Evaluation of the Cardiac Patient Before Non-Cardiac Surgery Saturday, April 10, 2016 MaRS Auditorium, 0850-0915 COVER PAGE (option 1) DRAFT ONLY (FILE NOT FINAL) Read before using template NOTE: The following elements of the template should remain untouched and cannot be modified: • Corporate (Université d'Ottawa | University of Ottawa) garnet header • Corporate uOttawa footer including the grey/garnet stripe and logo, with the exception of the URL which can be customized to a specific URL by following these simple steps: On the PowerPoint View tab, in the Master Views group, select Slide Master. Select the third slide on the left side panel, and type in the desired URL on the slide.  Department of Anesthesiology Département d’anésthesiologie

Disclosure of competing interests No financial CI No professional CI Member CCS Guidelines Panel

Objectives Using the 2014 ACC/AHA Guidelines as a framework, the learner will: Identify patients at risk for major adverse cardiac events following surgery Propose a rational approach to preoperative investigation Select therapies proven to reduce risk of major adverse cardiac events Contrast ACC/AHA and ESC/ESA guidance

Where to find this stuff 2014 ACC/AHA Guideline on perioperative … J Am Coll Cardiol 2014;64(22):e77–137 Circulation 2014;30(24):e278-333 2014 ESC/ESA Guidelines on non-cardiac surgery … Eur Heart J 2014;35(35):2383-431 Eur J Anaesthesiol 2014;31(10):517-73 ($) Twitter @glbryson

T1. Class and Level Applying Classification of Recommendations and Level of Evidence Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

2014 ACC/AHA New Sections Valvular Heart Disease ECHO within a year for mod-severe disease or change (IC) Consider valve repair/replacement (IC) Implantable Electric Devices Have an individualized plan! (IC) Pulmonary vascular disease Continue meds (IC) Use a validated risk tool (IIaB)

2007/2009 ACC/AHA Guidelines Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical conditions. †See Class III recommendations in Section 5.2.3. Noninvasive Stress Testing. ‡See Table 3 for estimated MET level equivalent. §Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management. ∥Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperative beta blockade (see Table 12) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent. Lee A. Fleisher et al. Circulation. 2007;116:e418-e500 Copyright © American Heart Association, Inc. All rights reserved.

2014 ACC-AHA Guidelines Stepwise approach to perioperative cardiac assessment for CAD. Colors correspond to the Classes of Recommendations in Table 1. Step 1: In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment (see Section 2.1 for more information on CAD). (For patients with symptomatic HF, VHD, or arrhythmias, see Sections 2.2, 2.4, and 2.5 for information on evaluation and management.) Step 2: If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs.18,20Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator (http://www.riskcalculator.facs.org) or incorporate the RCRI131 with an estimation of surgical risk. For example, a patient undergoing very low-risk surgery (eg, ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE, whereas a patient undergoing major vascular surgery with few risk factors would have an elevated risk of MACE (Section 3). Step 4: If the patient has a low risk of MACE (<1%), then no further testing is needed, and the patient may proceed to surgery (Section 3). Step 5: If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI.133 If the patient has moderate, good, or excellent functional capacity (≥4 METs), then proceed to surgery without further evaluation (Section 4.1). Step 6: If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (eg, decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT (Section 5.3). Step 7: If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CPG, clinical practice guideline; DASI, Duke Activity Status Index; GDMT, guideline-directed medical therapy; HF, heart failure; MACE, major adverse cardiac event; MET, metabolic equivalent; NB, No Benefit; NSQIP, National Surgical Quality Improvement Program; PCI, percutaneous coronary intervention; RCRI, Revised Cardiac Risk Index; STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; and VHD, valvular heart disease. Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

2014 ACC-AHA Guidelines Step 1: In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment (see Section 2.1 for more information on CAD). (For patients with symptomatic HF, VHD, or arrhythmias, see Sections 2.2, 2.4, and 2.5 for information on evaluation and management.) Step 2: If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs. Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

2014 ACC-AHA Guidelines Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator (http://www.riskcalculator.facs.org) or incorporate the RCRI131 with an estimation of surgical risk. For example, a patient undergoing very low-risk surgery (eg, ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE, whereas a patient undergoing major vascular surgery with few risk factors would have an elevated risk of MACE (Section 3). Step 4: If the patient has a low risk of MACE (<1%), then no further testing is needed, and the patient may proceed to surgery (Section 3). Step 5: If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI.133 If the patient has moderate, good, or excellent functional capacity (≥4 METs), then proceed to surgery without further evaluation (Section 4.1). Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

