Cardiac evaluation for non cardiac Sx Dr Mithilesh

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Cardiac evaluation for non cardiac surgery

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Moderator Dr. P.D. Nigam Presented by Dr. Mithilesh Kumar DNB Cardiology CARDIAC EVALUATION FOR NON-CARDIAC SURGERY: ASSESSMENT & TREATMENT

Introduction:

I ntroduction  Cardiovascular complications pose one of the most significant risks to patients undergoing major noncardiac surgery Goldmann et al in 1977 evaluated 1001 patients over age 40; the overall risk of postoperative cardiac death or major cardiac complications (including nonfatal myocardial infarction [MI], pulmonary edema, or ventricular tachycardia) was 5.8 percent Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297:845.

Introduction:

Introduction A 1995 review of major published series found that outcome of MI and cardiac death varied with the population studied. Among unselected patients over age 40 — MI in 1.4% and cardiac death in 1.0%. Among patients selected to undergo preoperative thallium scintigraphy — MI in 6.9 % and cardiac death in 3.2%. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333:1750 .

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Goals : To identify patients at risk through history, physical examination & ECG. To evaluate the severity of underlying cardiac disease through cardiac tests. Stratify the extent of risk & determine the need for preoperative interventions to minimize risk of peri operative complications.

Why is there perioperative risk?:

Major hemodynamic stress, Changes in cholinergic activity, Changes in catecholamine activity, Body temperature fluctuations, Pulmonary function is altered, Fluid shifts, Pain. Why is there perioperative risk?

Risks of anesthesia : :

Decreased systemic vascular resistance, Decreased stroke volume, Induction of general anesthesia lowers systemic arterial pressures by 20-30%, tracheal intubation increases the blood pressure by 20-30 mm Hg, and many anesthetic agents lower cardiac output by 15%. Risks of anesthesia :

Assessment of Risk:

Assessment of Risk Revised cardiac risk index (RCRI) - The most recent index was developed in a study of 4315 patients > 50 years undergoing elective major non-cardiac procedures - Included Six independent predictors Lee et al. Circ 1999;100:1043

Revised cardiac risk index (RCRI) :

Revised cardiac risk index (RCRI) Risk facters cardiovascular risk 0 Low 1-2 Intermediate >3 High Patients can be stratified into low, intermediate, and high cardiovascular risk on the basis of having zero, one/two, or three or more RCRI risk factors, respectively. The RCRI has become the standard tool assessing the probability of perioperative cardiac risk directs the decision to perform cardiovascular testing implement perioperative management protocols

Revised Cardiac Risk Index :

Revised Cardiac Risk Index Lee et al. Circ 1999;100:1043. *Cardiac death, MI, pulmonary edema, arrhythmic arrest, heart block

Revised Cardiac Risk Index :

Revised Cardiac Risk Index Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173:627. Adverse outcomes:- cardiac death, nonfatal MI, and nonfatal cardiac arrest

Evaluation of cardiac risk:

Evaluation of cardiac risk

History & Physical examination:

History & Physical examination A detailed history & physical examination of the patient's symptoms, signs, clinical course, and exercise tolerance yields valuable information about previous coronary heart disease, symptoms of angina, heart failure (HF), aortic stenosis, severe hypertension, and peripheral artery disease (PAD) for risk assessment. High risk findings :- severe AS murmur, elevated JVP, S 3 gallop, LVF.

Functional capacity :

Functional capacity  An assessment of cardiac functional status should also be performed. It provides valuable prognostic information, since patients with good functional status have a lower risk of complications . One important indicator of poor functional status and an increased risk of postoperative cardiopulmonary complications after major noncardiac surgery is the inability to climb two flights of stairs or walk four blocks Girish M, Trayner E Jr , Dammann O, et al. Symptom-limited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery. Chest 2001; 120:1147. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999; 159:2185 .

