Preoperative Cardiovascular Evaluation for Noncardiac Surgery An Update - PowerPoint PPT Presentation

Loading...

PPT – Preoperative Cardiovascular Evaluation for Noncardiac Surgery An Update PowerPoint presentation | free to view - id: 85b51-YjEyY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Preoperative Cardiovascular Evaluation for Noncardiac Surgery An Update

Description:

Preoperative Cardiovascular Evaluation for Noncardiac Surgery - An Update. February 27, 2002 ... Preoperative CABG ... Preoperative PCI ... – PowerPoint PPT presentation

Number of Views:758
Avg rating:3.0/5.0
Slides: 42
Provided by: coyccarpen
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Preoperative Cardiovascular Evaluation for Noncardiac Surgery An Update


1
Preoperative Cardiovascular Evaluation for
Noncardiac Surgery - An Update
  • February 27, 2002
  • Robert B. Preli

2
Overview
  • Scope of the Problem
  • Purpose of Clinical Practice Guidelines
  • ACC/AHA 2002 Guideline Update/Review
  • The ACP Guideline
  • Validation Study
  • Lees Revised Cardiac Risk Index
  • Conclusions

3
Scope of the Problem - Epidemiology
  • 27 million patients per year in the United States
    are given anesthesia for surgeries
  • 8 million have known CAD or risk factors
  • 50,000 who undergo noncardiac surgery will have a
    perioperative MI
  • 1 million will have a perioperative complication
  • Common reason for consultation during AIM rotation

4
Scope of the ProblemPurpose of Assessment
  • Revascularization before noncardiac surgery to
    enable the patient to get through the procedure
    is appropriate for only a small subset of
    patients.
  • Determine who can go directly to surgery
  • Determine who
  • have additional tests prior to surgery
  • needs medical management prior to surgery
  • Risk stratify patients, NOT clear them for
    surgery

5
Practice Guideline Characteristics
  • Comprehensive review of the evidence
  • Expert opinion used to make value judgements
  • Official endorsement by an organization
  • Intention to influence your practice patterns

6
ACC/AHA Guidelines
  • Guidelines for Perioperative Cardiovascular
    Evaluation for Noncardiac Surgery
  • First published in 1996 by the ACC/AHA
  • Updated in January, 2002
  • Guidelines are available at
  • www.acc.org
  • www.americanheart.org

7
Preop Cardiac Assessment
8
Exercise Tolerance
9
Surgical Risk
10
2002 Guideline Highlights
  • New intermediate clinical predictor is Renal
    Insufficiency
  • Preoperative creatinine gt 2.0 mg/dl
  • New Shortcut to Noninvasive Testing table to
    assist in clinical decision making
  • New When and Which Test table to assist in
    choosing testing modality
  • Strong endorsement for beta blocker use in the
    appropriate patient population
  • More than 400 new relevant articles went into the
    2002 guidelines

11
(No Transcript)
12
Revascularization
  • In general, limit to patients who have a clearly
    defined need independent of surgery
  • Preoperative CABG
  • Should be reserved for high-risk patients
    undergoing high risk procedures in whom long-term
    outcome would be improved by CABG
  • Preoperative PCI
  • Indications are identical to the general ACC/AHA
    guidelines for the use of PTCA
  • Wait 2-4 weeks after stent placement for elective
    noncardiac surgery

13
Revascularization
  • Coronary Artery Surgery Study (CASS)
  • 24,959 patients in database from the NHLBI
    between 1974-1979
  • All CASS patients had coronary angiography at
    enrollment
  • Database enrollees treated with CABG or medical
    management based on physician preference
  • Identified 3368 patients who required noncardiac
    surgery during 10 years of followup
  • Surgeries included general (631), orthopedic
    (214), urologic (327), minor (90)

Eagle, Circulation, 199796
14
CASS
  • End points included mortality within 30 days of
    procedure or myocardial infarction
  • Among 1961 patients undergoing high risk surgery,
    prior CABG was associated with fewer events when
    compared to medical management
  • Death 1.7 versus 3.3 (p0.03)
  • MI 0.8 versus 2.7 (p0.002)
  • 1297 patients undergoing low risk procedures had
    a mortality of lt1 regardless of prior coronary
    treatment

Eagle, Circulation, 199796
15
Medical Therapy - So What About Beta Blockers?
  • Mangano et al (NEJM, 1996)
  • Poldermans et al (NEJM, 1999)

16
Medical Therapy
  • Mangano et al (NEJM, 1996)
  • 200 men at a VA with CAD or at risk for CAD
  • Randomized to IV Atenolol 30 minutes prior to
    noncardiac surgery continued throughout
    hsopitalization versus placebo
  • No difference in perioperative mortality or
    cardiovascular endpoints
  • At 2 years
  • Mortality ARR 11, NNT 9
  • CV events ARR 15, NNT 7
  • 2 year endpoints, aggressive HR control

17
Medical Therapy
  • Poldermans et al (NEJM, 1999)
  • 112 high-risk patients (positive DSE)
  • high-risk major vascular surgeries (AAA repair,
    Aorto-fem bypass)
  • Randomized to Bisoprolol 5-10 QD (starting one
    week prior to surgery and continued 30 days
    post-op), or standard care
  • Combined 30 day endpoints of mortality or
    non-fatal MI
  • ARR 31, NNT 3
  • Generalizability, aggressive HR control

