Perioperative Cardiac Evaluation &

Management for Noncardiac Surgery:

2014 ACC/AHA Guidelines

Steven L. Cohn, MD, FACP, SFHM Medical Director - UHealth Preoperative Assessment Center

Director – Medical Consultation Service

University of Miami Hospital

Professor of Clinical Medicine

University of Miami Miller School of Medicine

Disclosures

No relevant COI for this topic except:

Agenda

Cardiac risk assessment

Risk indices & biomarkers

Clinical risk factors

Surgical risk/urgency

Exercise capacity

ACC/AHA algorithm Testing

○ NIT - DSE/MPI, cath, ECHO

Risk reduction strategies Interventions

○ CABG/PCI

Medical therapy

○ Beta-blockers, statins, ASA

Postop surveillance

○ Troponin

Classification of Recommendations - Levels of Evidence

Purpose of Preop Medical Consultation

Identify risk factors and assess severity & stability

Provide a clinical risk profile for informed and shared decision-making

Make recommendations for any management changes, need for further testing, or specialty consultation

NOT to CLEAR FOR SURGERY!

Pt is in his/her OPTIMAL MEDICAL CONDITION for surgery.

2014 1987 1996 1997 1999 2002 2006 2009

2010 1960 1977 1986

Detsky

Cardiac Risk Indices

ACC Lee RCRI VSGNE

Gupta ACC ACP Goldman Larssen

ASA

2011 2013

ACS NSQIP

RCRI-2 ACC

Cohn S, Subramanian S. Estimation of cardiac risk before noncardiac surgery: the evolution of cardiac risk indices. Hosp Pract 2014 ;42:46-57.

Revised Cardiac Risk Index (Lee et al, Circulation 1999;100:1043-1049)

4315 pts, >50 y/o, LOS >2 days

6 independent predictors: high-risk surgery, hx ischemic heart disease, CHF, CVA, DM Rx with insulin,

preop creat >2.0 # of risk factors % major cardiac complications

0 - 0.4-0.5%

1 - 0.9-1.3%

2 - 4-7%

>3 - 9-11%

Low Interm High

Separates low vs high risk

Underestimates risk- vasc surg

Doesn’t tell you what to do

ACS

NSQIP

Surgical

Risk

Calculator

http://riskcalculator.facs.org

Bilimoria et al.

J Am Coll Surg 2013

Definitions of Urgency & Risk

Urgency

Emergency: <6 hours

Urgent: 6-24 hours

Time sensitive: can delay 1-6 weeks

Elective: can delay up to 1 year

Risk (combined surg & pt characteristics)

Low risk: <1% MACE

Elevated: >1% MACE

Clinical Risk Factors

CAD Isch Sx/NYHA, prior MI/timing, CABG/PCI,

elevated biomarkers

HF Decompensated + depressed LV funct worst;

Sx > asympt; syst (EF<30-40%) > diastolic

Valvular disease Type (stenotic>regurg), severity, symptoms

Arrhythmias Hemodynamic effects, underlying structural heart

disease

Evaluation of Valvular Heart Disease

Echocardiography (I-C) is recommended in patients

with suspected moderate to severe stenotic or

regurgitant lesions if:

worsening in clinical condition

not done within the past year

If indicated, valvular intervention to reduce risk. (I-C)

Asymptomatic severe AS, AR, or MR: (IIa-C)

reasonable to perform elevated risk noncardiac surgery

using appropriate perioperative hemodynamic monitoring

Asymptomatic severe MS: (IIb-C)

may be reasonable if not a candidate for repair

2014

ACC/AHA

ALGORITHM

ACC/AHA 2014: Periop Cardiac Assessment for CAD

Step 1

Step 2

Step 3

Step 6

Need for emergency

noncardiac surgery?

ACS?

Estimate risk of MACE (combined clin/surg risk –

RCRI or ACS-NSQIP)

Moderate or greater (>4METS)

functional capacity

(<4METS)

Will further testing impact

decision making or periop care?

