Perioperative Cardiac Evaluation

Perioperative Cardiac Evaluation Caroline McKillop Advisor: Dr. Tam Psenka 10-3-2007

Importance of Cardiac Guidelines -Used multiple times every day -Patient Safety -Part of Surgical Care Improvement Project (SCIP)- national quality initiatives and eventual pay for performance -Cost efficiency

History -ACC/AHA guidelines first published in 1996. 2002 guidelines delineate risk stratification, preoperative testing, perioperative medical therapy. -2004- Coronary Artery Revascularization before elective vascular surgery does not significantly alter long-term outcomes. -2006 ACC/AHA guidelines- recommend broader use of beta blockade. -Waiting for further recommendations on beta blockade and stents.

2002 ACC/AHA- Patient Predictors of Perioperative Cardiovascular Risk -Major Clinical Predictors: -Unstable coronary syndromes- MI in last month, unstable or severe angina. -Decompensated heart failure -Severe valve disease -Significant arrhythmia- high AV block, SVT with uncontrolled rate or with underlying heart disease. -Intermediate Clinical Predictors: -Mild Angina -Previous MI (Q wave) -History of heart failure -Diabetes (especially insulin dependent) -Renal Insufficiency (creatinine > 2)

2002 ACC/AHA- Patient Predictors of Perioperative Cardiovascular Risk -Minor Clinical Predictors: -Advanced age -Abnormal EKG- LVH, LBBB, ST-T abnormalities -Rhythm other than sinus -Low functional status (cannot climb one flight of stairs with groceries) -History of stroke -Uncontrolled hypertension

2002 ACC/AHA- Estimated Energy Requirements -1 MET- Activities of Daily Living. -4 METs- Range from light house work to climbing stairs, heavy house work, moderate sports activity. -Greater than 10 METs- Strenuous sports.

2002 ACC/AHA- Surgery Specific Risks -High Risk (cardiac risk often greater than 5%) -Emergent major operation, particularly in the elderly. -Aortic, major vascular surgery. -Peripheral vascular surgery. -Prolonged surgery, large fluid shifts and/or blood loss. -Intermediate Risk (Cardiac risk generally less than 5%) -Carotid endarterectomy -Head and neck, orthopedic, prostate, intraperitoneal, intrathoracic surgery. -Low Risk (Cardiac Risk generally less than 1%) -Endoscopic or superficial procedures. -Cataract or breast surgeries.

5. Pacemakers and ICDs- Know the type and if the patient is dependent on the pacer. Switch off ICDs right before surgery and switch on again post-op. 2002 ACC/AHA- Specific Cardiovascular Conditions 1. Hypertension- Stage 3 (SBP>180, DBP >110) should be controlled before surgery. 2. Valvular Heart Disease- Symptomatic regurgitant valve disease should be medically (and often surgically) stabilized. 3. Myocardial Disease- Maximize preoperative hemodynamics in patients with dilated and hypertrophic cardiomyopathy. 4. Arrhythmias- No need to treat frequent PVCs or asymptomatic nonsustained VT. Should evaluate and treat symptomatic and hemodynamically significant arrhythmias.

2002 ACC/AHA Guidelines for Preoperative Testing 1. Echocardiography- for uncontrolled heart failure. Consider if history of heart failure or dyspnea of unknown origin. 2. 12 Lead EKG- Recent chest pain in intermediate or high risk patient going for intermediate to high risk procedure. Consider in asymptomatic diabetics, history of PCI, asymptomatic male > 45 (female >55) with 2 or more risks, and if hospitalized in past for cardiac cause. 3. Stress Test- To diagnose intermediate risk of CAD, prognosis/evaluation if known CAD, to prove ischemia before revascularization, to evaluate adequacy of medical therapy. Consider when cannot assess exercise capacity, to diagnose CAD in high or low pretest probability, to detect restenosis in high risk asymptomatic patients several months after PCI.

2002 ACC/AHA- Guidelines for Preoperative Testing 4. Invasive Testing- -Angiography recommended if high risk of adverse outcome based on noninvasive testing, if angina not treated on adequate medical therapy, if unstable angina, if noninvasive testing equivocal and patient or surgery is high risk. Consider if multiple intermediate risks and vascular surgery, ischemia on noninvasive tests but no high risk factors, urgent noncardiac surgery with recent acute MI. -PCI and CABG- same indications as for use of these techniques normally (unstable symptoms, severe CAD).

2002 ACC/AHA- Perioperative Medical Therapy -Beta Blockade Recommended if: -Beta-blockers required in past to control angina, symptomatic arrhythmias, or hypertension. -High cardiac risk due to ischemia on preoperative testing and having vascular surgery. -Consider if untreated hypertension, known CAD or major risks for CAD. -Can also consider alpha 2 agonist for perioperative control of hypertension, known CAD or major risks for CAD.

2002 ACC/AHA Algorithm

2002 ACC/AHA Algorithm 2002 ACC/AHA Algorithm

2004- Coronary Revascularization -Patients undergoing a vascular operation were randomized to revascularization before surgery (59% PCI, 49% CABG) or no revascularization before surgery. -Conclusion: Revascularization before elective vascular surgery does not significantly change long-term outcome. -Study also states that 2002 ACC/AHA guidelines support this and that revascularization is only recommended for unstable cardiac symptoms or advanced CAD. Yet until now there has still been a lack of consensus on when to revascularize.

2006 ACC/AHA Updates -Emphasis on Perioperative Beta Blockade: -Beta blockers continued perioperatively if receiving them for angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications (Vascular Surgery in patient with CHD or high cardiac risk- no ischemia on preop testing needed). -Beta blockers probably recommended for patients with high cardiac risk due to multiple clinical factors. -Beta blockers probably indicated if CHD or high cardiac risk due to multiple clinical factors and patient having intermediate or high risk procedures.

2006 ACC/AHA Updates -Beta blockers may be considered in patients undergoing vascular surgery with low cardiac risk who are not currently on beta blockers. -Beta blockers may be considered if having intermediate or high risk procedures if the patient has intermediate cardiac risk due to one clinical risk factor.

Summary and Areas for -Better beta blockade studies. Improvement -Therapy becoming more symptom based, more beta blockade, less invasive interventions. -Which one?-atenolol may be better than metoprolol/long acting better than short acting. -Dose, length of therapy, patient population? -Increased patient education on the importance of compliance: -Current studies showing that patients do not understand the importance of continuing beta blockade. -Physicians/nurses better emphasizing that beta blockade should be continued perioperatively.

References -Beckman, Joshua A., et.al. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. Journal of the American College of Cardiology. 47:11 (2006). -Eagle, Kim A., et. al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery- Executive Summary. Circulation. 105 (2002), p1257-1267. -Fleisher, Lee A. The Preoperative Evaluation: An Opportunity for Education and Other Strategies to Improve. Journal of Cardiothoracic and Vascular Anesthesia. 21:3 (2007), p323-324. -McFalls, Edward O., et. al. Coronary Artery Revascularization before Elective Major Vascular Surgery. The New England Journal of Medicine. 351: 27 (2004), p2795-2804. -Rosenfeld, D.M., Trentman, T.L., and J.G. Hentz, et. al. Patient Understanding pf Beat Blocker Use in the Perioperative Period. Journal of Cardiothoracic and Vascular Anesthesia. 21 (2007), p325-329. -Win, Htut K., et al. Clinical Outcomes and Stent Thrombosis Following Off-Label Use of Drug-Eluting Stents. JAMA. 297:18 (2007), p2001-2009.