How to Keep Your Surgeon Out of Trouble: Perioperative Medicine: Risk Stratification

How to Keep Your Surgeon Out of Trouble: Perioperative Medicine: Risk Stratification Jalal K. Ghali, M.D., F.A.C.C. Professor of Medicine Associate Chair for Clinical Research Chief, Division of Cardiology Department of Medicine Mercer University School of Medicine Macon, GA

How to Make Your Surgeon Happy

Dear Dr. GS, Your patient Mr. MC has been cleared for the planned surgery. I would like to assure you that no medical complications will arise from the planned surgery and furthermore, should they arise, I take full responsibility for managing them. Our commitment extends for full 30 days post op.

How to Keep Your Surgeon Out of Trouble:

Impossible

Disclosures Internists: Surgeons: Know everything and do no procedures Know nothing and do everything Psychiatrists: Have no clue Pathologists: Know everything, one day late do everything

Definition of the Medical Consultant

Perioperative Medicine Magnitude of the problem Is there a need for medical consultation? Pathophysiology Predictive models Revised Cardiac Risk Index Thoracic Revised Cardiac Risk Index Vascular Study Group of New England Surgical Mortality Probability Model Risk Calculator for Prediction of Cardiac Risk

Perioperative Medicine Clinical Recommendations Special considerations Biomarkers Hypertension PCI Statins Beta Blockers Summary Definition of the medical consultant

10 million major noncardiac surgery 4 million in patients 65 years High risk account for 80% of death 250 million procedures worldwide

Common preventable complications after non-cardiac surgery that may be prevented by enhanced perioperative care Pneumonia Superficial and deep wound infection Myocardial infarction Arrhythmias Severe pain Pulmonary embolism Acute kidney injury Stroke Respiratory failure Acute confusion or delirium Cardiac arrest Pearse RM, et al. BMJ 2011;343:d5759.

84,730 patients who had undergone inpatient general and vascular surgery 2005-2007 Very low mortality Very high mortality 3.5% 6.9% Ghaferi AA. N Engl J Med 2009;361:1368-75

Rates of All Complications, Major Complications, and Death after Major Complications Ghareri AA, et al. N Engl J Med 2009;361:1368-1375.

Survival Probability All Patients Patients surviving beyond 30 days postop Days Patients with no complications Patients with 1 or more 30-day postop complications Khuri SF, et al. Ann Surg 2005;242(3):326-343.

Hospital-specific rates of preoperative medical consultation for major elective noncardiac surgery Wijeysundera DN, et al. Anesthesiology 2012;116:25-34.

Associations Between Perioperative Consultation, Quality of Care, and Subsequent Complications Auerbach AD, et al. Arch Intern Med 2007;167:2338-2344.

217,082 39% (n = 104,716) underwent anesthesia consultations - Reduced mean hospital length of stay 8.17 vs 8.52 day - No reduction of 30 day or 1 year mortality Wijeysundera DN, et al. Arch Intern Med 2009;169(6):595-602.

1994 2004 269,866 n = 104695 (38.8%) underwent consultation 30 day mortality RR 1.16 (1.07 1.25) Number needed to harm 516 1 year mortality RR 1.08 (1.04 1.12) Number needed to harm 227 Wijeysundera DN, et al. Arch Intern Med 2010;170(15):1365-1374.

Pathophysiology

Emotional stress Pain Surgical trauma Tissue injury Hypothermia Hypoxemia Immobility Bleeding and anemia Fasting

Landesberg G et al. Circulation 2009;119:2936-2944.

Potential triggers of states associated with perioperative elevations in troponin levels, arterial thrombosis and fatal myocardial infarction Devereaux PJ, et al. CMAJ 2005;173(6):627-634.

Risk Prediction Models

Revised Cardiac Risk Index

Lee TH, et al. Circulation 1999;100:1043-1049.

Risk of Cardiac Death and Nonfatal Myocardial Infarction for Noncardiac Surgical Procedures Risk of procedure High (> 5%) Aortic and major vascular surgery, peripheral vascular surgery Intermediate (1 to 5%) Intraperitoneal or intrathoracic surgery, carotid endarterectomy, head and neck injury, orthopedic surgery, prostate surgery Low (< 1%) Ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, cataract surgery

Thoracic Revised Cardiac Risk Index

Thoracic Revised Cardiac Risk Index Ischemic Heart Disease 1.5 CVA or TIA 1.5 Pneumonectomy 1.5 Creatinin >2 mg/dl 1.0 Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.