Estimated Energy Requirements for Various Activities:

Estimated Energy Requirements for Various Activities NO . OF METS QUESTION : CAN YOU 1 take care of yourself? Eat, dress, or use the toilet? Walk indoors around the house? Walk a block or two on level ground at 2 to 3 mph (3.2-4.8 kph) 4-10 Do light work around the house like dusting or washing dishes? Climb a flight of stairs or walk up a hill? Walk on level ground at 4 mph (6.4 kph)? Run a short distance? Do heavy work around the house, like scrubbing floors or lifting or moving heavy furniture? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? >10 Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

SURGERY-SPECIFIC RISK :

SURGERY-SPECIFIC RISK   The type and timing of surgery significantly affects the patient's risk of perioperative cardiac complications.  Emergency surgery is associated with particularly high risk, as cardiac complications are two to five times more likely than with elective procedures  dental procedures are considered to be of low cardiovascular risk and were not mentioned in the ACC/AHA guidelines . Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990; 72:153.

Cardiac Risk Stratification for Noncardiac Surgical Procedures :

Cardiac Risk Stratification for Noncardiac Surgical Procedures RISK STRATIFICATION EXAMPLES OF PROCEDURES High (reported cardiac risk often >5%) Aortic and other major vascular  Surgery Peripheral vascular surgery Intermediate (reported cardiac risk generally = 1-5%) Intraperitonal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low (reported cardiac risk generally <1%) ( These procedures generally do not require further preoperative cardiac testing.) Endoscopic procedures Superficial procedures Cataract surgery Prostate surgery Ambulatory surgery

Active Cardiac Conditions Requiring Evaluation and Treatment Before Non cardiac Surgery (Class I, level of evidence: B):

Active Cardiac Conditions Requiring Evaluation and Treatment Before Non cardiac Surgery (Class I, level of evidence: B) CONDITION EXAMPLES Unstable coronary syndromes Unstable or severe angina *  (CCS class III or IV) Recent MI (>7 days and < 30days) Decompensated HF (NYHA functional class IV; worsening or new-onset HF)    Significant arrhythmias High-grade atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR higher than 100 beats per minute at rest) Symptomatic bradycardia Newly recognized ventricular tachycardia Severe valvular disease Severe aortic stenosis (mean pressure gradient higher than 40 mm Hg,  aortic valve area less than 1 cm 2 , or symptomatic) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional   presyncope , or HF)

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Perioperative Evaluation of Cardiac Patients Undergoing Noncardiac Surgery proposed algorithm for decisions regarding the need for further evaluation

Guidelines:

Guidelines Ancillary Testing In the ACC/AHA guidelines, the routine 12-lead electrocardiogram (ECG) is recommended for patients undergoing vascular surgery or with at least one RCRI clinical risk factor. They recommend restraint in the use of ECGs for asymptomatic patients undergoing low-risk procedures. Routine use of echocardiography to assess left ventricular (LV) function is discouraged unless patients have worsening heart failure or dyspnea of unknown cause. Similarly, routine use of exercise or pharmacologic stress testing in asymptomatic patients without evidence of coronary artery disease is considered a Class III indication (not supported by evidence).

Non invasive stress testing :

Non invasive stress testing Different modalities eg :- exercise ECG, exercise or pharmacologic nuclear stress testing, and exercise or pharmacologic stress ECHO. Exercise is the modality of choice. It provides an objective assessment of functional capacity. Stress echo offers the advantage of providing additional information about ventricular and valvular function.

Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery:

Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery Class l Patients with active cardiac conditions in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines *  before noncardiac surgery Class lla   Noninvasive stress testing of patients with three or more clinical risk factors and poor functional capacity ( <4  METs) who require vascular surgery  is reasonable if it will change management Class llb    Noninvasive stress testing may be considered for patients with at least one or two clinical risk factors and poor functional capacity ( <4 METs) who require intermediate risk or vascular surgery if it will change management Class lll 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery 2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery

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Reducing Cardiac Risk of Non-cardiac Surgery

Surgical Revascularization:

Surgical Revascularization Coronary revascularization has been suggested as a means of reducing perioperative risk surrounding noncardiac surgery. Retrospective evidence indicates that prior successful preoperative revascularization may decrease postoperative cardiac risk two- to four-fold in patients undergoing elective vascular surgery. The strongest evidence comes from the Coronary Artery Surgery Study (CASS) Registry, which enrolled patients from 1978 to 1981.The operative mortality for patients with CABG before noncardiac surgery was 0.9% but was significantly higher (2.4%) in patients without prior CABG. However, a 1.4% mortality rate was associated with the CABG procedure itself.

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The ACC/AHA recommendations for the use of coronary revascularization aim to improve the patient's long-term cardiovascular prognosis and minimize the risk of an acute complication during the procedure. For patients who require percutaneous revascularization, a strategy using balloon angioplasty alone or in conjunction with a bare metal stent is recommended because of the mandate for 12 months of dual antiplatelet therapy after drug-eluting stent deployment.  The ESC guidelines recommended that percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) be performed according to the applicable guidelines for management in stable angina pectoris.

Preoperative Coronary Revascularization with CABG or Percutaneous Coronary Intervention:

Preoperative Coronary Revascularization with CABG or Percutaneous Coronary Intervention Class I 1     Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have significant left main coronary artery stenosis 2     Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have three-vessel disease (survival benefit is greater when LV ejection fraction [EF] is less than 0.50 3     Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have two-vessel disease with significant proximal LAD stenosis and either EF less than 0.50 or demonstrable ischemia on noninvasive testing 4     Coronary revascularization before noncardiac surgery is recommended for patients with high-risk unstable angina or non–ST-segment elevation myocardial infarction 5     Coronary revascularization before noncardiac surgery is recommended for patients with acute ST-elevation MI

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Class IIa 1     In patients in whom coronary revascularization with PCI is appropriate for mitigation of cardiac symptoms and who need elective noncardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare metal stent placement followed by 4 to 6 weeks of dual antiplatelet therapy is probably indicated 2     In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible (level of evidence: C). Class IIb 1     The usefulness of preoperative coronary revascularization is not well established in high-risk ischemic patients (e.g., abnormal dobutamine stress echocardiogram, with at least five segments of wall motion abnormalities; level of evidence: C). 2     The usefulness of preoperative coronary revascularization is not well established for low-risk ischemic patients with an abnormal dobutamine stress echocardiogram (segments 1 to 4; level of evidence: B).

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Class III 1     It is not recommended that routine prophylactic coronary revascularization be performed in patients with stable coronary artery disease (CAD) before noncardiac surgery (level of evidence: B). 2     Elective noncardiac surgery is not recommended within 4 to 6 weeks of bare metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients for whom thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued perioperatively (level of evidence: B). 3     Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty (level of evidence :  B).

 Recommendations on Timing of Noncardiac Surgery in Cardiac-Stable or Asymptomatic Patients with Prior Revascularization:

 Recommendations on Timing of Noncardiac Surgery in Cardiac-Stable or Asymptomatic Patients with Prior Revascularization RECOMMENDATIONS CLASS OF RECOMMENDATION LEVEL OF EVIDENCE It is recommended that patients with previous CABG in the last 5 years be sent for noncardiac surgery without further delay. I C It is recommended that noncardiac surgery be performed in patients with recent bare metal stent implantation after a minimum of 6 weeks and optimally 3 months following the intervention. I B It is recommended that noncardiac surgery be performed in patients with recent drug-eluting stent implantation no sooner than 12 months following the intervention. I B Consideration should be given to postponing noncardiac surgery in patients with recent balloon angioplasty until at least 2 weeks following the intervention. IIa B

Post CABG timing of non cardiac surgery:

