ART PREOP RISK DR SABER 2011

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

The Art of Pre Operative Cardiac Risk Assessment:

The Art of Pre Operative Cardiac Risk Assessment By Dr Saber A Malak M.B.B.Ch, M.Sc., DCV(Cardiology ) MRCP-UK, FRCP-Edinburgh Consultant Physician (Based on ESC 2009 Guidelines)

Magnitude of the problem EU:

Magnitude of the problem EU Annually 40.000.000 Surgical Procedures 400.000 Myocardial Infarctions (1%) 133.000 Cardiovascular Death (0.3%) DR Saber A M 2

Types of Risks:

Types of Risks Surgical Factors Type of surgery Type of anesthesia Timing: Elective vs. urgent procedure Patient Factors Age Existing Co-morbidity Exercise Tolerance Medication DR Saber A M 3

Cardiac Risk In focus:

Cardiac Risk In focus Cardiovascular disease represent the greatest challenge in preoperative risk assessment. Approximately 75% of patients who suffer perioperative death have cardiovascular disease After major surgery: cardiac death 0.5-1.5% with non-fatal cardiac complications ranging between 2 – 3.5% DR Saber A M 4

Agenda :

Agenda Role of m edical consultant Stepwise approach for preoperative cardiac risk assessment Identify different risk factors: cardiac risk factors and risk of surgical procedures and functional capacity New Strategies to reduce cardiovascular perioperative mortality DR Saber A M 5

Role of The Medical Consultant:

Role of The Medical Consultant DR Saber A M 6 Evaluate patient data, history and examination Further testing if needed to define CV status Risk stratify Optimize Treatment to improve underlying medical condition (Uncontrolled DM,HTN, BA ….etc.) Theophile Laennec (1781-1826), French physician who invented the stethoscope

Role of The Medical Consultant:

Role of The Medical Consultant DR Saber A M 7 Smart consultation Limit number of recommendations. Focus on critical problems. Be specific about drugs. Avoid delaying surgery. Misconception Advise on type of anesthesia: GA, LA or spinal Change ongoing treatment plans Initiate diagnostic work-ups from scratches

Perioperative mortality :

Perioperative mortality DR Saber A M 8 Who should be blamed ? Surgeon or Anesthetist?

Mortality related to anesthesia:

Mortality related to anesthesia Rare: Approx. 1:26,000 anesthetics One third of deaths are preventable Causes in order of frequency - inadequate patient preparation - inadequate postoperative management - wrong choice of anesthetic technique - inadequate crisis management DR Saber A M 9

Pathophysiology of Perioperative MI:

Pathophysiology of Perioperative MI Coronary plaque rupture >> Thrombosis >> MI Due to: I- Surgical Stress Response : Catecholamine surge (hemodynamic stress and vasospasm) Reduced fibrinolytic activity Platelet activation Hypercoagulability state II- Myocardial supply/demand imbalance DR Saber A M 10

Stepwise Approach:

11 Pre-operative Cardiac Risk Assessment DR Saber A M Stepwise Approach

Stepwise Approach:

Stepwise Approach Step 1: Urgent Surgery Step 2: Active or Unstable Cardiac condition Step 3: What is the risk of the surgical procedures Step 4: What is the functional capacity of the patient Step 5: In patient with low to moderate functional capacity consider the risk of surgical procedure Step 6: Consider cardiac risk factors Step 7: Consider non invasive tests DR Saber A M 12

Step 1 Is Surgery Urgent or Planned?:

Step 1 Is Surgery Urgent or Planned? Urgent surgery No time for further cardiac testing or treatment . Plan on perioperative medical management Surveillance for cardiac events Resume chronic CVS treatment after surgery Continue chronic aspirin therapy after surgery If Non urgent surgery Move to step 2 DR Saber A M 13

Urgency and Operative Mortality:

Urgency and Operative Mortality Ambroise Pare, French surgeon who lived in the 1500's. He has been called the father of modern surgery 14 Urgent Operations have a higher mortality rate for the same medical status (High Risk Consent)

Aspirin Therapy ESC 2009 Recommendation:

Aspirin Therapy ESC 2009 Recommendation Class IIa – B Consider continuation of chronic aspirin therapy during perioperative period for most surgeries DC aspirin only in patients with difficult hemostasis DR Saber A M 15 Why ?

