ACC/AHA 2007 Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery Doris Lin, M.D.

Outline Recommendations Recommendations Algorithm 2002 vs 2007 Algorithm 2002 vs 2007 Misc Misc

Introduction In US, millions of pts undergo surgical procedures each yr In US, millions of pts undergo surgical procedures each yr Most morbidity & death occur in the post-op period & is of cardiac, pulm, neurologic, or infectious origin Most morbidity & death occur in the post-op period & is of cardiac, pulm, neurologic, or infectious origin MI usually occurs w/in the first 4 days after surgery & is assoc with a 15-25% mortality rate MI usually occurs w/in the first 4 days after surgery & is assoc with a 15-25% mortality rate

Introduction Nonfatal post-op MI is an independent risk factor for future infarction and death w/in 6 months after surgery Nonfatal post-op MI is an independent risk factor for future infarction and death w/in 6 months after surgery ACP guidelines similar to ACC/AHA except that ACP does not recommend use of exertional capacity (METs) to guage cardiovasc risk ACP guidelines similar to ACC/AHA except that ACP does not recommend use of exertional capacity (METs) to guage cardiovasc risk

Purpose of the Guidelines Goal is not to “medically clear” pt Goal is not to “medically clear” pt Provide a risk profile based on pt’s medical status and make recommendations concerning the management and risk of cardiac problems over the entire perioperative period Provide a risk profile based on pt’s medical status and make recommendations concerning the management and risk of cardiac problems over the entire perioperative period

Methodology and Evidence ACC/AHA conducted literature searches in PubMed, MEDLINE, and Cochrane Library from ACC/AHA conducted literature searches in PubMed, MEDLINE, and Cochrane Library from Searches limited to English language and human subjects Searches limited to English language and human subjects

Applying Classification of Recommendations and Level of Evidence (LOE) Class I- Evidence that procedure is beneficial, useful, and effective Class I- Evidence that procedure is beneficial, useful, and effective Class II- Conflicting Evidence Class II- Conflicting Evidence Class IIa- Weight is in favor of usefulness/efficacy Class IIa- Weight is in favor of usefulness/efficacy Class IIb- Efficacy is less well established Class IIb- Efficacy is less well established Class III- Evidence that procedure is not useful and may be harmful Class III- Evidence that procedure is not useful and may be harmful

Applying Classification of Recommendations and Level of Evidence Level of Evidence A- Data from multiple, randomized, clinical trials Level of Evidence A- Data from multiple, randomized, clinical trials Level of Evidence B- Data from single- randomized trial or non-randomized trial Level of Evidence B- Data from single- randomized trial or non-randomized trial Level of Evidence C- Only consensus opinion of experts, case studies, or standard-of-care Level of Evidence C- Only consensus opinion of experts, case studies, or standard-of-care

Cardiac Risk Stratification for Surgical Procedures High (cardiac risk > 5%) High (cardiac risk > 5%) Aortic and major vascular surgery Aortic and major vascular surgery Peripheral vascular surgery Peripheral vascular surgery Emergent major operations, esp in elderly Emergent major operations, esp in elderly Prolonged surgeries associated with large fluid shifts or blood loss Prolonged surgeries associated with large fluid shifts or blood loss

Cardiac Risk Stratification for Surgical Procedures Intermediate (cardiac risk 1-5%) Intermediate (cardiac risk 1-5%) Intraperitoneal/intrathoracic surgery Intraperitoneal/intrathoracic surgery Carotid endarterectomy Carotid endarterectomy Head and neck surgery Head and neck surgery Orthopedic surgery Orthopedic surgery Prostate surgery Prostate surgery

Cardiac Risk Stratification for Surgical Procedures Low (cardiac risk < 1%) Low (cardiac risk < 1%) Endoscopic procedures Endoscopic procedures Superficial procedure Superficial procedure Cataract Cataract Breast surgery Breast surgery Ambulatory procedure Ambulatory procedure

