1. Evaluating the Heart before Non-Cardiac Surgery Dr Rob Stephens Anaesthetist UCLH + UCL

2. www.ucl.ac.uk/anaesthesia/people/stephens www.ucl.ac.uk/anaesthesia/people/stephens Google UCL Stephens

3. www.ucl.ac.uk/anaesthesia/people/stephens www.ucl.ac.uk/anaesthesia/people/stephens Google UCL Stephens

4. Contents Introduction Basic Principles Guidelines: Decisions Guidelines: Putting it all together Which test? ECHO CPEx B Block? Summary

5. You’re all experts! Seems big, complex Conflicting, absent and changing evidence! Problem: Assessing CVS system vs Lack of effectiveness of interventions Introduction

6. Background: Basic Principles Why assess the CVS system? Assess risk: consent + patient decisions Assess risk: specific interventions Diagnose conditions : caution Cancer surgery- ‘time limited’ Test: what next? Ischaemia vs Heart Failure “Probably”, “reasonable”, “is not well established”

7. Guidelines 1 2014 ACC/AHA guideline revision ACC/AHA 2007 (small revision 2009) ESC 2009 Guidelines - Cardiology Fraud of Poldermans B Blocker story Individual Studies ?ASA / RCoA / AAGBI ?

8. 2014 Guidelines + others ‘MACE’ Major Adverse Cardiac Event Different Order to risk asses Risk Asses using NSQIP CPEX ’considered for elevated risk procedures in unknown functional capacity’ Coronary Stent Guidelines POISE 2 study – no benefit in adding aspirin ‘MINS’ myocardial injury after non-cardiac surgery Troponin –uncertain usefulness in high risk patients

10. ESC 2009

11. Mythen, Biccard

12. Wait for surgery after MI? Postoperative MI 0 - 30 days32.8% 31 - 60 days18.7% 61 - 90 days8.4% 91 - 180 days5.9% 30-day mortality 0 - 30 days14.2% 31 - 60 days11.5% 61 - 90 days10.5% 91 - 180 days9.9% Livhits 2011

13. CARP Vascular Surgery 5859 patients screened; 510 selected revascularization vs not Postoperative 30 day mortality 3.1% vs 3.4%, rev vs not; P =.87 Long term mortality 2.8 years 22% vs 24%, rev vs not P =.92 McFalls 2004

14. Guideline 2 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers

15. Guideline 3 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers

16. Guideline 4 Surgery Urgency – Emergency/ Immediate proceed

17. Urgency AHA 2014 Emergency no/little time limited clinical evaluation life or limb is threatened if no surgery within <6 hours Urgent may be time for a limited clinical evaluation when life or limb is threatened if no surgery within 6 - 24 Time-sensitive a delay of >1 - 6 week for evaluation / treatment will negatively affect outcome. Elective the procedure could be delayed for up to 1 year.

18. NCEPOD 2004

19. Guideline 5 Surgery Urgency – Truly Elective – time to treat / discuss – Treat/refer broadly as according to non- preoperative guidelines – warn about possible delay to surgery – evidence of benefit for subsequent surgery ?

20. Guideline 6 Surgery Urgency (US vs NCEPOD) – Cancer = ‘time limited’ Consider – lack of benefit from CVS interventions – potential delay after CVS intervention – coronary stent anticoagulation

21. Guideline 7 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers

22. Guideline 8 ACC AHA Patient Risk factors 3 levels: Serious / ‘Intermediate ‘ / ’Minor’ ‘Serious’ ; ‘active cardiac conditions’ – Recent MI/Unstable Angina – New /Acute Ht Failure – Serious abnormal rhythm – Severe valve disease Pause and discuss with teams

23. Guideline 8 ACC AHA Patient Risk factors 3 levels: Serious / ‘Intermediate ‘ / ‘minor’ ‘Intermediate’- same as ‘Lees rCRI’ or Calculate NSQIP ‘MACE’ score