Stepwise Approach:

Stepwise Approach Step 1: Urgent Surgery Step 2: Active or Unstable Cardiac condition Step 3: What is the risk of the surgical procedures Step 4: What is the functional capacity of the patient Step 5: In patient with low to moderate functional capacity consider the risk of surgical procedure Step 6: Consider cardiac risk factors Step 7: Consider non invasive tests DR Saber A M 16

Step 2 Active Cardiac Conditions:

Step 2 Active Cardiac Conditions Active or Unstable Cardiac Conditions Unstable coronary syndromes (Recent MI within 30 days + ischemia or UA ) Acute/ Decompensated HF Significant arrhythmias (2nd OR 3rd Degree HB, Symptomatic Ventricular arrhythmias, uncontrolled SVT/AF, Symptomatic severe bradycardia) Severe valvular disease :( Severe AS, Symptomatic MS.) DR Saber A M 17

Step 2 When to postpone an elective surgery for further cardiac testing or treatment?:

Step 2 When to postpone an elective surgery for further cardiac testing or treatment? Treatment Before Noncardiac Surgery AMI: Postpone non-emergent procedures for at least 6 months after an MI ACS: Coronary angiography and intervention A.S: Repair severe aortic stenosis first M.S: Balloon mitral valvuloplasty first HF: Treat CHF aggressively preoperative If no active cardiac conditions Move to Step 3 DR Saber A M 18

Stepwise Approach:

Stepwise Approach Step 1: Urgent Surgery Step 2: Active or Unstable Cardiac condition Step 3: What is the risk of the surgical procedures Step 4: What is the functional capacity of the patient Step 5: In patient with low to moderate functional capacity consider the risk of surgical procedure Step 6: Consider cardiac risk factors Step 7: Consider non invasive tests DR Saber A M 19

Step 3 Risk of surgery for cardiac events within 30 days:

Step 3 Risk of surgery for cardiac events within 30 days DR Saber A M 20 Low Risk (<1%) Endoscopic and dental procedures Superficial procedures - gynecological Cataract surgery – knee surgery Breast surgery Intermediate Risk (1- 5%) Intraperitoneal & Intrathoracic surgery * Head / neck surgery Carotid surgery Major Orthopedic surgery esp. hip and spine * Prostate surgery Lung/liver/kidney transplant High Risk (>5 %) A cute abdomen M ajor trauma Aortic/major vascular surgery Prolonged surgery with large fluid shifts/blood loss Peripheral vascular surgery

Cataract Surgery:

Cataract Surgery No benefit of preoperative testing No difference in event rate or cancellations (Schein et al. NEJM 2000;342:168-175 .) DR Saber A M 21

Step 3 :

Step 3 DR Saber A M 22 Action : Class IIa B In these cases proceed with surgery with no further cardiac testing Test results unlikely to change management Postoperative evaluation and control of cardiac risk factors recommended Low Risk (<1%) Endoscopic Dental procedures Superficial procedures Gynecological Cataract surgery Knee surgery Breast surgery Endocrine If the risk of surgical procedure is intermediate to high Move to Step 4

Stepwise Approach:

Stepwise Approach Step 1: Urgent Surgery Step 2: Active or Unstable Cardiac condition Step 3: What is the risk of the surgical procedures Step 4: What is the functional capacity of the patient Step 5: In patient with low to moderate functional capacity consider the risk of surgical procedure Step 6: Consider cardiac risk factors Step 7: Consider non invasive tests DR Saber A M 23

Functional Capacity CardioPulmonary Exercise Test (CPET):

Functional Capacity CardioPulmonary Exercise Test (CPET) The patient is asked to exercise at a known work rate on some form of ergometer while a number of variables are measured: ECG Blood pressure; Expired air flow; O2 uptake from the air; CO2 output from the body; Arterial blood gases. DR Saber A M 24

Step 4 Assess Functional Capacity:

Step 4 Assess Functional Capacity 1 MET = eating, dressing, and using toilet 3 MET = light housework, walking 100m, golfing with a cart 4 MET = climbing 2 flights of stairs OR walk uphill 6 MET = short run >10 MET = able to participate in strenuous sport (tennis, football, ..etc.) DR Saber A M 25 MET indicates metabolic equivalent; *Modified from Hlatky et al,11 copyright 1989 1 MET = 3.5 ml O2 / kg / min (Oxygen consumption by 40 yo 70 kg man at rest)

Step 4:

Step 4 Exercise Tolerance and Risk : If unable to walk 4 blocks OR climb 2 flights of stairs = Poor Exercise Tolerance Poor exercise tolerance had twice the incidence of perioperative complications (cardiovascular and neurological) 20% vs. 10% p<0.001 High Functional Capacity: Excellent prognosis. Proceed to surgery (Even in presence of risk factors or stable CAD) DR Saber A M 26 Reilly DF et al Arch Intern Med 1999;159:2185

Step 4 Assess Functional Capacity:

Step 4 Assess Functional Capacity Good Functional Capacity : 4 METS OR More ( 2 flights of stairs, walking uphill, short run) Class IIa B Proceed to surgery. In patients with CAD: Initiate Statins and low dose B Blockers ideally 30 days (optimal) and at least one week before surgery If Moderate OR Poor Functional Capacity Move to step 5 DR Saber A M 27

Pre-operative Beta-Blockers and statins:

Pre-operative Beta-Blockers and statins Beta-adrenergic blockade and statin therapy: Decrease in perioperative ischemic events. Start: Minimum 7 days, Ideal 30 days before surgery DR Saber A M 28