Recommendations- Who needs these tests prior to surgery? EKG EKG Assess LV function Assess LV function Noninvasive stress testing Noninvasive stress testing Pre-op coronary revascularization Pre-op coronary revascularization Beta-blocker therapy Beta-blocker therapy

Recommendations for Pre-op EKG Class I & II Class I & II 0-1 clinical risk factor & vasc surgery (LOE: B) 0-1 clinical risk factor & vasc surgery (LOE: B) 1 risk factor & intermediate risk surgery (LOE: B) 1 risk factor & intermediate risk surgery (LOE: B) Class III Class III Not indicated in asymptomatic persons & low risk procedure (LOE: B) Not indicated in asymptomatic persons & low risk procedure (LOE: B)

Clinical Risk Factors Ischemic heart disease Ischemic heart disease Compensated or prior heart failure Compensated or prior heart failure Cerebrovascular disease Cerebrovascular disease Diabetes mellitus Diabetes mellitus Renal insufficiency Renal insufficiency

Recommendation for Noninvasive Eval of LV function Class IIa Class IIa Dyspnea of unknown origin (LOE: C) Dyspnea of unknown origin (LOE: C) Current or prior HF with worsening dyspnea or other change in clinical status (LOE: C) Current or prior HF with worsening dyspnea or other change in clinical status (LOE: C) Class IIb Class IIb Stable cardiomyopathy may not need (LOE: C) Stable cardiomyopathy may not need (LOE: C) Class III Class III Routine echo in pts not recommended (LOE: B) Routine echo in pts not recommended (LOE: B)

Recommendatons for Noninvasive Stress Testing Class I Class I Active cardiac conditions should be treated prior to surgery (LOE: B) Active cardiac conditions should be treated prior to surgery (LOE: B) Class IIa Class IIa 3+ clinical risk factors & < 4 METS who require vascular surgery (LOE: B) 3+ clinical risk factors & < 4 METS who require vascular surgery (LOE: B)

Active Cardiac Conditions Unstable coronary syndromes Unstable coronary syndromes Decompensated heart failure Decompensated heart failure Significant arrythmias Significant arrythmias High grade AV blocks, symptomatic arrythmias High grade AV blocks, symptomatic arrythmias Severe valvular disease Severe valvular disease Severe AS (mean pressure gradient > 40 mmHg or valve area 40 mmHg or valve area < 1.0 cm2, or symptomatic) Symptomatic MS Symptomatic MS

Energy Requirements 1 MET 1 MET Take care of self Take care of self Eat, dress, use toilet Eat, dress, use toilet 2-3 METs 2-3 METs Walk indoors around the house Walk indoors around the house Walk a block Walk a block 4 METs 4 METs Light housework like dusting or washing dishes Light housework like dusting or washing dishes

Energy Requirements 4-5 METs 4-5 METs Climb stairs, walk up a hill Climb stairs, walk up a hill 6-9 METs 6-9 METs Run a short distance Run a short distance Heavy housework Heavy housework Moderate recreational activities Moderate recreational activities 10 METs 10 METs Strenuous activities (swimming, tennis, skiing) Strenuous activities (swimming, tennis, skiing)

Recommendatons for Noninvasive Stress Testing Class IIb- considered for: Class IIb- considered for: 1-2 clinical risk factors & < 4 METS & intermediate risk surgery 1-2 clinical risk factors & < 4 METS & intermediate risk surgery 1-2 clinical risk factors & > 4 METS & vascular surgery 1-2 clinical risk factors & > 4 METS & vascular surgery Class III Class III Not needed if no risk factors & intermediate surgery Not needed if no risk factors & intermediate surgery Not needed if low risk procedure Not needed if low risk procedure

