence of major contraindications,
therapeutic doses of beta-adrenergic antagonists
should be given to patients with an intermediate
or high risk of cardiac complications. Patients
who are not already receiving beta-blockers
should be given one of these agents. Even if the
drug causes complications, such as fatigue or
impotence, these side effects can be tolerated
during the perioperative period. Patients who are
already receiving a beta-blocker should be
evaluated to ensure that therapeutic serum
concentrations have been achieved. Lee, T.
Reducing Cardiac Risk in Noncardiac Surgery. N
Engl J Med 3411838-40, 1999
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Perioperative Beta BlockersWhat really is the
evidence?
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Mangano, 1996

• In hospital post op adverse events not counted.
• In hospital atenolol group 4 deaths, control
  group 2 deaths. If included the difference in
  death between the two groups not significant
• Did beta blocker withdrawl favor the beta blocker
  group?
• 8 patients taken off beta blocker to enter
  placebo group
• 40 did not tolerate full dose atenolol, 15 did
  not tolerate any atenolol
• Trend toward sicker patients (prior MI, angina,
  diabetes,prior coronary revasc) in placebo group.
• Atenolol group trended toward more comprehensive
  cardiac therapy (ie ACE inhibitors) at discharge

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59 pts beta blocker 53 pts std care59 p
N Engl J Med 19993411789-94
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????
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N Engl J Med 2005 353349-61 (July 28, 2005)
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Lindenauer et al. N Engl J Med, 2005

• Retrospective database review
• 329 Hospitals ( small mid sized, non-teaching)
• 663635 pts without contraindication to beta
  blocker
• 122338 pts received beta blocker during first 2
  hosp days
• Revised Cardiac Risk Index Score (RCRI)
• High risk surgery (thoracic, intraperitoneal,
  suprainguinal vascular)
• Ischemic heart disease
• Cerebrovascular disease
• Renal insuficiency
• Diabetes

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Adjusted Odds Ratio for In-Hospital Death
Associated with Perioperative Beta-Blocker
Therapy among Patients Undergoing Major
Noncardiac Surgery, According to the RCRI Score
and the Presence of Other Risk Factors in the
Propensity-Matched Cohort and the Entire Study
Cohort
50 RCRI 0 38 RCRI 1 12 RCRI 2 2 RCRI 3 lt1
RCRI gt4
RCRI High risk surgery Ischemic Ht dx Cerebrovasc
dx Renal insufficiency Diabetes
Lindenauer, P. et al. N Engl J Med
2005353349-361
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ACC / AHA 2006 Perioperative Beta Blocker Update

• Most trials inadequately powered
• Few randomized trials of medical therapy to
  prevent perioperative cardiac complications
• Few randomized trials examined therapy titration
• Few randomized trials re role of periop beta
  blockers
• Studies lacking to determine role of beta
  blockers in intermediate and low risk populations
• No studies have addressed how, when, by whom
  perioperative beta blockade should be implemented
  or monitored

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Perioperative Beta BlockersPOISE Trial

• PeriOperative ISchemic Evaluation
• Canadian Institutes of Health Research
• Noncardiac surgery
• Hx cad, pvd, cva, chf within 3 yrs of surgery,
  or vascular surgery
• 30 days of controlled release metoprolol
• Metoprolol CR 100 mg 2-4 hrs preop
• IV or po metoprolol 6 hrs postop (equiv
  metoprolol CR 100mg)
• Metoprolol CR 200 mg daily for 30 days
• Outcomes cardiovascular death fatal MI
  non-fatal MI
• 190 centers, 23 countries
• Goal 10000 patients (final enrollment 8351)

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POISE trial online release Lancet May 13, 2008
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POISE

• Metoprolol prevented MI but increased risk of
  stroke, death.
• Metoprolol decreased incidence Afib.
• Metoprolol increased hypotension, bradycardia.

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POISE Metoprolol sustained release 1000 patients

• PREVENT
• 15 MI
• 3 Coronary revasc
• 7 Afib

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POISE Metoprolol sustained release 1000 patients

• PREVENT
• 15 MI
• 3 Coronary revasc
• 7 Afib

• CAUSE
• 8 Death
• 5 Stroke
• 53 sig hypotension
• 42 significant bradycardia

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POISE
Trial Design POISE was a randomized trial of
metoprolol (n 4,174) or placebo (n 4,177) in
patients undergoing noncardiac surgery. Study
drug was given 2 to 4 hours prior to surgery and
for the next 30 days. Primary endpoint was major
CV events (defined as CV death, MI, or cardiac
arrest through 30 days.

