1. Perioperative Cardiovascular Evaluation 순환기 내과 김 수 중

2. Role of Medical Consultant Preoperative assessment Preoperative assessment Identification of modifiable risk factors Identification of modifiable risk factors Optimization of the condition of pt. for op. Optimization of the condition of pt. for op. Prompt, Precise, & Thorough Prompt, Precise, & Thorough Written recommendation – overlooked Written recommendation – overlooked Communication & timely follow-up Communication & timely follow-up

3. Perioperative evaluation Patient-specific Patient-specific Procedure-oriented Procedure-oriented Time-focused Time-focused

4. Cardiovascular risk assessment Preop. evaluation : focus on C-V system Preop. evaluation : focus on C-V system Cardiac events : primary cause of death after op. Cardiac events : primary cause of death after op. Thorough examination for occult CAD Thorough examination for occult CAD Optimization of existing CAD Optimization of existing CAD Op. performed safely, even in significant cardiac disease Op. performed safely, even in significant cardiac disease

5. Significant postop. cardiac events Significant postop. cardiac events Unstable angina Unstable angina MI MI Pulmonary edema Pulmonary edema Serious arrhythmias (VT, VF) Serious arrhythmias (VT, VF) Cardiovascular risk assessment

6. Goldman & colleagues Goldman & colleagues Nine risk factor index (Hx, P/Ex, ECG, activity level, Lab, type of op.) Nine risk factor index (Hx, P/Ex, ECG, activity level, Lab, type of op.) Mangano & Goldman Mangano & Goldman Five independent preop. clinical predictors of postop. myocardial ischemia Five independent preop. clinical predictors of postop. myocardial ischemia HTN, ECG-LVH, DM, CAD, digoxin use HTN, ECG-LVH, DM, CAD, digoxin use Jeffrey & colleagues / Zeldin Jeffrey & colleagues / Zeldin Underestimation of risk of C-V events in major abdominal aortic op. Underestimation of risk of C-V events in major abdominal aortic op. Overestimation of cardiac Cx. in high risk pt. Overestimation of cardiac Cx. in high risk pt. Cardiovascular risk assessment

7. 1. Clinical markers or predictors (pt.-specific) Angina, previous MI, CHF, DM major, intermediate, minor groups 2. Level of functional capacity 4 MET poor functional capacity : a/w cardiac event after op. 3. Surgery specific risks ACC/AHA Consensus

8. Major clinical predictors Abnormal ECG · Symptomatic or significant arrhythmia · Symptomatic or significant arrhythmia · High-grade atrioventricular block · High-grade atrioventricular block Coronary artery disease · Unstable or severe angina · Unstable or severe angina · Recent myocardial infarction (within 7-30 days) · Recent myocardial infarction (within 7-30 days) Decompensated CHF Severe valvular disease Cardiovascular risk assessment Clinical predictors of periop. C-V risk

9. Intermediate clinical predictors Intermediate clinical predictors Abnormal ECG · Evidence of previous myocardial infarction · Evidence of previous myocardial infarction Coronary artery disease · Chronic stable or mild angina pectoris · Chronic stable or mild angina pectoris Compensated CHF or history of CHF Diabetes mellitus Cardiovascular risk assessment Clinical predictors of periop. C-V risk

10. Minor clinical predictors Minor clinical predictors Abnormal ECG · Nonsinus rhythm · Nonsinus rhythm Uncontrolled hypertension History of stroke Low functional capacity Advanced age Cardiovascular risk assessment Clinical predictors of periop. C-V risk

11. Cardiovascular risk assessment 4 MET 4 MET Level of functional capacity

12. Surgery specific risks Cardiovascular risk assessment Cardiac risk > 5% Cardiac risk < 5% Cardiac risk < 1%

13. ACC/AHA Guidelines

15. Non-invasive testing in preop pt if any 2 factors (+) Non-invasive testing in preop pt if any 2 factors (+) Intermediate clinical predictors Intermediate clinical predictors Poor functional capacity Poor functional capacity High surgical risk procedure High surgical risk procedure