Distribution of Patients in Each Class of the Recalibrated Revised Cardiac Risk Index (ThRCRI) ThRCRI Score Risk Class No. of Cases Major Cardiac Complications 0 A 1,909 18 (0.9%) 1-1.5 B 616 26 (4.2%) 2-2.5 C 25 2 (8%) >2.5 D 71 13 (18%) p < 0.0001 Brunelli A, et al. Ann Thorac Surg 2011;92:445-8..

Rates of cardiac complication according to the Thoracic Revised Cardiac Risk Index classes A, B, C, D Brunelli A, et al. Ann Thorac Surg 2011;92:445-8..

Vascular Study Group of New England(VSG-CRI)

Vascular Surgery Group Cardiac Risk Index (VSG-CRI) scoring system and predicated risk of adverse cardiac events Bertges, et al. J Vasc Surg 2010;52(3):674-83.

Surgical Mortality Probability Model

ASA PS Classification ASA PS I II III IV V Definition A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation Glance LG, et al. Ann Surg 2012;255:696-702.

S-MPM Scoring System for Estimating Risk of 30-Day Mortality After Noncardiac Surgery Glance LG, et al. Ann Surg 2012;255:696-702.

S-MPM Class Levels and Associated Risk of Mortality Class Point Total Mortality I 0-4 <0.50% II 5-6 1.5%-4.0% III 7-9 >10% Glance LG, et al. Ann Surg 2012;255:696-702.

Risk Calculator for Prediction of Cardiac Risk After Surgery

Calculator to Predict the risk of myocardial infarction or cardiac arrest (MICA) Type of surgery Functional status Abnormal creatinine American Society of Anesthesiologists class Increasing age The MICA risk calculator is available at www.surgicalriskcalculator.com Gupta PK, et al. Circulation 2011;124:381-387.

Clinical Recommendations

CCS ACC/ AHA ESC HFSA

CCS ACC/AHA ESC HFSA

Definition Something that provides direction or advice as to a decision or course of action; A detailed plan or explanation to guide you in setting standards or determining a course of action Collins English Dictionary http://www.thefreedictionary.com/guideline

Definition Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances 1 To assist health care providers in clinical decision making by describing a range of generally acceptable approaches 2 1. Institute of Medicine. Washington, DC: National Academy PR; 1992 2. Hunt S, et al. Circulation 2005;112:1825-52.

Electrocardiogram

Class I Recommendations for Preoperative Resting 12-Lead ECG 1. Patients with at least 1 clinical risk factor who are undergoing vascular surgical procedures. 2. patients with known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Recommendations for Preoperative Resting 12-Lead ECG Class III 1. Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Suggested algorithm for performing preoperative electrocardiography Feely MA, et al. Am Fam Physician 2013;87(6):414-8.

Echocardiography

264, 823 patients undergoing elective intermediate to high risk noncardiac surgery 1998-2008 Echocardiography 40,084 (15.1%) 70,996 30 day mortality 1 year mortality 1.14 (1.02-1.27) 1.07 (1.01-1.12) Wijeysundera DN, et al. BMJ 2011;342:d3695.

Recommendations for Preoperative Noninvasive Evaluation of LV Function Class IIa 1. It is reasonable for patients with dyspnea of unknown origin. 2. It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical status if not performed within 12 months. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Recommendations for Preoperative Noninvasive Evaluation of LV Function Class IIb 1. Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. Class III 1. Routine perioperative evaluation of LV function in patients is not recommended. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Stress Testing

Association of preoperative stress testing with one year survival in the subgroup analyses Wijeysundera DN, et al. BMJ 2010;340:b5526.

Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery Unstable coronary symptoms Decompensated HF (NYHA functional class IV: worsening or new-onset HF) Significant arrythmias Severe valvular disease Fleisher LA, et al. Circulation 2009;120:e169-e276.

Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery Class I 1. Patients with active cardiac conditions. Class IIa 1. 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery is reasonable if it will change management. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery Class IIb 1. may be considered for patients with at lease 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate risk or vascular surgery if it will change management. Class III 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing low or intermediate-risk noncardiac surgery. Fleisher LA, et al. Circulation 2009;120:e169-e276.

Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery McFalls EO, et al. NEJM 2004;351:2795-2804.