• Results
• Primary endpoint of CV death, MI, or cardiac
  arrest ? in metoprolol (Figure), driven by ?
  nonfatal MI (3.6 vs. 5.1, HR 0.70, p 0.0007)
• Total mortality ? in metoprolol group (Figure)
  as did stroke (1.0 vs. 0.5, HR 2.17, p 0.005)
• Metoprolol group also had ? rates of significant
  hypotension (15.0 vs. 9.7, p lt 0.0001) and
  significant bradycardia (6.6 vs. 2.4, p lt
  0.0001)
• Conclusions
• Among patients undergoing noncardiac surgery,
  treatment with beta-blocker metoprolol was
  associated with reduction in primary endpoint of
  CV death, MI, or stroke at 30 days compared with
  placebo, but total mortality and stroke were
  increased with metoprolol
• Prior studies with prophylactic beta-blocker in
  patients undergoing vascular surgery have shown
  mixed results
• While post-surgical CV event rate was high,
  given increased risk of death, stroke, and severe
  hypotension with metoprolol, routine prophylactic
  therapy does not appear to be a safe approach to
  reducing CV events in this population

CV Death, MI, or Cardiac Arrest (HR 0.83, p
0.04)
Total Mortality (HR 1.33, p 0.03)

Metoprolol
Placebo


Presented at AHA 2007
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Why didnt the beta blocker decrease mortality in
POISE?
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POISE

• ? Started too soon before surgery to have a
  plaque stabilizing effect.
• POBBLE and DIPOM both started beta blocker less
  than 24 hours preop and showed no protective beta
  blocker effect)
• High dose beta blocker
• Doses not titrated
• Beta blocker only stopped if systolic BP dropped
• lt 100 mm Hg
• Beta blocker related significant hypotension
  contributed to 37 of deaths
• Beta blocker related significant hypotension was
  most common prelude to stroke

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Perioperative beta blockade Class I
recommendation (2009)(evidence / agreement that
treatment is beneficial, useful, effective)

• Beta blockers should be continued for patients
  who are receiving them to treat angina,
  symptomatic arrhythmia, hypertension, or other
  Class I guideline indications.

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Perioperative beta blockade Class IIa
recommendation(evidence / opinion in favor of
usefulnes, effective)

• Beta blockers when used should be titrated to
  heart rate and blood pressure.
• Beta blockers probably for vascular surgery when
  high risk due to CAD or ischemia on preop
  testing.
• Beta blockers probably for vascular surgery in
  patients at high cardiac risk (defnpresence of gt
  1 clinical risk factor).
• Beta blockers probably for patient with CAD or
  high cardiac risk (defn gt1 clinical risk factor)
  who is to undergo intermediate-risk surgery.

Clinical risk factors Ischemic heart disease
CHF Cerebrovasc disease DM Renal insuf
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When to start the beta blocker?
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Start beta blocker gt 1 week preop
Flu et al. JACC 2010, 561922
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Our Approach 2012

• Continue beta blockers for those already
  receiving
• Initiate beta blockers prior to surgery
  (cautiously) for patients who would otherwise
  need them
• Begin low dose as early as possible- gt1 week -
  not day of surgery
• Titrate to heart rate (60-70) and BP
• Carefully follow those on beta blockers in the
  postoperative period
• Hypotension
• Bradycardia
• Postoperative tachycardia look first for a
  treatable cause (hypovolemia, anemia) rather than
  just increasing beta blocker dose.

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Statins

• Retrospective studies suggestive of benefit of
  postoperative statins
• Poldermans et al.Statins are associated with a
  reduced incidence of perioperative mortality in
  patients undergoing major noncardiac surgery.
  Circulation. 20031071848-1851.
• Lindenauer PK et al. Lipid lowering therapy and
  in hospital mortality in major non cardiac
  surgery. JAMA 2004291(17)2092-9.

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2007 Guideline Perioperative Statins
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ASA withdrawl assoc with 3- fold higher risk of
major cardiac event
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Meta-analysis of 41 studies ASA increased risk of
bleeding complications 1.5 fold ASA withdrawl
preceeded 10 of Acute Coronary Syndromes Time
interval from ASA withdrawl to ACS was 8.5
days Conclusion ASA should be discontinued only
if low dose ASA may cause bleeding risk with
associated mortality
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Anesthesia General vs. Regional

• No difference morbidity - mortality
• ADVANTAGES of regional in the cardiac pt.
• Less myocardial, respiratory depression
• Avoid endotracheal intubation (autonomic
  stimulation)
• DISADVANTAGES of regional
• Anxiety catecholamine release MVO2
• Spinal vasodilation BP

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2005 Evidence review
Benefits of neuraxial anesthesia and
analgesia Less blood loss Superior pain
control Decreased ileus Fewer pulmonary
complicatons No Mortality benefit No definite
improvement in cardiac outcome No fewer
thromboembolic events when DVT prophylaxis used
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ACC/AHA Guideline - 2002Philosophy

• Preoperative intervention is rarely necessary to
  simply lower operative risk.
• Identify most appropriate testing and treatment
  strategies to optimize patient care and assess
  short and long term risk.
• Avoid unnecessary testing in this era of cost
  containment.