16. ACC/AHA Guidelines

20. Hx. taking & physical examination Hx. taking & physical examination Lab. & specialized testing Lab. & specialized testing ECG : arrhythmia, high-degree AVB, LVH ECG : arrhythmia, high-degree AVB, LVH  a/w adverse outcome Recent MI (<3M) Recent MI (<3M) Unstable angina Unstable angina CHF or S3  aggressive preoperative medical tx. CHF or S3  aggressive preoperative medical tx. (pul. edema risk : x5) Severe valvular disease (AS) Severe valvular disease (AS)  stroke, MI, arrhythmia, acute HF  stroke, MI, arrhythmia, acute HF Preoperative evaluation

21. Duration & severity of DM & HTN Duration & severity of DM & HTN Hx. of stroke  adverse perioperative cardiac events DBP > 100 mmHg  should be controlled before op. DBP > 100 mmHg  should be controlled before op. Advanced age : indirect marker of surgical cardiac risk Advanced age : indirect marker of surgical cardiac risk Preoperative evaluation

22. Ambulatory ECG : assess of silent ischemia Ambulatory ECG : assess of silent ischemia : assess of arrhythmia : assess of arrhythmia Echocardiography : assess of LV resting fx. Echocardiography : assess of LV resting fx. Performed when HF suspected Performed when HF suspected : assess of valvular dis. : assess of valvular dis. Exercise or pharmacologic stress testing with imaging Exercise or pharmacologic stress testing with imaging : detection of occult CAD : estimate of functional capacity Expensive, subjective(interpreter-dependent) Expensive, subjective(interpreter-dependent) Stress ECG with imaging  reliable tool for CAD & functional capacity evaluation Stress ECG with imaging  reliable tool for CAD & functional capacity evaluation Role of specialized testing

23. Stress testing Stress testing False (+) : female, >50 yrs & in LVH cases False (+) : female, >50 yrs & in LVH cases False (-) : taking BB or CCB False (-) : taking BB or CCB 201-Tl : specific & good (-) predictive value 201-Tl : specific & good (-) predictive value Coronary angiography Coronary angiography Reserved for pt at high risk & should be done only if angioplasty or CABG is considered Reserved for pt at high risk & should be done only if angioplasty or CABG is considered Role of specialized testing

24. CABG CABG No randomized trials No randomized trials CASS study CASS study No benefit of CABG in minor surgery No benefit of CABG in minor surgery CABG protective in pt with multivessel disease & severe angina CABG protective in pt with multivessel disease & severe angina VA study VA study Recent intervention offers only modest protection Recent intervention offers only modest protection CABG itself has own mortality CABG itself has own mortality Long-term outcome improvement should be considered, Long-term outcome improvement should be considered, not just to get them through not just to get them through Indication essentially identical to ACC/AHA guideline Indication essentially identical to ACC/AHA guideline Perioperative therapy for reduction of periop. risk

25. PCI PCI No randomized trials regarding prophylactic PCI No randomized trials regarding prophylactic PCI Coronary Revascularization before elective major vasuclar op. Coronary Revascularization before elective major vasuclar op. 18 VA medical center (Coronary Artery Revascularization Prophylaxis trial) 510 established CAD pt. undergoing major vascular op. Revascularization group (258) No Revascularization group (258) 33% abd. aorta an. op. 67% ASO of leg op. Primary end point : long-term mortality 59% PCI, 41% CABG 54 days 18 days

26. Results Results RevascNo revasc mortaltiy (2.7ry)22%23%(p=0.92) Post op MI(30D)11.6%14.3%(p=0.37)

27. ACC/AHA guideline ACC/AHA guideline It is almost never appropriate to recommend CABG or other invasive procedure (PCI) in an effort to reduce the risk of non-cardiac surgery when they would not otherwise be indicated It is almost never appropriate to recommend CABG or other invasive procedure (PCI) in an effort to reduce the risk of non-cardiac surgery when they would not otherwise be indicated