Recommendations for Pre-op Revascularization with CABG or PCI Class I Class I Stable angina & left main stenosis Stable angina & left main stenosis Stable angina & 3 vessel disease Stable angina & 3 vessel disease Stable angina & 2 vessel disease (prox LAD stenosis) & either EF < 50% or ischemia on stress test Stable angina & 2 vessel disease (prox LAD stenosis) & either EF < 50% or ischemia on stress test High risk unstable angina or NSTEMI High risk unstable angina or NSTEMI Acute STEMI Acute STEMI

PCI: angioplasty Delay surgery for > 14 days to allow healing of vessel injury Delay surgery for > 14 days to allow healing of vessel injury Should continue aspirin perioperatively (vs bleeding risk) Should continue aspirin perioperatively (vs bleeding risk)

PCI: bare-metal stent Delay surgery for 4-6 wks to allow for at least partial endothelialization Delay surgery for 4-6 wks to allow for at least partial endothelialization Clopidogrel usually not needed after 4 wks Clopidogrel usually not needed after 4 wks Should continue aspirin perioperatively (vs bleeding risk) Should continue aspirin perioperatively (vs bleeding risk)

PCI: Drug-eluting stents Delay surgery for 12 months due to risk of in- stent thrombosis Delay surgery for 12 months due to risk of in- stent thrombosis Should continue aspirin perioperatively (vs bleeding risk) Should continue aspirin perioperatively (vs bleeding risk) Thrombosis may occur up to 1.5 years after implantation, particularly in the context of discontinuing antiplatelet agents before surgery Thrombosis may occur up to 1.5 years after implantation, particularly in the context of discontinuing antiplatelet agents before surgery

Beta-blocker therapy Class I Class I Continue if already on beta-blocker Continue if already on beta-blocker Vascular surgery & high cardiac risk (ischemia on pre-op testing) Vascular surgery & high cardiac risk (ischemia on pre-op testing) Class IIa- probably recommended for: Class IIa- probably recommended for: Vascular surgery & coronary disease Vascular surgery & coronary disease Vascular surgery & > 1 clinical risk factor Vascular surgery & > 1 clinical risk factor Intermediate surgery & > 1 clinical risk factor Intermediate surgery & > 1 clinical risk factor

Beta-blocker therapy Class IIb- uncertain for: Class IIb- uncertain for: Intermediate/high risk surgery & 1 clinical risk factor Intermediate/high risk surgery & 1 clinical risk factor High risk/Vascular surgery & no clinical risk factors High risk/Vascular surgery & no clinical risk factors Class III Class III Contraindication to beta-blockers Contraindication to beta-blockers Routine administration of high-dose beta blockers w/o dose titrati is not useful and may be harmful to pts not currently taking beta blockers (POISE trial) Routine administration of high-dose beta blockers w/o dose titration is not useful and may be harmful to pts not currently taking beta blockers (POISE trial)

Beta-blockers Since 2002, few randomized trials have not demonstrated efficacy of beta-blockers but weight of evidence still suggests benefit esp high-risk pts Since 2002, few randomized trials have not demonstrated efficacy of beta-blockers but weight of evidence still suggests benefit esp high-risk pts Should be started 7-10 days before elective surgery Should be started 7-10 days before elective surgery Long-acting agents may be better than short- acting Long-acting agents may be better than short- acting

Beta-blockers Accumulating evidence suggests HR target is beats/min Accumulating evidence suggests HR target is beats/min Should continue beta-blocker therapy through peri-op period & titrate to tight HR control Should continue beta-blocker therapy through peri-op period & titrate to tight HR control

Algorithm for 2007

2002

Active Cardiac Conditions Unstable coronary syndromes Unstable coronary syndromes Decompensated heart failure Decompensated heart failure Significant arrythmias Significant arrythmias High grade AV blocks, symptomatic arrythmias High grade AV blocks, symptomatic arrythmias Severe valvular disease Severe valvular disease Severe AS (mean pressure gradient > 40 mmHg or valve area 40 mmHg or valve area < 1.0 cm2, or symptomatic) Symptomatic MS Symptomatic MS