Post CABG timing of non cardiac surgery After CABG, non-cardiac surgery should be delayed by at least 30 days Begg A, Jennings K, Ritchie L, et al. Management of stable angina . A National Clinical Guideline. The Scottish Intercollegiate Guidelines Network (SIGN) 2007; 96: 23 – 4 Breen P, Lee JW, Pomposelli F, Park KW. Timing of high-risk vascular surgery following coronary artery bypass surgery: a 10-year experience from an academic medical centre. Anaesthesia 2004; 59: 422 – 7

Proposed approach to the management of patients with previous PCI requiring noncardiac surgery:

Proposed approach to the management of patients with previous PCI requiring noncardiac surgery From Fleisher LA, Beckman JA, Brown KA, et al: 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 54:e13, 2009.)

Pharmacologic Interventions:

Pharmacologic Interventions Beta-Adrenergic Blocking Agents Statin Therapy Nitroglycerin

B- BLOCKERS:

B- BLOCKERS Beta blockers are the best-studied medical treatment, and guidelines for their use in the perioperative period have been published recently

Recommendations for Perioperative Beta Blocker Therapy:

Recommendations for Perioperative Beta Blocker Therapy Class l     Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs Class lla     Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk because of coronary artery disease or the finding of cardiac ischemia on preoperative testing 2    Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than one clinical risk factor 3    Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than one clinical risk factor, * who are undergoing intermediate-risk surgery.

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Class llb   1. The usefulness of beta blockers is uncertain for patients who are undergoing intermediate-risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease    2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers Class lll 1.Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade    2.Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery Recommendations for Perioperative Beta Blocker Therapy

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Statin Therapy In addition to their cholesterol-lowering properties, statins have anti-inflammatory and plaque-stabilizing properties . Given the potential mechanisms of perioperative MIs, statins could have theoretical benefits. Accumulating evidence suggests that statin therapy should continue during the perioperative period, and consideration should be given for starting statin therapy in high-risk patients, particularly those who meet the National Cholesterol Education Program's Adult Treatment Panel III's recommendations, because it could be argued that the patient should have been on a statin already. Nitroglycerin Only two randomized trials have evaluated the potential protective effect of prophylactic nitroglycerin for reducing perioperative cardiac complications after noncardiac surgery.  Taken together, the evidence suggests that prophylactic nitroglycerin does not reduce the incidence of perioperative cardiac morbidity, although neither trial was powered to detect a modest benefit of nitroglycerin. Because prophylactic nitroglycerin has considerable hemodynamic effects and is not known to prevent MI or cardiac death, it would seem prudent to avoid the prophylactic use of nitroglycerin, although there are clear indications for its use once myocardial ischemia develops.

Nonpharmacologic Interventions:

Nonpharmacologic Interventions Temperature Frank and coworkers completed a randomized trial of regional versus general anesthesia for lower extremity vascular bypass procedures and noted an association between hypothermia (temperature < 35°C) and myocardial ischemia. They subsequently performed a trial in 300 high-risk patients undergoing a diverse group of intermediate-risk and high-risk procedures, randomizing patients to maintenance of normothermia or routine care. They observed a significantly reduced incidence of perioperative cardiac morbidity and mortality within 24 hours of surgery in the group that was kept normothermic . Transfusion Threshold Much controversy surrounds the optimal hemoglobin level at which to transfuse high-risk noncardiac surgical patients. Several small cohort studies have shown that hematocrits in the 27% to 29% range represent the point below which the incidence of myocardial ischemia and potentially MI increases.  The evidence suggests that patients with known ischemic heart disease that has not been revascularized should be maintained perioperatively with a hemoglobin level higher than 9 g/ dL .

Hypertension:

Hypertension Several large prospective studies did not establish mild to moderate hypertension as an independent predictor of postoperative cardiac complications, so pt may undergo elective operation with continued antihypertensive medications. Severe HTN should be controlled. B blockers preffered .