Stepwise Approach:

Stepwise Approach Step 1: Urgent Surgery Step 2: Active or Unstable Cardiac condition Step 3: What is the risk of the surgical procedures Step 4: What is the functional capacity of the patient Step 5: In patient with low to moderate functional capacity consider again the risk of surgical procedure Step 6: Consider cardiac risk factors Step 7: Consider non invasive tests DR Saber A M 29

Step 5 Intermediate risk surgery with moderate to poor functional capacity:

Step 5 Intermediate risk surgery with moderate to poor functional capacity DR Saber A M 30 Class II a- B ECG, Echo Statin and B Blockers ACIs if with LV dysfunction Proceed with surgery Intermediate Risk (1- 5%) Intraperitoneal & Intrathoracic surgery * Head / neck surgery Carotid surgery Major Orthopedic surgery esp. hip and spine * Prostate surgery Lung/liver/kidney transplant High risk surgery with moderate to poor functional capacity move to step 6

Step 6 and 7 :

31 Cardiac Risk Factors Assessment Non invasive cardiac testing Coronary angiography and Revascularization DR Saber A M Step 6 and 7 High risk surgery with intermediate or poor functional capacity

Intermediate Cardiac Risk Factors:

Intermediate Cardiac Risk Factors DR Saber A M 32 Intermediate Cardiac Risk Factors: Mild effort angina pectoris (CCS class I-II ) Prior MI ( Hx Or Q-waves on ECG) with no evidence of residual ischemia Compensated or prior HF Diabetes Mellitus (on insulin ) Renal insufficiency (CR more than 200mmol/L) Prior Stroke Major / Active Cardiac Risk Factors: Unstable coronary syndromes Decompensated CHF Significant Arrhythmias Severe valvular disease

STEP 6 Cardiac Risk Factors in High Risk Surgery with poor FC:

STEP 6 Cardiac Risk Factors in High Risk Surgery with poor FC DR Saber A M 33 Cardiac Risk Factors 2 Or Less Class I B Do as in step 5 (ECG, Echo, Statin, B Blockers, ACIs and proceed) Cardiac Risk Factors 3 Or More Move to step 7 Intermediate Cardiac Risk Factors: Mild effort angina pectoris (CCS class I-II) Prior MI ( Hx Or Q-waves on ECG) with no evidence of residual ischemia Compensated or prior HF Diabetes Mellitus (on insulin) Renal insufficiency (CR more than 200mmol/L) Prior Stroke

Step 7 Cardiac stress testing:

Step 7 Cardiac stress testing Do cardiac stress testing (exercise ECG, Dobutamine echo or nuclear scan) A - If no or moderate stress induced ischemia do as in step 5 (statin, B Blockers, ACIs and proceed to surgery) – Class I B B - If extensive ischemia send the patient for coronary angiography prior to surgery DR Saber A M 34

Echo in pre-operative assessment:

Echo in pre-operative assessment Information about 3 cardiac risk markers: LV Dysfunction Myocardial ischemia Valvular abnormalities Class IIa C Pre-operative Echocardiography should only be considered in patients undergoing high risk surgery OR if you suspect severe valvular lesions . DR Saber A M 35

Cardiac Stress Testing:

Cardiac Stress Testing Class I C Should be done in patients with 3 or more risk factors scheduled for high risk surgery. Class IIa May be considered in patients with 2 or less risk factors or in patients undergoing intermediate risk surgery DR Saber A M 36

Step 7 Management of patients after coronary revascularization:

Step 7 Management of patients after coronary revascularization Balloon angioplasty Bare Metal Stents (BMS) Drug Eluting Stents (DES) Timing of surgery (postpone non- urgent surgery) Proceed only After 2 weeks Minimum After 6 weeks Optimal after 3 months Proceed only After 12 months Drugs Aspirin for life Aspirin plus Plavix for 6 weeks up to 3 months then Aspirin for life Aspirin plus Plavix for 12 months then Aspirin for life DR Saber A M 37 Class I B

Take Home Messages:

Take Home Messages History and clinical examination is the cornerstone of medical preoperative assessment. Continue the patients same medications. Change of treatment is rarely required before surgery. Do not ask for cardiac testing or coronary angiography in stable patients unless absolutely needed DR Saber A M 38

Take Home Messages:

Take Home Messages Strategies to Reduce P eri-operative Mortality Start statin and B Blockers in cardiac patients if not previously started. Start ACIs in patients with LV dysfunction. Do not stop Aspirin before surgery as a routine Do not stop Plavix – Consult cardiologist DR Saber A M 39

Take home messages:

Take home messages DR Saber A M 40 Good communication between surgeon, anesthesiologist, and physician is the key word for a good Perioperative evaluation and management

Thank You For Listening:

Thank You F or L istening

authorStream Live Help