18
So Who Gets Beta Blockers?
Fleisher. NEJM, Vol 345, 2001
19
Medical Therapy - Summary
  • Very few randomized trials
  • Appropriately administered beta blockers may
    reduce the risk of MI and death in high-risk
    patients
  • If possible, start beta blockers days or weeks
    before elective surgery
  • Titrate dose to a resting HR between 50-60
  • Alpha-2 agonists may have similar effects
    (clonidine, mivazerol)

20
(No Transcript)
21
(No Transcript)
22
ACP Guideline
  • Does not take into account a patients functional
    status
  • Does not tend to recommend stress testing in
    situations when patient is intermediate risk
    where ACC/AHA guideline is more test oriented

23
Mark Wilsons Guideline
  • If the patient walked into your clinic (and was
    not going to surgery), would you order a stress
    test based on their history and physical?
  • Let sleeping dogs lie.

24
How Well Do We Risk Stratify?
  • Prospective Evaluation of Cardiac Risk Indices
    for Patients Undergoing Noncardiac Surgery
    Gilbert et al (Annals, 2000)
  • Compared four existing methods for predicting
    perioperative cardiac risk in a prospective
    cohort study
  • 2035 patients referred for medical consultation
    before urgent or elective non-cardiac surgery
  • Endpoints included cardiac events (MI, angina, or
    acute pulmonary edema), and death (all-cause
    mortality)

25
Gilbert - Methods
  • Patients were categorized according to the
    following indices
  • American Society of Anesthesiologists (ASA), 1963
  • Goldman, 1977
  • Detsky (ACP algorithm), 1997
  • Canadian Cardiovascular Society (CCS), 1976
  • Cardiac events were defined clinically and
    according to generally accepted criteria
  • myocardial infarction, unstable angina, acute
    pulmonary edema
  • Death defined as all-cause mortality

26
Gilbert - Methods
  • To determine the accuracy of the stratification
    systems
  • Receiver-operating characteristic (ROC) curves
    were calculated for each index
  • Areas under the ROC curve (accuracy) were
    compared

27
Patient Characteristics (2035)
28
Gilbert - Results
  • Cardiac Events - 130 (6.4)
  • MI - 36 (1.8)
  • Pulmonary Edema - 67 (3.3)
  • Unstable Angina - 27 (1.3)
  • Deaths - 48 (2.4)

29
Gilbert - ResultsAlgorithm Accuracy
30
Gilbert - Conclusions
  • None of the models was significantly superior to
    the others
  • Cardiac risk indices provide useful clinical
    information about risk, but have limited overall
    accuracy
  • There remains room for improvement in our ability
    to determine which patients are at greatest risk
    for cardiac complications

31
But Wait . . .
  • Prediction of Perioperative Risk The Glass May
    Be Three-Quarters Full, Eagle et al (Annals,
    2000)
  • Tested guidelines do not take into account
    functional status and therefore risk may have
    been underestimated
  • Patients may not have had implementation of
    medical therapy based on their risk
  • Most importantly, identification of risk is not
    synonymous with prediction of adverse events

32
Eagle - Editorial
  • The population studied was one in which there was
    a low prevalence of complications
  • Identification of high-risk individuals may have
    led to changes in therapy, and therefore low
    accuracy may be a marker of successful management

33
Lees Revised Cardiac Risk Index
  • Lee et al. Derivation and Prospective Validation
    of a Simple Index for Prediction of Cardiac Risk
    of Major Noncardiac Surgery. Circulation, 1999.
  • Prospective investigation to derive and validate
    a simple index for the prediction of the risk of
    cardiac complications in major elective
    noncardiac surgery

34
Lee - Methods
  • Patients gt 50 years old
  • Nonemergent, noncardiac surgery
  • All patients had serial CK enzymes and EKGs
    post-operatively
  • Major cardiac complications defined as MI,
    pulmonary edema, vfib, cardiac arrest, complete
    heart block

35
Lee - Subjects
  • Mean age 66 /- 10 years
  • 33 Orthopedic procedures
  • 40 High risk procedures
  • 16 History of MI

36
Lee - Subjects
37
Lee - Results
  • Patients who were using beta blockers at the time
    of admission had similar rates of complications
    as those who were not
  • Beta blockers - 2.4 complications
  • No beta blockers - 1.8 complications

38
Lee - Results
  • 6 independent correlates of major cardiac
    complications were identified in the derivation
    cohort
  • Variable Complication Rate
  • High risk surgery 3
  • Ischemic heart disease 4
  • Congestive heart failure 5
  • Hx of CVA 6
  • Insulin treated DM 6
  • Serum creatinine gt 2.0 mg/dl 9

39
Lee - Results
40
Lee - Conclusions
  • How the Revised Cardiac Risk Index should be
    used by clinicians remains to be defined
  • Possibly perform noninvasive testing on classes
    III and IV

41
Conclusions
  • Purpose of preoperative assessment is NOT to
    clear the patient
  • Risk stratify with guidelines
  • Treat the patient
  • High risk patients may benefit from further
    testing
  • Remember beta blockers in the appropriate patient
    population
About PowerShow.com