When I say risk, you say ....? 2007 ACC/AHA two-step risk evaluation Surgical risk (low, intermed, vasc) “Clinical risk factors” 2014 ESC/ESA two-step method 2014 ACC/AHA indicates “combined clinical surgical risk” Low risk <1% MACE Elevated risk >1% MACE

Are risk models the same? Characteristic RCRI ASC-NSQIP Derived N = 2,900 N = 1,414,000 Validated N = 1,400 Unclear Data collected Prospective Retrospective Variables 6 22 MACE outcomes Five Two Biomarkers Routine Clinical indication Procedures Mixed, 48h stay All NSQIP Lee TH. Circulation 1999;100:1043-49 Bilimoria KY. J Am Coll Surg 2013;217: 833e842.

An example 70 male Colectomy for CA colon STEMI 5 years ago, RCA BMS placed Angina-free, active (8 METS) DM2, oral meds Otherwise well

Revised Cardiac Risk Index Risk Factor  High risk surgery History of CAD History of CHF History of stroke Diabetes mellitus Cr > 177 Risk Factors Events (%) 95% CI 0.4 0.05 – 1.5 1 0.9 0.3 – 2.1 2 6.6 3.9 – 10.3 3 11.0 5.8 – 18.4 Lee TH. Circulation 1999;100:1043-49

ACS-NSQIP Risk Predictor http://riskcalculator.facs.org/PatientInfo/PatientInfo

ACS Surgical Risk Calculator http://riskcalculator.facs.org/Outcome

ACS Surgical Risk Calculator http://riskcalculator.facs.org/Outcome

2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

2014 ACC-AHA Guidelines Step 6: If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (eg, decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT (Section 5.3). Step 7: If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

T5. Supplemental Investigations 12 Lead LVEF Fancy Summary of Recommendations for Supplemental Preoperative Evaluation Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

CPG - Revascularization Left main 3 Vessel 2 Vessel + badness Left Main CAD Revascularization Recommendations From the 2011 CABG and PCI CPGs Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

T6. Perioperative Therapy Revascularization B-blockers Other Stuff Antiplatelet Summary of Recommendations for Perioperative Therapy CIED Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

Beta-blockers are a mess ACC/AHA ESC/ESA Continue IB Intermediate-high risk tests IIbC Known IHD ischemia IIbB ≥3 Risk Factors ≥2 Risk Factors or ASA ≥3 Don’t start without titrating IIIB Atenolol or bisoprolol

DECREASEing the effect Outcome All Trials RR (95%CI) DECREASE OTHERS Non-fatal MI 484/11,963 (4.0%) 0.66 (0.57 to 0.85) 0.22 (0.03 to 1.45) 0.72 (0.59 to 0.86) Stroke 68/11,611 (0.6%) 1.79 (1.09 to 2.95) 1.86 (1.09 to 3.16) 1.33 (0.30 to 5.93) Mortality 324/11,963 (2.7%) 0.96 (0.62 to 1.47) 0.42 (0.15 to 1.22) 1.30 (1.03 to 1.63) Wijeysundera DN. Circulation. 2014; 130: 2246-2264

T7. Anesthetic management RA v GA NTG TEE Summary of Recommendations for Anesthetic Consideration and Intraoperative Management PAC Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

Antiplatelet Rx and PCI Algorithm for antiplatelet management in patients with PCI and noncardiac surgery. Colors correspond to the Classes of Recommendations in Table 1. *Assuming patient is currently on DAPT. ASA indicates aspirin; ASAP, as soon as possible; BMS, bare-metal stent; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; and PCI, percutaneous coronary intervention. Lee A. Fleisher et al. Circulation. 2014;130:e278-e333 Copyright © American Heart Association, Inc. All rights reserved.

New DAPT recommendations Levine GN. Circulation 2016: doi 10.1161/CIR.0000000000000404

Summary Combined medical-surgical risk Surgery w MACE < 1% needs NOTHING Functional capacity remains key assessment Beta-blockers in evolution Anti-platelet agents in evolution ASA reconsidered after POISE 2 Wait following newer stents down to 6 mo. No longer just about CAD