Hypertension:

Hypertension Weksler and colleagues studied 989 chronically treated hypertensive patients who presented for noncardiac surgery with diastolic BP between 110 and 130 mm Hg and with no previous MI, unstable or severe angina, renal failure, pregnancy-induced HTN , LVH, previous coronary revascularization, aortic stenosis, preoperative dysrhythmias , conduction defects, or stroke. The control group had their surgery postponed and remained in the hospital for BP control, and the study patients received 10 mg of nifedipine , delivered intranasally . No statistically significant differences in postoperative complications were observed, suggesting that this subset of patients without significant cardiovascular comorbidities can proceed with surgery despite elevated BP on the day of surgery.

Heart Failure:

Heart Failure Goldman and colleagues have identified a third heart sound or signs of heart failure as portending the highest perioperative risks Identify the etiology( DCMP, ICMP, Valvular etc.) Treat the cause Heart failure should be optimally controlled preoperatively, avoid over- diuresis . HOCM:- risk is low, avoid intra operative hypotension and hypovolemia that can lead to exacerbation of dynamic outflow obstruction.

Valvular heart disease :

Valvular heart disease Critical aortic stenosis associated with the highest risk of cardiac decompensation in patients undergoing elective noncardiac surgery. It should be managed with valve replacement. Kertai has reported a substantially higher rate of perioperative complications in patients with severe aortic stenosis, compared with patients with moderate aortic stenosis—31% (5/16) versus 11% (10/92). Valvuloplasty used as a short term bridge for selected patients. Cannesson M, Earing MG, Collange V, Kersten JR: Anesthesia for noncardiac surgery in adults with congenital heart disease. Anesthesiology 2009; 111:432.

Valvular heart disease :

Valvular heart disease Mitral stenosis :- Mild – managed medically Severe & symptomatic – BMV or MVR should be considered MR or AR – optimize medical Mx

Prosthetic heart valve:

Prosthetic heart valve antibiotic prophylaxis and anticoagulation are major issues procedures that can cause transient bacteremia should receive antibiotic prophylaxis Patients with a mechanical prosthetic valve on oral anticoagulants undergoing noncardiac surgery :- the common practice is cessation of oral anticoagulants 3 days before surgery. This allows the international normalized ratio (INR) to fall to <1.5 times normal; oral anticoagulants can then be resumed on postoperative day 1. An alternative approach in patients at high risk for thromboembolism is conversion to heparin during the perioperative period, which can then be discontinued 4 to 6 hours before surgery and resumed shortly thereafter.

Prosthetic heart valve:

Prosthetic heart valve According to the AHA/ACC guidelines, heparin can usually be reserved for high-risk patients. High risk is defined by the presence of a mechanical mitral or tricuspid valve or mechanical aortic valve and of risk factors (e.g., atrial fibrillation, previous thromboembolism , hypercoagulable condition, older generation mechanical valves, ejection fraction less than 30%, or more than one mechanical valve). Subcutaneous LMWHs or unfractionated heparin offers an alternative outpatient approach but receives a tentative recommendation

Arrhythmias:

Arrhythmias Cardiac arrhythmias are common in the perioperative period, particularly in older patients or in patients undergoing thoracic surgery .Predisposing factors include prior arrhythmias, underlying heart disease, HTN perioperative pain (e.g., hip fracture), severe anxiety, and other situations that heighten adrenergic tone Identify the underlying disease, drug toxicity, or metabolic disturbances. Frequent PVCs and asymptomatic NSVT are not asso . With increase perioperative cardiac risk.

PPIs & ICDs:

PPIs & ICDs Check device (PPIs) 3-6 months prior to non cardiac surgery. Device should be reprogrammed to an asynchronors mode during surgery (VOO or DOO) Electrocautery should be used only briefly and with caution. Check & reprogrammed the device post-operatively ICDs are programmed to off preoperatively and to on after the procedure

Take Home Messages:

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.

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