28. Medical treatment Medical treatment Beta blockers Beta blockers Atenolol Atenolol Bisoprolol Bisoprolol Metoprolol Metoprolol Esmolol Esmolol Alpha 2- adrenergic agonists Alpha 2- adrenergic agonists Clonidine Clonidine Mivazerol Mivazerol NTG NTG Statins Statins Perioperative therapy for reduction of periop. risk Mechanism of periop ischemia periop neurohumoral activation increased catecholamine decreased endogenous tPA Platelet activation Coronayr spasm

30. ACC/AHA guideline Recommend for periop. medical therapy Recommend for periop. medical therapy Class I BB required in the recent to control sx of angina or pt with symptomatic arrhythmia or HTN BB required in the recent to control sx of angina or pt with symptomatic arrhythmia or HTN BB : pt with high cardiac risk owing to ischemia on preop test who are undergoing vascular surgery BB : pt with high cardiac risk owing to ischemia on preop test who are undergoing vascular surgery Class IIa BB : preop assessment identify untreated HTN, known CAD, or major risk factors for CAD BB : preop assessment identify untreated HTN, known CAD, or major risk factors for CAD Alpha2 agonists : periop control of HTN or known CAD, or major risk factors for CAD Alpha2 agonists : periop control of HTN or known CAD, or major risk factors for CAD Class III BB : contraIx to BB BB : contraIx to BB Alpha2 agonists : contraIx. Alpha2 agonists : contraIx.

31. Myocardial ischemia Myocardial ischemia Arrhythmia Arrhythmia CHF CHF Postoperative management

32. Myocardial ischemia Myocardial ischemia Silent, non-Q infarction Silent, non-Q infarction Peak incidence at POD #2~ #3 Peak incidence at POD #2~ #3 ECG at baseline, postop(immediate), POD #3 in high risk pts. ECG at baseline, postop(immediate), POD #3 in high risk pts. Cardiac marker if clinically suspected or abnormal ECG Cardiac marker if clinically suspected or abnormal ECG Postoperative management

33. Postop. Arrhythmia Postop. Arrhythmia Usually transitory Usually transitory VPC : tx only if sustained or hemodynamically significant VPC : tx only if sustained or hemodynamically significant Postoperative management

34. CHF CHF Excessive vol. administration, HTN, exacerbation of preexisting ventricular dysfunction Excessive vol. administration, HTN, exacerbation of preexisting ventricular dysfunction Unexplained pul. edema  suspicion of silent MI Unexplained pul. edema  suspicion of silent MI Postoperative management

35. Cardiovascular drugs Aspirin Discontinue 7 days before operation; restart 2 days after operation Beta blockers Continue, to prevent withdrawal; useful for postoperative adrenergic hyperactivity Clonidine HCl Continue, to avoid rebound hypertension Warfarin sodium, except when used for artificial valves Discontinue 3-5 days before operation; restart when patient resumes oral intake Warfarin therapy for prosthetic valves Thrombosis risk is higher in patient with mitral valve than with aortic valve. ACCP gives three options for perioperative anticoagulation: · Stop warfarin several days preoperatively and proceed to surgery once INR is at a safe level for operation; restart shortly after operation · Decrease dosing to keep INR low during procedure · Stop warfarin and start heparin preoperatively; stop heparin 2-4 hr preoperatively; proceed to surgery once INR is safe for operation; restart heparin postoperatively when safe; restart warfarin postoperatively when safe

36. Postoperative management Prophylaxis for infective endocarditisFor dental, respiratory, gastrointestinal, or genitourinary tract procedures or other situations when bacteremia is a risk Pacemaker management (consult technical consultant of pacemaker manufacturer, if needed) Temporarily program pacemaker to fixed-rate mode to avoid temporary pacemaker inhibition by electrocautery-induced electromagnetic interference; limit length and frequency of use of electrocautery, particularly near pacemaker site Safeguard with automatic implantable cardioverter-defibrillator Best to switch off temporarily during surgery; electrocautery may interfere with function Drug use in patient with transplanted heart (due to denervation, resting heart rate is increased but response to stress is blunted) Supersensitivity to adenosine (Adenocard), normally responds to beta blockers and calcium channel blockers, does not respond to atropine sulfate or digoxin (Lanoxicaps, Lanoxin)