24. Lee’s rCRI revised Cardiac Risk Index Major Surgery… and Ischemic heart disease Cardiac Failure Cerebrovascular disease Diabetes on Insulin Renal insufficiency (>177 μmol / litre) NoCVS+ 00.3- 0.4% 10.7- 0.9% 21.7- 6.6% 33.6- 11% Boersma 2005 Lee 1999 Bowl cutting Pelvic Vascular

25. Guidelines 9 NSQIP Risk Calculator >1%? – Think about Preoperative testing IHD – If it will change your management

28. Guideline 10 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers

29. Guideline 11 Severity of surgery Minorproceed Anything elseconsider further

30. Assessing CVS disease: Guideline 4 ESC 2009

31. Guideline 12 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers

32. Guideline 13 Patient Exercise Capacity 4 METS without significant symptoms Operations proceed Less than 4 METSconsider testing No Chest Pain No SOB

33. Guideline 14 Patient Exercise Capacity Metabolic Equivalent of Task - MET 1 MET is 0 2 uptake at rest = = 3.5 ml/min/kg 0 2 uptake 2 METS ~ 2x 0 2 uptake of 1 METS Easily Quantified by CPEx Mostly quantified by history

34. Guideline 15 Patient Exercise Capacity 2 MET Strolling 4 METFast flat walking, up 1 flight stairs ?do everything in a normal day walking a dog, moderate gardening 6+Most sports, running ‘Playing a heavy musical instrument while actively running in a marching band’ No Chest Pain No SOB

35. Rest 330ml/min 0 2 uptake 82kg 330/82 =4ml/min/kg= 1 MET Maximum 3900ml/min 0 2 uptake 82kg 3900/82 =47ml/min/kg 11 3/4 METS

36. Guideline 16 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Patient Exercise Capacity Surgery Severity ESC 2009 Biomarkers

37. Guideline 17 Biomarkers in Guidelines 2009 and 2014 “a characteristic that can be objectively measured that is an indicator of pathology or an abnormal response to treatments” Troponin - myocardial cell injury BNP - myocardial wall stress increases + pro NT BNP CRP- liver and smooth muscle ESC, Biccard, Devereaux 2012

38. Guideline 18 Biomarkers in ESC Guidelines 2009 Troponin Postop – small  associated  mortality ‘VISION’ Preop – predictive, no ideal cut off BNP + pro NT BNP Ht Failure /IHD / ACS - rises relate to outcome Preop – adds predictive ability >48 pg/ml CRP – ‘inflammatory marker’ ESC, Biccard, Devereaux 2012

39. Guideline 19 AHA/ACC 2014 ‘no data to suggest that targeting biomarkers for treatment or intervention will lower postoperative risk. Biomarkers in ESC Guidelines 2009 Higher in patients that have postoperative cardiac events or die Troponin BNP CRP

40. Assessing CVS disease: Together

41. ACC/AHA 2014

42. ACC/AHA 2009

43. ESC 2009

44. Putting it together 1: Urgency Emergency or Urgentoperation Time- limited or Electiveconsider further

45. Putting it together 2: Active Cardiac Condition

46. Serious’ = ‘active cardiac condition’ – Recent MI/Unstable Angina – Acute LVF – Serious abnormal rhythm – Severe valve disease

47. Putting it together 2: Active Cardiac Condition Putting it together: 2 Active Cardiac Condition Yes Emergencyoperation and Rx Urgent pause & consider refer Time- limited pause & consider refer Electivepause & refer/Ix/Rx No Urgent Time- limited consider further Elective

48. Putting it together 3: Patient Risk Factors Patient Risk of MACE > 1%? www.surgicalriskcalculator.com Lees revised Cardiac Risk Index More than 1%consider further Less than 1%proceed with surgery Any Ischaemic Ht Disease Any Ht Failure Any Cerebro-Vascular Disease Diabetes – insulin Renal Injury (Cr 177+)

49. Putting it together 4: Operation risk ?Low risk surgeryProceed operation Intermediate high consider further

50. Putting it together 5: Exercise capacity Can they do > 4 METS without symptoms……’probably’ operation Less than 4 METS or can’t tell consider further