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1. Evidence
2. Consensus guideline

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Coronary Artery Revascularization Prophylaxis
Trial (CARP)

• Elective vascular surgery
• Stable CAD, mean LVEF 54
• Most with 1 or 2 vessel CAD
• Cardiac cath
• Randomized to coronary revasc vs. optimized
  medical therapy
• Exclusions
• Left main
• LVEF lt 20
• Unstable angina
• Critical AS
• Hx prior revasc without recurrent ischemia
• Urgent / emergent surgery

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Coronary Artery Revascularization Prophylaxis
Trial (CARP)

• Coronary revascularization prior to vascular
  surgery is not of benefit in the patient with
  stable CAD if treated with beta blockers,
  aspirin, statins in the absence of
• unstable coronary disease
• left main coronary disease
• aortic stenosis
• severe left ventricular dysfunction

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Elective vascular surgery in high risk
patients. 101 patients 3 or more cardiac risk
factors All with extensive inducible ischemia by
stress test 43 with LVEF lt 35 75 with Left
main or 3-vd All received beta blocker titrated
to HR 60-65 Antiplatelet agents continued in
perioperative period No benefit of prophylactic
coronary revascularization Two patients died of
ruptured AAA following CABG
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ACC /AHA Preop Guideline Update, 2007 CABG
prior to Non-cardiac surgery
Same Recommendation as 2002 Guideline
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PTCA Prior to Noncardiac Surgery (planned)
PCI before noncardiac surgery is of no value in
preventing perioperative cardiac events, except
in those patients in whom PCI is independently
indicated for an acute coronary syndrome.
ACC /AHA Preop Guideline Update, 2007
PTCA prior to Non-cardiac surgery
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PTCA Prior to Noncardiac Surgery (planned)
ACC /AHA CABG Guideline, 2011
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• How about the patient who has already received a
  stent and requires noncardiac surgery ?

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Drug eluting stent related issues

• Stent thrombosis
• ASA clopidogrel
• Hemorrhage
• ASA clopidogrel

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ASA 325 mg Clopidogrel 75 mg daily / three
months
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ASA 325 mg Clopidogrel 75 mg daily / six
months
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On-line release January 24, 2007
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Joint Advisory Recommendations and Noncardiac
Surgery

• Consider bare metal stent if patient requires PCI
  and is likely to require invasive or surgical
  procedure within next 12 months.
• Educate patient prior to discharge re risk of
  premature antiplatelet discontinuation.
• Instruct patient to contact treating cardiologist
  before antiplatelet discontinuation
• Healthcare providers who perform surgical or
  invasive procedures must be made aware of
  catastrophic risks of premature antiplatelet
  discontinuation and should contact the treating
  cardiologist to discuss optimal management
  strategy

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Joint Advisory Recommendations and Noncardiac
Surgery

• Defer elective procedures for which there is
  bleeding risk until completion of antiplatelet
  course
• 1 month bare metal stent
• 12 months drug eluting stent
• For patient with drug eluting stent who are to
  undergo procedures that mandate discontinuation
  of thienopyridine (eg, clopidogrel), continue
  aspirin if at all possible and restart
  thienopyridine as soon as possible
• No evidence for bridging therapy with
  antithrombins, warfarin, or glycoprotein IIb/IIIa
  agents

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Key Points

• Clearance. Perform evaluation and make
  recommendations that will relate to perioperative
  and long term issues.
• Tests only if likely to influence treatment.
• Preoperative coronary revascularization if
  independently indicated.
• Selective use of beta blockers. (beware
  bradycardia)
• Statins
• Beware of premature antiplatelet discontinuation
  in the patient post PTCA stent.
• Continue beta blocker, aspirin, statins,

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High risk
N Engl J Med 19993411789-94
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Statins

• Retrospective studies suggestive of benefit of
  postoperative statins
• Poldermans et al.Statins are associated with a
  reduced incidence of perioperative mortality in
  patients undergoing major noncardiac surgery.
  Circulation. 20031071848-1851.
• Lindenauer PK et al. Lipid lowering therapy and
  in hospital mortality in major non cardiac
  surgery. JAMA 2004291(17)2092-9.

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Elective vascular surgery in high risk
patients. 101 patients 3 or more cardiac risk
factors All with extensive inducible ischemia by
stress test 43 with LVEF lt 35 75 with Left
main or 3-vd All received beta blocker titrated
to HR 60-65 Antiplatelet agents continued in
perioperative period No benefit of prophylactic
coronary revascularization Two patients died of
ruptured AAA following CABG
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DECREASE VI in progress preoperative NT-pro BNP
for the identification of patients who May
benefit from additional preoperative testing
prior to vascular surgery.
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DECREASE VI in progress preoperative NT-pro BNP
for the identification of patients who May
benefit from additional preoperative testing
prior to vascular surgery.