Energy Requirements 1 MET 1 MET Take care of self Take care of self Eat, dress, use toilet Eat, dress, use toilet 2-3 METs 2-3 METs Walk indoors around the house Walk indoors around the house Walk a block Walk a block 4 METs 4 METs Light housework like dusting or washing dishes Light housework like dusting or washing dishes

Energy Requirements 4-5 METs 4-5 METs Climb stairs, walk up a hill Climb stairs, walk up a hill 6-9 METs 6-9 METs Run a short distance Run a short distance Heavy housework Heavy housework Moderate recreational activities Moderate recreational activities 10 METs 10 METs Strenuous activities (swimming, tennis, skiing) Strenuous activities (swimming, tennis, skiing)

Revised Cardiac Risk Index Ischemic heart disease Ischemic heart disease Compensated or prior heart failure Compensated or prior heart failure Cerebrovascular disease Cerebrovascular disease Diabetes mellitus Diabetes mellitus Renal insufficiency (creatinine > 2 mg/dL) Renal insufficiency (creatinine > 2 mg/dL) High risk surgical procedure High risk surgical procedure Intraperitoneal/intrathoracic, vascular Intraperitoneal/intrathoracic, vascular Based on 4315 pts undergoing elective major surgery Lee, TH et al, Circulation 1999, 100:

Risk of Major Cardiac Event POINTSCLASSRISK 0I0.4% 1II0.9% 2III6.6% ≥ 3 IV11% “Major Cardiac Event” includes MI, pulm edema, vfib, cardiac arrest, complete heart block

Misc Points Pre-op labs Pre-op labs Medications Medications Chronic anticoagulation Chronic anticoagulation

Pre-op lab testing Order fewer selective, evidence based tests Order fewer selective, evidence based tests 30-60% of abnormalities found on pre-op tests are generally ignored anyway 30-60% of abnormalities found on pre-op tests are generally ignored anyway Lab tests normal in last 4 months and no clinical change probably do not require repeat tests Lab tests normal in last 4 months and no clinical change probably do not require repeat tests

Medications Continue beta-blockers, oral nitrates, & most antihypertensives until the morning of surgery Continue beta-blockers, oral nitrates, & most antihypertensives until the morning of surgery Suggest holding ACE-I & ARBs on morning of surgery to decrease risk of renal dysfunction Suggest holding ACE-I & ARBs on morning of surgery to decrease risk of renal dysfunction Aspirin, aggrenox, clopidogrel- stop 7 days prior Aspirin, aggrenox, clopidogrel- stop 7 days prior Cilastazol, COX-1 inh cause reversible platelet inhibition- stop 2-3 days prior Cilastazol, COX-1 inh cause reversible platelet inhibition- stop 2-3 days prior COX-2 inh do not affect platelets COX-2 inh do not affect platelets

Medications NSAIDS affect renal function- stop 1-3 days prior NSAIDS affect renal function- stop 1-3 days prior SSRIs increase bleeding by depleting serotonin stores- stop days prior depending on half-life SSRIs increase bleeding by depleting serotonin stores- stop days prior depending on half-life Hormones, Raloxifene, Tamoxifen increase risk of thromboemboli Hormones, Raloxifene, Tamoxifen increase risk of thromboemboli Anti-convulsant/psychotic/depressant meds should be continued Anti-convulsant/psychotic/depressant meds should be continued Metformin held to reduce lactic acidosis Metformin held to reduce lactic acidosis

Medications Supplements or herbal meds- stop 1 wk prior Supplements or herbal meds- stop 1 wk prior Ginger, ginkgo, ginseng, garlic, & feverfew can cause bleeding Ginger, ginkgo, ginseng, garlic, & feverfew can cause bleeding Ginseng assoc w/ hypoglycemia Ginseng assoc w/ hypoglycemia Garlic assoc w/ hypoglycemia, hypotension Garlic assoc w/ hypoglycemia, hypotension Kava, echinacea assoc w/ hepatotoxicity Kava, echinacea assoc w/ hepatotoxicity

