Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery

1
Perioperative Evaluation and Treatment of the
Cardiac Patient Undergoing Noncardiac Surgery
November 4, 2003

• Thomas Vrobel, M.D.
• Antonio Cooper, M.D.
• with thanks to Robert Finkelhor, M.D.

2
Perioperative MIScope of the Problem

• 27 M noncardiac operations/year
• 8 M with known CAD or risk factors
• CAD leading cause of nonsurgical postoperative
  death

3
Perioperative MIScope of the Problem

• 50,000 perioperative MI (0.2 of surgeries)
• 30-50 mortality with MI
• 1 M cardiac complications (4)
• 20 billion added cost to surgery

4
Perioperative MIMechanisms

• Unstable plaque
• Catecholamines
• pain
• anemia
• BP swings
• pain
• anemia/hypovolemia

5
Post MI Noncardiac Surgery Risk
Mortality
Months post MI
6
Goldman Criteria

• Recent MI (lt6 mos)
• Unstable angina
• CHF
• Abdominal or thoracic surgery
• Severe AS
• Emergent surgery

• Age gt70
• Rhythm other than sinus
• S3
• Other medical/metabolic problems

7
Cardiac Risk Stratification Proposals

• Goldman
• Detsky
• Eagle
• ASA

8
Revised Cardiac Risk IndexIndependent
PredictorsLee et al. Circ 19991001043.

• High risk surgery
• History of ischemic heart disease
• History of CHF
• History of CVA
• Diabetes requiring insulin
• Crgt2.0 mg/dl

9
Revised Cardiac Risk IndexLee et al. Circ
19991001043.
ROC Curves
Validation Set, n1422
Goldman (0.70)
Detsky (0.58)
ASA (0.71)
Revised (0.81)
0.5
1
0
Specificity
10
Revised Cardiac Risk Index
Cardiac death, MI, pulmonary edema, arrhythmic
arrest, heart block
Lee et al. Circ 19991001043.
11
Revised Cardiac Risk IndexLee et al. Circ
19991001043.
Number of Risk Factors
Thoracic, Abdominal, Orthopedic, etc.
12
Perioperative Cardiac Mortality with CABG
N1001
Hertzer, Ann Surg 1984199223.
13
Preoperative TestingPositive Predictive Value
MI or Death
Eagle et al. JACC 199627910.
14
Preoperative TestingNegative Predictive Value
Freedom from MI or Death
Eagle et al. JACC 199627910.
15
Functional Capacity Metabolic Equivalents (METs)

• Low (lt 4 METs)
• increased surgical risk
• Intermediate (4-10 METs)
• Excellent (gt 10 METs)

Eating Dressing Walking around the
house Dishwashing
16
Postoperative MortalityPreoperative Hemoglobin
Carson et al. Lancet 19963481055.
17
Perioperative Cardiac Mortality with CABG
N1001
Hertzer, Ann Surg 1984199223.
18
Proven Indications for CABG

• Significant left main disease
• 3 V CAD and LV dysfunction
• 2 V CAD with proximal LAD involvement
• Intractable ischemia

19
Perioperative Cardiac Events with PTCAVascular
Patients
Death and Nonfatal MI
Khot UN, Ellis SG. ACC Current J Rev 20011057.
20
PROBLEMS WITH PREOP CORONARY INTERVENTIONS

• No proven benefit
• May not treat the culprit
• Delays surgery versus higher coronary risk
• PTCA only few days but higher
  restenosis risk
• Stent two to six weeks

21
Postoperative Mortality ReductionBeta-Blockers
Mangano, et al. NEMJ 19963351713.
22
Postoperative Cardiac Events In High Risk
Patients
Bisoprolol n59
Placebo n53
Poldermans et al. NEJM 19993411789.
23
BETA-BLOCKERSUNKNOWN FACTORS

• What is the optimal dose?
• How frequent are complications?
• Who should receive therapy?
• Are all beta blockers effective?
• When should they be started?
• How long should they be used?
• Are Alpha-Blockers also effective?