American College of Cardiology (ACC)/ American Heart Association (AHA) 2007 Guidelines Open Vascular Surgery Required Emergent No Yes Active Cardiac Condition No Known Functional Capacity No Proceed with planned procedure Yes Class I: Non-Invasive Stress Testing Class I: Coronary Revascularization indications same as in patients not undergoing surgery < 3 Clinical Risk Factors Class I: No Further Testing Class I: Continue β-blocker if currently prescribed No Yes Class IIa: Consider Non-Invasive Stress Testing

Biomarkers

Postoperative NT-proBNP Thresholds and the Incidence of Mortality or Nonfatal MI at 30 Days after Surgery Rodseth et al. Anesthesiology 2013;119:270-83.

Postoperative BNP Thresholds and the Incidence of Mortality or Nonfatal MI at 30 Days after Surgery Rodseth et al. Anesthesiology 2013;119:270-83.

Risk of death for patients with estimated glomerular filtration rate <60 ml-min-1.73 m -2 compared with 60 mil-min-1.73 m -2 at both short-term and long-term follow up Mooney et al. Anesthesiology 2013;118:809-24.

Kaplan-Meier estimates of 30-Day mortality based on peak Troponin T values 15,133 noncardiac surgery (2007 2011) The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. JAMA 2013;307:2295-2304.

Le Manach, et al. Anesthesiology 2005;102:885-891.

Kikura M, et al. J Thromb Haemost 2008;6:742-748.

Statins

Effect of perioperative statins on myocardial infarction, atrial fibrillation, and death. Chopra V, et al. Arch Surg 2012;147(3):181-9.

Effect of perioperative statins on hospital and intensive care unit length of stay. Chopra V, et al. Arch Surg 2012;147(3):181-9.

Forest plot of comparison: I Statin versus placebo/no treatment, outcome: 1.2 All-Cause mortality Sanders RD, et al. Cochrane Database Syst Rev 2013;7.

Forest plot of comparison: I Statin versus placebo/no treatment, outcome: 1.4 Myocardial Infarction (non-fatal) Sanders RD, et al. Cochrane Database Syst Rev 2013;7.

The highest-risk period for ST after PCI with either BMS or DES following NCS is the first 4 weeks. Therefore, it seems reasonable to withhold NCS, if possible, for at least 4 weeks after PCI. Singla S, et al. JACC 2012;60:2005-2016.

Proposed approach to the management of patients with previous PCI requiring noncardiac surgery Fleisher LA, et al. Circulation 2009;120:e169-e276.

Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery Fleisher LA, et al. Circulation 2009;120:e169-e276.

Perioperative Hypertension

No link between perioperative complications with either preexistant hypertension or an elevated blood pressure Types of surgery: CABG, AA, CEA, PVS, intraperitoneal or intrathoracic Perioperative cardiac complications are associated with hemodynamic lability (>20% change in mean BP)

Consider lowering the dose of ACE inhibitors or AR antagonist 24 hours ( at least 10 hours) before surgery

Perioperative Beta Blockers

8,351 patients with, or at risk of, atherosclerotic disease received extended-release metoprolol succinate (n=4174) or placebo (n=4177) started 2-4 h before surgery and continued for 30 days. Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.

Kaplan-Meier estimates of the primary outcome (A), myocardial infarction (B), stroke (C) and death (D) Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.

Metoprolol (n = 4179) Placebo (n = 4177) Death 129 79 32 Strokes 41 19 32 Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.

Meta-analysis of β-blocker trials in patients undergoing noncardiac surgery Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47..

Comparison of effect of perioperative β-blockade on nonfatal strokes in secure and non-secure trials. Bouri S et al. Heart 2013.

Meta-analysis of nine secure randomised controlled trials showing a significant increase in mortality with perioperative β-blockade. Bouri S et al. Heart 2013.

Prevalence of hypotension in β-blocker and control groups. Bouri S et al. Heart 2013.

Thirty-Day Mortality Propensity Model London MJ, et al. JAMA 2013;309(16):1704-13.

Beta Blockers 28,263 adults with IHD who underwent noncardiac surgery 2004-2009 MACE Mortality Heart Failure 22% 18% MI within 2 years 46% 20% MI 2 5 years 29% 26% MI > 5 years 35% 33% No MI or HF 44% 30% Anderson C et al. Annual Congress of the European Society of Cardiology. September 18, 2013.

Summary of ACC/AHA Guideline Recommendations Beta-Blocker Medical Therapy Class I Class III Beta-blockers should be continued in patients undergoing surgery who are receiving betablockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications Routine administration of high-dose betablockers 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

Fleisher LA. Cleve Clin J Med 2009;76:S9-15.

Medical Consultant Provide informed clinical judgment based on knowledge, experience and the individual patient s data to optimize short and long term outcomes.