Clinical risk stratification &

proceed to surgery

Evaluate & treat

according to GDMT

Proceed to

surgery (no further testing)

Proceed to surgery (no further testing)

No

No

No or unknown

Yes

Yes

Yes

Yes

Pharmacologic stress testing

Fleisher

et al.

JACC

2014

Low risk

(<1%)

Elevated

risk

Step 4

Step 5

No

Proceed to surgery (GDMT)

or alternative strategies

Yes

Coronary revascularization (as per clinical practice guidelines)

Abnormal

Step 7

Valve dis

HF

Arrhythmias

as per GDMT

Supplemental Testing

ECG

ECHO

Stress testing

The 12-Lead ECG

Supplemental Preoperative Evaluation

Recommendations COR LOE

Preoperative resting 12-lead ECG is reasonable for patients

with known coronary heart disease, significant arrhythmia,

peripheral arterial disease, cerebrovascular disease, or

other significant structural heart disease, except for those

undergoing low-risk surgical procedures.

IIa B

Preoperative resting 12-lead ECG may be considered for

asymptomatic patients without known coronary heart

disease, except for those undergoing low-risk surgery.

IIb B

Routine preoperative resting 12-lead ECG is not useful for

asymptomatic patients undergoing low-risk surgical

procedures.

III: No

Benefit B

There is NO AGE requirement mandating a preop ECG!

Assessment of LV Function

Supplemental Preoperative Evaluation

Recommendations COR LOE

It is reasonable for patients with dyspnea of unknown origin

to undergo preoperative evaluation of LV function. IIa C

It is reasonable for patients with HF with worsening dyspnea

or other change in clinical status to undergo preoperative

evaluation of LV function.

IIa C

Reassessment of LV function in clinically stable patients

with previously documented LV dysfunction may be

considered if there has been no assessment within a year.

IIb C

Routine preoperative evaluation of LV function is not

recommended.

III: No

Benefit B

Why repeat ECHO in stable patients?

What is the likelihood it will be different?

How will it change management?

?

Noninvasive Pharmacological Stress Testing

Before Noncardiac Surgery

Supplemental Preoperative Evaluation

Recommendations COR LOE

It is reasonable for patients who are at an elevated risk for

noncardiac surgery and have poor functional capacity (<4

METs) to undergo noninvasive pharmacological stress

testing (either DSE or pharmacological stress MPI) if it will

change management.

IIa B

Routine screening with noninvasive stress testing is not

useful for patients undergoing low-risk noncardiac surgery. III: No

Benefit B

Recommendation COR LOE

Routine preoperative coronary angiography is not

recommended. III: No

Benefit C

Preoperative Coronary Angiography

CABG and PCI – no evidence of better outcome vs medical therapy alone

○ Need to consider risk of intervention

CARP ○ Stable cardiac disease, elective vascular surgery

○ Benefit with LM disease; CABG better than PCI

DECREASE V ○ Abnormal DSE (5 segments or more)

If previously revascularized (survived, asymptomatic), potentially beneficial (CASS) Also need to consider timing after PCI (BA,BMS,DES)

Prophylactic Coronary Intervention

Coronary Revascularization Prior to Noncardiac

Surgery

Perioperative Therapy

Recommendations COR LOE

Revascularization before noncardiac surgery is

recommended in circumstances in which revascularization

is indicated according to existing CPGs. I C

It is not recommended that routine coronary

revascularization be performed before noncardiac surgery

exclusively to reduce perioperative cardiac events.

III: No

Benefit B

Timing of Noncardiac Surgery

After PCI

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

<30 31-90 <90 91-180 181-365 >365

BMS

DES

M

A

C

E

Anesthesiology 2008

Days from PCI to surgery

Outcomes of NCS after PCI with DES

Crit Pathways in Cardiol, 2012

What do we do

now??? Individualize!