24
Statin Use and Perioperative Death

• Patients PV surgery 1991-2000
• Study Type retrospective case-controlled
• 160 deaths (5.6 of total)
• 21 survivors non-survivors
• Vascular death 104 (65 cases)
• Statin use
• 8 cases vs 25 controls (plt0.001)
• odds ratio 0.22, (95 CI 0.10-0.47)

Poldermans et al. Circ 20031071848.
25
(No Transcript)
26
Minor Clinical Predictors

• Advanced age
• Abnormal ECG
• Rhythm other than sinus
• History of CVA
• Uncontrolled HTN

27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
In-Hospital MortalityPerioperative PA Catheter
1994 Randomized High Risk Surgical Patients
Favors PA Catheter Favors Standard Care
Overall
NYHA I or II III or IV
0
10
-10
Difference
Sandham et al. NEJM 20033485.
32
Major Clinical Predictors

• Acute or recent MI (lt one month)
• Unstable or severe angina
• Large ischemic burden (stress testing)
• Decompensated CHF
• Significant arrhythmias

33
Intermediate Clinical Predictors

• Remote MI ( gt1 month)
• Stable angina
• Compensated CHF
• Creatinine ? 2.0
• Diabetes

34
Surgery Specific RiskHigh (gt5 Mortality)

• Emergent (esp. in the elderly)
• Aortic
• Peripheral vascular

35
Surgery Specific RiskIntermediate (1-5
Mortality)

• Intraperitoneal /intrathoracic
• Orthopedic
• Head neck
• Carotid endarterectomy

36
Surgery Specific RiskLow (lt1 Mortality)

• Endoscopic (cholecystectomy, arthroplasty,
  urologic, etc.)
• Breast
• Skin
• Cataracts

37
Functional Capacity Metabolic Equivalents (METs)

• Low (lt 4 METs)
• increased surgical risk
• Intermediate (4-10 METs)
• Excellent (gt 10 METs)

38
Functional Capacity Metabolic Equivalents (METs)

• Low (lt 4 METs)
• increased surgical risk
• Intermediate (4-10 METs)
• Excellent (gt 10 METs)

Climbing a flight of stairs Level walking at 4
mph Scrubbing floors Moving heavy furniture Golf
39
Functional Capacity Metabolic Equivalents (METs)

• Low (lt 4 METs)
• increased surgical risk
• Intermediate (4-10 METs)
• Excellent (gt 10 METs)

Swimming Singles tennis Basketball
40
Operative Risk Stratification
Surgical Urgency
emergent
OR
Eagle et al. ACC/AHA Executive Summary. JACC
200239542-53.
41
Operative Risk Stratification
Surgical Urgency
urgent or elective
Prior (lt5 years) revascularization
OR
no
no
yes
Further Risk Stratification
yes
Recurrent signs/symptoms
42
Operative Risk Stratification
Clinical Predictors
Major
Intermediate
Minor/none
Eagle et al. ACC/AHA Executive Summary. JACC
200239542-53.
43
Operative Risk Stratification
Clinical Predictors
Major
Intermediate
Minor/none
Postpone Surgery?
Medical Rx and Risk Factor Optimization
Coronary Angiography
44
Operative Risk Stratification
Clinical Predictors
Major
Intermediate
Minor/none
gt 4 METs
lt 4 METs
Stress Testing
Surgical Procedural Risk
High
Intermediate or Low
OR
45
Operative Risk Stratification
Clinical Predictors
Major
Intermediate
Minor/none
lt 4 METs
gt 4 METs
Surgical Procedural Risk
Intermediate or Low
OR
46
Operative Risk Stratification
Clinical Predictors
Major
Intermediate
Minor/none
lt 4 METs
Surgical Procedural Risk
Stress Testing
High
47
Operative Risk StratificationStress Testing
Summary
Surgery Specific Risk
Low Intermediate High
Medical Risk
Minor Intermediate Major
Functional capacity lt4 METs stress test
OR
Stress test
Optimize RF and/or further eval.
48
Prevention of Perioperative MIGoals

• Identify severe or symptom limiting CAD - risk
  stratification
• Minimize risk from CAD (standard Rx of CAD)

49
Perioperative Issues

• Risk stratification
• Minimize risk
• Monitoring
• Treating complications

History, physical, ECG, lab tests Selective
stress testing Clinically indicated
catheterization
50
Perioperative Issues

• Risk stratification
• Minimize risk
• Monitoring
• Treating complications

?-blockers Correct anemia Risk directed
PCI Clinically indicated CABG
51
Perioperative MIRisk Predictors

• Severity of underlying CAD
• clinical markers
• Type of surgery
• hemodynamic stress and duration
• Functional capacity

52
Diabetes and Coronary Mortality
1373 Nondiabetic 1059 Diabetic
Haffner et al. NEJM 1998339229.
53
Preop Stress TestingBasic Principles

• Same indications as with the non-preop patient
• Without standard indications for stress testing -
  intermediate cardiac risk
• How will the results will change management?

54
Preoperative Imaging Testing

• Higher risk with ischemia versus scar
• Graded risk with ischemia by severity and extent
• LBBB special case (adenosine Tl)

55
Postoperative MortalityPreoperative Hemoglobin
n1958
Carson et al. Lancet 19963481055.
56
Postoperative MortalityOperative Fall in
Hemoglobin
57
Role of Preoperative EchoHalm et al. Ann Int Med
1996125433.