51. Putting it together: Investigations Always in the context of ‘what next?’ ie ‘will/should it change management?’ “Consider testing” ACC/AHA Stress ECHO Myocardial Perfusion Scan CPEx – includes Exercise ECG Exercise ECG MRI or CT

52. ECHO Evidence Valves, Function, estimates pulmonary pressures Degree of dysfunction, regional wall motion abn LVEF <40% - 2x higher risk – sensitivity 43% – positive predictive 13% “resting LV function was not found to be a consistent predictor of perioperative ischemic events or death” But ECHO enthusiasts in preassessment.. – 30% new CVS disease,  Mx 20% Mx  34% Halm, Rofdhe, Canty

53. ECHO indication Routine Evaluation – NO Dyspnea of unknown origin – reasonable New murmur - reasonable Ht Failure with  symptoms - reasonable Ht Failure clinically stable - ‘may be considered’ Valves clinically stable - ‘recommended’ > 1 year ACC/AHA

54. CPEx / CPET Background Functional assessment Population data – survival VO 2 peak, AT, VE/VCO 2, ECG ischaemia etc But Associations with outcome and complications Most studies unblinded, small Await results of only RCT ‘Prehabilitation’ studies- some positives Older, Hennis, Snowden, O’Doherty

55. n=548 Lower anaerobic threshold worse: higher mortality Raised Respiratory Equivalent: higher mortality Mortality AT more 14 ml/min /kg 0% AT more 11 ml/min /kg but other badness 1.7% AT less 11 ml/min /kg 4.6% CPEx / CPET Background Older 1999

56. ComplicationAT 10.1 p= on day 7n= 51 n=65 Pulmonary 57% 15% <0.0001 Renal 40%11%0.0004 GI 33%11%0.005 Infective 27%11%0.003 Cardiovascular 25%3%0.0005 Neurological 10% 5%0.29 Hematology 8%00.04 Pain 8%00.04 Wound 4% 00.2 Snowden 2010 CPEx / CPET Background

57. CPEx / CPET use ACC/AHA 2014 “…considered for patients undergoing elevated risk procedures with unknown functional capacity” Awaiting RCT on CPEx vs Dr Use very variable, increasing Best not to emphasise one single value – VO 2 peak, AT, VE/VCO 2, ECG ischaemia Enthusiasts vs sceptics

58. B Block? background B blockers – in community – reduce adrenergic activity + myocardial 0 2 use – associated with survival RCT Perioperative studies Mangano POISE ‘DECREASE’, Others Observational perioperative data US and European Perioperative Guidelines Mangano, London, Sear, Devereaux, Bouri

59. B Block? ESC 2009

60. B Block?: Endpoints important! POISE Lancet 2008 8351 patients with/at risk of, atherosclerotic disease non-cardiac surgery B Block 24 hrs preoperatively – 30 days postop Metoprolol vs Placebo MI 4·2% vs 5·7%0·84 p=0·002 Stroke 1·0% vs 0·5% 2·17p=0·005  BP 15.0% vs. 9.7% p < 0.0001 Bradycardia 6.6% vs. 2.4%p < 0.0001 Deaths 3·1% vs 2·3% 1·33 p=0·03 Devereaux

63. B Block Maintain current B Blockade Treat concomitant anaemia Meta-analysis / prospective studies don’t support May use in ‘high risk’ people only – Those that may be on B Blockers anyway – rCRI >1 ?Atenolol or Bisoprolol Start /titrate 60-80 bpm ?7+ days before

64. ‘VISION’: MINS 15,065 patients > 45+ yrs; in-patient non-cardiac surgery ‘MINS’ myocardial injury after non-cardiac surgery= Troponin T level of > 0.03 ng/ml MINS 30-day mortality 3.87x (adjusted hazard ratio; 95% CI, 2.96-5.08) 8.0% had MINS 58.2% of these did not fulfill a conventional MI definition 15.8% of patients with MINS had ischemic symptoms Botto 2014

65. Summary Introduction Basic Principles Guidelines: Decisions Guidelines: Putting it all together Which test? ECHO CPEx B Block? Summary

66. Thank you For listening Please Google ‘stephens UCL’ for website This full talk Some References AHA/ACC and European Guidelines