Low Bleed Risk Continue warfarin (can consider lower INR of ) Continue warfarin (can consider lower INR of ) Cataract Cataract Endoscopy, colonoscopy, ERCP w/o sphincterotomy Endoscopy, colonoscopy, ERCP w/o sphincterotomy Superficial dermatologic Superficial dermatologic Dental procedures Dental procedures Joint and soft tissue aspirations or injections Joint and soft tissue aspirations or injections Minor podiatric procedures (nail avulsions) Minor podiatric procedures (nail avulsions)

High Risk- Bridging advised DVT/PE or arterial thromboemboli < 3 mo DVT/PE or arterial thromboemboli < 3 mo Thromboembolic event + hypercoaguable problem (i.e. protein C or S def…) Thromboembolic event + hypercoaguable problem (i.e. protein C or S def…) Recurrent arterial or idiopathic VTE Recurrent arterial or idiopathic VTE Rheumatic atrial fib Rheumatic atrial fib Acute intracardiac thrombus Acute intracardiac thrombus Atrial fib + mech heart valve in any position Atrial fib + mech heart valve in any position Older mech valves in mitral position (single disk or ball-in-cage) Older mech valves in mitral position (single disk or ball-in-cage) Recently placed mech valve (<3 months) Recently placed mech valve (<3 months) Atrial fibrillation with h/o cardioembolism Atrial fibrillation with h/o cardioembolism

Intermediate Risk- Bridging case-by- case basis Newer model mech valve in mitral position (St. Jude) Newer model mech valve in mitral position (St. Jude) Older model mech valve in aortic position Older model mech valve in aortic position Atrial fib w/o cardioembolism but with multiple risks for cardioembolism (CHADS2 ≥ 3) Atrial fib w/o cardioembolism but with multiple risks for cardioembolism (CHADS2 ≥ 3) VTE > 3-6 months ago VTE > 3-6 months ago

CHADS2 score 1 pt each 1 pt each Heart failure (EF < 30%) Heart failure (EF < 30%) HTN HTN age ≥ 75 yrs age ≥ 75 yrs diabetes diabetes 2 pts 2 pts Prior stroke Prior stroke

Low risk- bridging not advised One remote VTE (>6 months ago) One remote VTE (>6 months ago) Intrinsic cerebrovascular disease (carotid atherosclerosis) w/o recurrent stroke or TIA Intrinsic cerebrovascular disease (carotid atherosclerosis) w/o recurrent stroke or TIA Atrial fib w/o multiple risks for cardiac embolism (CHADS2 1-2) Atrial fib w/o multiple risks for cardiac embolism (CHADS2 1-2) Newer model mech valve in aortic position (St. Jude) Newer model mech valve in aortic position (St. Jude)

Conclusions Successful peri-op eval and management requires careful teamwork Successful peri-op eval and management requires careful teamwork Use of noninvasive and invasive pre-op testing should be limited to circumstances in which the results will affect pt management Use of noninvasive and invasive pre-op testing should be limited to circumstances in which the results will affect pt management Goal is to make recommendations to lower immediate peri-op cardiac risk Goal is to make recommendations to lower immediate peri-op cardiac risk

References Fleisher, LA, et al., ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary, Circulation, Oct 23, 2007, Fleisher, LA, et al., ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary, Circulation, Oct 23, 2007, Beckman, JA, et al., ACC/AHA 2006 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Focused Update on Perioperative Bets-Blocker Therapy, JACC, Vol. 47. Beckman, JA, et al., ACC/AHA 2006 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Focused Update on Perioperative Bets-Blocker Therapy, JACC, Vol. 47. Lee, TH, et al., Derivation and prospective validation of a simple index for prediction of cardiac risk in major noncardiac surgery. Circulation 1999;100: Lee, TH, et al., Derivation and prospective validation of a simple index for prediction of cardiac risk in major noncardiac surgery. Circulation 1999;100: