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ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for noncardiac surgery
Dr. Sonia Anand
McMaster University
Overview
• Guidelines- reflect evidence synthesis and consensus
• Evidence as of October 2007
• Important Decision points:– Urgent vs Elective Surgery– High risk surgery vs intermediate vs low– Active Cardiac Condition vs non-active
The Search For High Risk
Methods for Assessing Risk Pre-Operatively
Patient Based– High risk conditions– Functional Capacity
Surgery Based– Vascular Surgery– Emergency surgery
Intervention Based–Medications–Revascularization
Six Independent predictors of cardiac risk
1) ischemic heart disease
2) congestive heart failure
3) cerebrovascular disease
4) high risk surgery (AAA, orthopedic sx)
5) pre-operative insulin tx for diabetes
6) preoperative creatinine for creat > 2 mg/dL
Lee et al
Active/Major Cardiac Conditions
• Unstable Coronary Conditions
• Decompensated CHF
• Significant arrhythmias (i.e. 3 HB, new ⁰Vtach)
• Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????
Non-Active Cardiac Factors
• Intermediate Risk • Hx of CHD• History of prior
CHF• Hx of stroke• Diabetes • Renal insufficiency
• Minor Risk*• Age > 70• Abnormal ECG• Nonsinus rhythm• Uncontrolled
systolic BP
* Not associated with cardiac risk
Functional Capacity
• Functional status has shown to be a reliable periop and long-term predictor of cardiac events
• Functional status determined based on ability to do ADL’s
• MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest
• Periop risk is increased if person cannot > 4 METS
1 MET 4 MET 10 MET
Eat, d
ress
DO li
ght h
ouse
wor
k i.e.
Was
hing d
ishes
Climb a
fligh
t of s
tairs
Run a sh
ort d
istan
ces
Mod
erat
e rec
reat
iona
l gol
f, da
ncin
g, b
aseb
all
Stre
nuou
s spo
rts s
wimm
ing,
bas
ketb
all
The Trump Card: Functional Capacity
• Perioperative cardiac risk is increased in patients unable to exercise 4 METs
• Functional capacity can be estimated in the office
– Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs
– Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs
– Swimming and singles tennis exceeds 10 METs
Surgery Risk Type
Type Cardiac risk examples
High > 5% Aortic, peripheral vasc sx
Intermediate risk 1-5% IntraperitonealIntrathoracicCarotid EndHead and neckOrthopedic SxProstate Sx
Low <1% Endoscopic proceduresSuperficialCataract SxBreast SxAmbulatory Sx
Surgery-Specific Risk: High Risk*
• Major emergency surgery
• Vascular surgery including: aortic surgery, infra-inguinal bypass
• Prolonged surgery with large fluid shifts or blood loss
* Reported risk of cardiac death or nonfatal MI >5%
Stepwise Approach
• Step 1: Determine urgency of surgery
• Step 2: Active cardiac condition?-→test
• Step 3: Undergoing low-risk surgery? < 1%*
• Step 4: Good functional capacity?
* Combined morbidity and mortality < 1% even in high risk
patients
The Catheterization Questions to Ask Yourself
• Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now?
• Am I willing to send the patient to CABG?
• Am I doing this just to know the anatomy?
Is pre-op coronary revasc advantageous?
• If high risk surgery and patient has active cardiac issue
• Functional test and perfusion Imaging and if
• L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op
• CARP – if none of these – no advantage of revasc
Functional Test
• Exercise test with ECG
• If abnormal ECG, Rx perfusion imaging– Adenosine– Dipyridamole– Dobutamine– Dobutamine stress echo
Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry
0
2
4
6
8
10
No CAD CAD:Medical Rx
CAD: CABG
(n=314)
Periop MIDeath
3.0
0
8.5
2.8
0.6 1.1
***
***
*
*
Eagle et al. Circulation, 1997
Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes
0
5
10
15
20
25
Post-Op MI 30 DayMortality
2.7 YearMortality
Revascularization Conservative Mgmt
510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized toRevasc (PCI 59%, CABG 41%) or conservative management.
McFalls, E. CARP Trial;AHA 2004
High Risk Patients & Revascularization Pre-Op
101 pts with extensive ischemia randomly assigned to pre-op revascularization or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up.
%
7 14 21 28
50
40
30
20
10
0
Days since surgery Months since surgery
0 3 6 9 12
Poldermans, D. JACC 2007; 49(17): 1763
2VD in 12 (24%), 3VD in 33 (67%), Left main in 4 (8%).
The Effect of Percutaneous Revascularization Above Optimal Medical Therapy:
COURAGE
1.0
0.9
0.8
0.7
0.6
0.5
0 1 2 3 4 5 6 7
Years
Su
rviv
al F
ree
of
De
ath
/MI
2287 Pts w/myocardial ischemia and CAD randomized to PCI with
optimal medical therapy (PCI group) and 1138 to medical therapy alone.
Boden, W. NEJM 2007; 356:1503
Medical therapy
PCI + Medical therapy
STENTS
If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after
If received DES....– 1) postpone sx until > 12 months,– 2) do sx on both asa+clop – 3) do sx on single ap tx
Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended
Medical tx
1) beta blockers-if on keep them if not....
2) Statins continue, ? Start -need randomized trials
Statins Improve Survival After Vascular Surgery
Durazzo, AES. JVS 2004:39(5):975
100 pts randomized 20 mg atorvastatin or placebo for 45 days.Vascular surgery ~ 30 days after randomization. F/U 6 months
Primary EndpointCV death +NFMI+Ischemic stroke+Unstable Angina
Statins Improve Long-Term Survival After Vascular Surgery
0 20 40 60 80 100
1.00
.75
.50
.25
0
Time (months)
Su
rviv
al
Statin (+)
Statin (-)
Ward, RP. Int J Card 2005; 104(3):264
Retrospective review of 446 consecutive infrainguinal bypass surgeries
p < 0.004
Other Issues
• DVT/PE prophylaxis
• Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B)
• No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes
• Routine troponin monitoring not recommended
Surveillance for Perioperative Myocardial Infarction
• ECGs–All intermediate and high-risk patients
should get a post-op ECG.–As need for signs or symptoms of
ischemia
• Troponin / CK – In patients with signs or symptoms of
ischemia–Do not do screening biomarkers
High Risk Features
• Severe obstructive or restrictive pulmonary disease
• Diabetes
• Renal impairment
• Anemia, polycythemia, thrombocytosis
PCI pre-op
• ST-elevation MI
• Unstable angina
• Non ST elevation MI
2007 ACC/AHA Perioperative Guidelines
Take Home Messages• Unstable syndromes require management prior to surgery. Look
for
– Unstable angina
– Signs of heart failure
– Stenotic valve lesions
– Ventricular arrhythmias
• Functional tolerance is the best single predictor of outcome
• Be very specific in your history (one step at at time, regular or slow pace, etc)
• If patient on beta blockers & statins continue them, more trials to mandate them
• PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.