Urgency of surgery

Type of surgery

Patient clinical risk factors

Risk factors for stent thrombosis

○ Patient (ACS, low EF, DM, age)

○ Procedure (LAD/LM, multiple stents/vessels)

○ Lesion (bifurcation, length, diameter, multiple)

Management of antiplatelet therapy

○ Continue both, stop one, stop both

Individualize

Timing of Elective Noncardiac Surgery in Patients With

Previous PCI

Recommendations COR LOE

Elective noncardiac surgery should be delayed 14 days

after balloon angioplasty… I C

…and 30 days after BMS implantation I B

Elective noncardiac surgery should optimally be delayed

365 days after DES implantation. I B

In patients in whom noncardiac surgery is required, a

consensus decision among treating clinicians as to the

relative risks of surgery and discontinuation or continuation

of antiplatelet therapy can be useful.

IIa C

Perioperative Therapy

Timing of Elective Noncardiac Surgery in Patients With

Previous PCI (cont’d)

Recommendations COR LOE

Elective noncardiac surgery after DES implantation may be

considered after 180 days if the risk of further delay is

greater than the expected risks of ischemia and stent

thrombosis.

IIb* B

Elective noncardiac surgery should not be performed within

30 days after BMS implantation or within 12 months after

DES implantation in patients in whom DAPT will need to be

discontinued perioperatively.

III:

Harm B

Elective noncardiac surgery should not be performed within

14 days of balloon angioplasty in patients in whom aspirin

will need to be discontinued perioperatively.

III:

Harm C

*Because of new evidence, this is a new recommendation since the publication of the 2011

PCI CPG

Perioperative Therapy

Antiplatelet Agents (cont’d)

Recommendations COR LOE

In patients undergoing nonemergency/nonurgent

noncardiac surgery who have not had previous coronary

stenting, it may be reasonable to continue aspirin when the

risk of potential increased cardiac events outweighs the risk

of increased bleeding.

IIb B

Initiation of aspirin is not beneficial in patients undergoing

elective noncardiac noncarotid surgery who have not had

previous coronary stenting,… III: No

Benefit

B

…unless the risk of ischemic events outweighs the risk

of surgical bleeding. C

Perioperative Therapy

Results

28

Outcome

Aspirin (4998)

Placebo (5012)

HR (95% CI)

P

1O outcome: death or MI

351 (7.0)

355 (7.1)

0.99 (0.86-1.15)

0.92

2O outcome: death, MI, or stroke death, MI, revasc, or VTE

362 (7.2)

402 (8.0)

370 (7.4)

407 (8.1)

0.98 (0.85-1.13)

0.99 (0.86-1.14)

0.80

0.90

3O outcomes: MI

309 (6.2)

315 (6.3)

0.98 (0.84-1.15)

0.85

Safety outcome Major bleeding

230 (4.6)

188 (3.8)

1.23 (1.01-1.49)

0.04

Impact on Practice

• Should stop ASA preop for primary prevention

• Should postpone restarting ASA early postop

• Unanswered questions: subgroups

• Recent stents (were excluded)

• Recent cardiovascular events (within 1 yr)

• Primary vs secondary prevention

• High-bleeding risk surgery vs other procedures

BETA-BLOCKERS

CONTROVERSY: - Poldermans – question about scientific integrity of DECREASE trials

- POISE – question regarding dosing of metoprolol

Perioperative beta-blockers (RCTs) Author # pts Drug Duration Endpoint Outcome*

Mangano (NEJM 1996)

200 (noncard)

Atenolol (titrated)

<7 days 2 yr death 10 vs 21% RR 0.5

Poldermans (NEJM 1999)

DECREASE-I

112 (vasc;abn

DSE)

Bisoprolol (titrated)

30 days 30 d cardiac

death/MI

3.4 vs 34% RR 0.1

Dunkelgrun (Ann Surg 2009)

DECREASE-IV

1066 (noncard)

Bisoprolol (titrated)

30 days 30 d cardiac

death/MI

2.1 vs 6%

HR .34

Juul (DIPOM)

(BMJ 2006)

921DM

(noncard)

Metoprolol (not titrated)

7 days In-hosp CV

events

21 vs 20%

Brady(POBBLE)

(J Vasc Surg 2005)

103 (vasc)

Metoprolol (not titrated)

7 days 30 day CV

events

32 vs 34%

Yang (MaVS)

(Am H J 2006)

497 (vasc)

Metoprolol (not titrated)

5 days 30 day CV

events

10.1 vs 12%

Devereaux

(POISE)

(Lancet, 2008)

8351 (noncard)

Metoprolol

ER;High-dose

30 days 30 day CV

events:

1° MI, CA, CV death;

2° CVA,death,AF,revasc

1° 5.8 vs 6.9%

CVA: 1 vs 0.5%

Total mort: 3.1 vs 2.3%

*all statistically significant

Periop Beta-Blocker – Efficacy/Safety Mixed results depending on studies in meta-analyses.

Outcome Beta-blocker use

Ischemia Beneficial

MI Beneficial

CVA Harmful based primarily on POISE;

neutral/possible harm without POISE

Hypotension

& bradycardia

Harmful

Total mortality Possibly beneficial without POISE;

detrimental with POISE

Periop Beta-Blockers – Which one?

Variations in pharmacology of beta-blockers may

contribute to heterogeneous results in trials of

perioperative beta-blockade. Badgett RG, Lawrence VA, Cohn

SL. Anesthesiology. 2010;113(3):585-92.

B1/B2 selectivity:

• Metoprolol 2.3

• Atenolol 4.7

• Bisoprolol 13.5

Impaired physiologic response to blood loss may lead to CVA

Less selective BB impair increases in cardiac output, cerebral

blood flow, cerebrovascular dilatation more than selective BB.

Metoprolol is more dependent on metabolism via cytochrome

p450 system

Perioperative Therapy

Perioperative Beta-Blocker Therapy

Recommendations COR LOE

Beta blockers should be continued in patients undergoing

surgery who have been on beta blockers chronically. I BSR

It is reasonable for the management of beta blockers after

surgery to be guided by clinical circumstances, independent of

when the agent was started.

IIa BSR

In patients with intermediate- or high-risk myocardial ischemia

noted in preoperative risk stratification tests, it may be

reasonable to begin perioperative beta blockers.

IIb CSR

In patients with 3 or more RCRI risk factors (e.g., diabetes

mellitus, HF, CAD, renal insufficiency, cerebrovascular

accident), it may be reasonable to begin beta blockers before

surgery.

IIb BSR

These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s

systematic review. See the ERC systematic review report, “Perioperative beta blockade in noncardiac surgery: a

systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of

patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.

Perioperative Beta-Blocker Therapy (cont’d)

Recommendations COR LOE

In patients with a compelling long-term indication for beta-

blocker therapy but no other RCRI risk factors, initiating

beta blockers in the perioperative setting as an approach to

reduce perioperative risk is of uncertain benefit.

IIb BSR

In patients in whom beta-blocker therapy is initiated, it may

be reasonable to begin perioperative beta blockers long

enough in advance to assess safety and tolerability,

preferably more than 1 day before surgery.

IIb BSR

Beta-blocker therapy should not be started on the day of

surgery.

III:

Harm BSR

What they don’t tell you:

- Bisoprolol and atenolol may be better than metoprolol

- BB should probably be started at least 1 week before surgery

Perioperative Therapy

Perioperative Statins: RCTs

Study #

pts

Surgery Statin Started Outcome

Durrazo 100 vasc Atorvastatin

20 mg

2 wks

preop

↓ composite

endpoint

UA,CVA,MI,CV death

(8 vs 26%) at 6 mos

DECREASE

III

497 vasc Fluvastatin

XL 80 mg

>30 days

preop

↓ isch (11 vs 19%)

MI/CV death

(5 vs 10%) at 30 days

DECREASE

IV

1066 Interm

risk

Fluvastatin

XL 80 mg

>30 days

preop

Statistically

insignificant ↓

MI/CV death

(3 vs 5%) at 30 days

STATINS

What they don’t tell you:

- Which statin? Longer-acting to prevent withdrawal, more potent statin

- What dose? Moderate to high

- When to start it? Unclear – may have some benefit early on

- Downside? No evidence of harmful effects (rhabdo/LFTs)