• Not an independent predictor
• Only for standard indications
• murmur/valvular disease
• atrial fibrillation/flutter
• dyspnea/CHF/cardiomyopathy
• unstable angina

58
Role of Preoperative EchoRohde LE, et al. Am J
Cardiol 200187505.

• Clues to order echo
• Prior CHF or MI
• Evidence of valvular heart disease
• Predictive utility only for Revised Cardiac Risk
  Index III and IV

59
Perioperative MI PreventionTransesophageal Echo
(TEE)

• Detects new wall motion abnormalities
• Labor intensive
• Interpreter expertise
• Expensive
• No objective evidence of benefit

60
Perioperative MI PreventionSwan-Ganz
Catheterization

• Early detection of altered filling pressures
• Expertise in interpreting and troubleshooting
• Presumed benefit
• high risk cardiac patients (AS, MS, CHF)
• surgery with likely major fluid shifts

61
Perioperative MI PreventionNitroglycerin

• Reduces myocardial ischemia
• arterial and venodilator
• reduces ventricular preload
• Hypotension can exacerbate ischemia
• No proven benefit in prophylaxis

62
Diagnosing Perioperative MI

• Often without typical angina
• 2/3 present with ST depression
• CK-MB/Troponins

• ECG/Troponin (high risk patients)
• q 8 h first 24 hrs then
• next 2 days

63
Treatment of Postoperative MI

• Aggressive medical Rx
• Antiplatelet Rx
• ? blocker
• Statin
• ACEI
• Correct anemia
• Further noninvasive assessment
• Appropriate revascularization

• ST depression (non ST elevation)
• medical Rx with appropriate diagnostic testing
• ST elevation
• acute intervention (emergent PCI or CABG) as
  bleeding risk warrants

64
Treatment of Postoperative MI

• ST depression
• medical Rx with appropriate diagnostic testing
• ST elevation
• acute intervention (emergent PCI or CABG) as
  bleeding risk warrants

65
Postoperative MIImmediate Invasive Strategy

• 48 patients 1.6 ? 1.9 days post surgery
• intraabominal 14, ortho 11, vascular 11, misc. 12
  
• ST elevation MI in 33 (75)
• Shock in 21(44)
• Cardiac arrest in 12 (25)

Berger PB, et al. Am J Cardiol 2001871100-2.
66
Postoperative MIImmediiate Invasive Strategy

• Intervention
• 41 PTCA
• 2 CABG
• 4 medical
• 1 died in cath.

• Results
• Survival in 31 (65)
• Post arrest 9/12 (75)
• Post shock 11/21 (52)

Berger PB, et al. Am J Cardiol 2001871100-2.
67
Clinical Case History

• 46 y/o male smoker
• T3-4 diskectomy and laminectomy for herniated
  disc
• Post ectopy v. tach v.fib defib

68
Clinical CaseHospital Course

• Echo LVEF 40
• Cath 100 proximal LAD,
• PTCA without anticoagulation
• IABP
• Beta-blockade, ACEI

69
Clinical CaseHospital Course

• Repeat cath day 10 reocclusion of LAD, 50 OM1,
  65 prox RCA
• Repeat PCA with stent
• D/C meds
• lisinopril
• metropolol
• ASA and ticlopidine

70
Perioperative MITreatment Limitations

• Few randomized studies concerning treatment to
  prevent MI
• No studies specifically on treating perioperative
  MIs

71
Thrombolysis of Acute MI

• Reduces mortality from 10-15 to 7-10
• Indicated for
• ST elevation
• lt12 hrs. from onset
• Contraindicated for
• excessive bleeding risk

72
Acute MI MortalityISIS-2. Lancet 19882349.
73
Acute MI RevascularizationGusto IIb
74
Optimizing Patency After PTCA

• Heparin
• Glycoprotein IIb/IIIa inhibitor
• IABP
• Stents

75
IABP After Primary PTCAStone et al. JACC
1997291459.
(n226)
P0.03
(n211)
76
Clinical Markers of Severe CAD

• Major
• recent MI
• unstable or severe angina
• uncompensated CHF

77
Clinical Markers of Severe CAD

• Intermediate
• less severe from major
• DM
• Minor
• advanced age
• abnormal ECG
• poor functional capacity

78
Preoperative RevascularizationRisk Guidelines

• Standard indications for revascularization
• Noncardiac surgery risk gt 5
• Cardiac revascularization risk lt 3