Recommendations COR LOE

Statins should be continued in patients currently taking

statins and scheduled for noncardiac surgery. I B

Perioperative initiation of statin use is reasonable in

patients undergoing vascular surgery. IIa B

Perioperative initiation of statins may be considered in

patients with clinical indications according to GDMT who are

undergoing elevated-risk procedures. IIb C

OTHER MEDICAL THERAPY

POISE-2: Clonidine - Did not reduce periop MI/death

- Increased nonfatal cardiac arrest

- Increased periop hypotension

ACEIs: - associated with hypotension during induction of anesthesia

- no evidence of increased MI/death

- potential benefit with HF and uncontrolled HTN

Periop Surveillance:Troponin & Mortality After NCS

Author (yr) # pts Troponin % abnormal Outcome

Devereaux POISE

(2011)

8,351 T

(CPK)

13.3% 5% with Dx of MI

8.3% elevated w/o MI

Beattie (2012) 51,701 I 11% >0.7ug/L

Postop

LR 3.0 for 30 day mortality;

gradient “dose response” relationship

Devereaux-VISION

(2012)

15,133 T

4th gen

12% >0.01ng/ml

8% >0.03ng/ml

Postop

Peak trop assoc with 30 day mortality; the

higher the value,the higher the mortality and

shorter time to death;added prognostic value

Levy (2011)

Systematic review

3,318 I and T 8-52%

Postop

OR 3.4 – independent predictor of mortality

VanWaes-CHASE

(2013)

2,232 I 19% >0.07ug/L

Postop

Trop level correlated with incr risk of 30-day

mortality; gradient response

Sandhu (2013)

Systematic review

– elderly hip Fx pts

979 I and T 22-39%

Postop

Higher troponin level correlated with

increased mortality

Weber (2013) 979 hsTnT

5th gen

24%>14ng/L

Preop

Trop level was the strongest predictor for

comb of mortality, MI, card arrest, CHF

Naegle (2013) 608 hsTnT

5th gen

41% >14ng/L

Preop

Trop was associated with incr MI and long-

term mortality

Kavsak (2011)

Subset of VISION

325 hsTnT

5th gen

21% >14ng/L Preop

45% >14ng/LPostop

More pts had elevated 5th generation hsTnT

vs 4th generation troponin T

VISION Increasing troponin predicted mortality

JAMA. 2012;307(21):2295-2304

MINS

>0.03

Perioperative Surveillance

Surveillance and Management for Perioperative MI

Recommendations COR LOE

Measurement of troponin levels is recommended in the

setting of signs or symptoms suggestive of myocardial

ischemia or MI.

I A

Obtaining an ECG is recommended in the setting of signs or

symptoms suggestive of myocardial ischemia, MI, or

arrhythmia.

I B

The usefulness of postoperative screening with troponin

levels in patients at high risk for perioperative MI, but

without signs or symptoms suggestive of myocardial

ischemia or MI, is uncertain in the absence of established

risks and benefits of a defined management strategy.

IIb B

Surveillance and Management for Perioperative MI (cont’d)

Recommendations COR LOE

The usefulness of postoperative screening with ECGs in

patients at high risk for perioperative MI, but without signs

or symptoms suggestive of myocardial ischemia, MI, or

arrhythmia, is uncertain in the absence of established risks

and benefits of a defined management strategy.

IIb B

Routine postoperative screening with troponin levels in

unselected patients without signs or symptoms suggestive

of myocardial ischemia or MI is not useful for guiding

perioperative management.

III: No

Benefit B

Perioperative Surveillance

KEY POINTS TO REMEMBER

1) Aims: risk assess, mgmt change, team

approach - shared decision-making

2) Low vs elevated risk - if elevated & <4METS,

stress testing only if it changes mgmt

3) Surg OK with monitoring for asympt valv dis

4) NCS may be OK if >6;<12 mos after DES (esp

newer DES) - try to continue ASA or DAPT

5) Continue periop BB if already on it - starting BB

may be OK if isch, RCRI>3 and >2days before

surgery