1. CCS 2016 Guideline: Perioperative Cardiac Risk Assessment and Management for Patients Undergoing Non- Cardiac Surgery October 2016

2. Disclosures All CCS guideline and position statement panel conflicts of interest can be found on the CCS website (www.ccs.ca).www.ccs.ca

3. Worldwide >200,000,000 major noncardiac surgical procedures annually 1:20 suffer myocardial injury/infarction or cardiac arrest/death within 30 days Perioperative cardiac complications account for 1/3 of perioperative deaths Speaker: Joel Parlow Scope of Problem

4. CCS and Canadian experts felt new guidelines needed for perioperative assessment and management in noncardiac surgery Speaker: Joel Parlow Scope of Problem

5. Co-chairs: – PJ Devereaux (Cardiology) – Joel Parlow (Anesthesiology) Primary Panel: – Emmanuelle Duceppe (GIM) – Paul MacDonald (Cardiology) – Kristen Lyons (Cardiology) – Michael McMullen (Anesthesiology) – Sadeesh Srinathan (Thoracic Surgery) – Michelle Graham (Cardiology) – Vikas Tandon (Cardiology) – Kim Styles (Cardiology) – Amal Bessissow (GIM) – Dan Sessler (Anesthesiology) – Greg Bryson (Anesthesiology) Speaker: Joel Parlow Primary Panel

6. Multidisciplinary- 22 members – 8 general internists – 4 cardiologists – 6 anesthesiologists – 1 general surgeon – 1 vascular surgeon – 1 orthopedic surgeon – 1 academic nurse Reviewed and provided feedback on draft guidelines Speaker: Joel Parlow Secondary Panel

7. CCS Guidelines Committee CCS Council Editor of Canadian Journal of Cardiology Speaker: Joel Parlow Final Review / Approval

8. Four themes: 1.Preoperative cardiac risk assessment 2.Perioperative cardiac risk modification 3.Monitoring for perioperative cardiac events 4.Management of perioperative cardiac complications  Significant change from previous guidelines…  Shift of emphasis from preoperative noninvasive cardiac testing to increased use of biomarkers and postoperative monitoring of patients at risk and management of cardiac complication Speaker: Joel Parlow Scope of Guidelines

9. Population: – adult patients undergoing major noncardiac surgery defined as requiring at least overnight stay in hospital Only cardiovascular outcomes considered Focus on highest quality evidence in the literature Speaker: Joel Parlow Scope of Guidelines

10. Primary panel members each took lead of topics Thorough discussion and voting of each topic by panel Literature search, GRADE quality assessment Excluded studies by Dr. Poldermans – Meta-analyses included if results consistent Voting – Recommendation required 2/3 majority of non-conflicted primary panel members – 2/3 felt evidence too weak: no recommendation – Good clinical practice statement required 2/3 majority to believe recommendation indicated based only on values and preferences All votes documented in appendix Speaker: Joel Parlow Guideline Process

11. Academic/intellectual or financial conflicts of interest declared Conflicted members could participate in discussion but not voting Table listing conflicts of interest of panel members for every topic Speaker: Joel Parlow Conflicts

12. Preoperative cardiac risk assessment Speaker: Joel Parlow

13. ≥45 years of age, or 18-44 years of age with known significant cardiovascular disease – coronary artery disease, – cerebral vascular disease, – peripheral arterial disease, – congestive heart failure, – severe pulmonary hypertension, or – severe obstructive intra-cardiac abnormality e.g., aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy Speaker: PJ Devereaux Which patients should undergo cardiac risk assessment before noncardiac surgery?

14. Emergency surgery – an acute life or limb threatening condition Urgent surgery – e.g., surgery for an acute bowel obstruction, hip fracture Semi-urgent surgery – e.g., surgery for cancer that has potential to metastasize Elective surgery Speaker: PJ Devereaux Categories of Surgery

15. For patients requiring emergency surgery, we recommend against delaying surgery for preoperative cardiac risk assessment Speaker: PJ Devereaux Good Practice Statement

16. For patients requiring urgent or semi-urgent sx, we recommend undertaking preoperative cardiac risk assessment only if patient’s hx or P/E suggests potential undiagnosed severe obstructive intra-cardiac abnormality, severe pulmonary hypertension, or unstable cardiovascular condition Speaker: PJ Devereaux Good Practice Statement

17. For patients undergoing elective noncardiac surgery who are ≥45 years of age or 18-44 years of age with known significant cardiovascular disease, we recommend preoperative cardiac risk assessment Speaker: PJ Devereaux Good Practice Statement

18. Ethical requirement to accurately apprise patients about benefits and risks of surgery Survey of 104 general internists (Taher 2002) – marked variability in definitions of low, moderate, and high perioperative cardiac risk Systematic review of surgical and non-surgical RCTs (Trevena 2006) – patients have more accurate perception of risk presented as numbers rather than subjective words (low, moderate, or high-risk), probabilities, or effect measures (e.g., RRR) Speaker: PJ Devereaux Risk Communication

19. We recommend communicating to patients their perioperative cardiac risk Speaker: PJ Devereaux Good Practice Statement

20. We recommend explicit communication of perioperative cardiac risk based on expected event rate among 100 patients or range of risk consistent with 95% confidence interval of risk estimate Strong recommendation, moderate-quality evidence Speaker: PJ Devereaux Recommendation

21. Clinical risk indices – Revised Cardiac Risk Index (RCRI) – National Surgical Quality Improvement Program (NSQIP) risk scores Speaker: Amal Bessissow Method of preop cardiac risk assessment

22. RCRI – systematic review - 792,740 pts, 24 studies (Ford 2010) RCRI had moderate discrimination to predict major perioperative cardiac complications – RCRI has undergone extensive external validation NSQIP risk scores – NSQIP MICA (Gupta 2011), ACS NSQIP (Bilimoria 2013) based on large datasets suggest superior discrimination than RCRI likely underestimate risks – no systematic monitoring of events no external validation Speaker: Amal Bessissow Clinical Risk Indices

23. Variables Pts Hx of IHD 1 Hx of CHF1 Hx of CVD1 Insulin for diabetes 1 Crt >177  mol/L 1 High-risk surgery 1 Total RCRI points Risk of MI, cardiac arrest, or death 30 days after surgery 95% CI 0 3.9% 2.8%-5.4% 1 6.0% 4.9%-7.4% 2 10.1% 8.1%-12.6% ≥3 15.0% 11.1%-20.0% * based on high-quality external validation studies Speaker: Amal Bessissow Revised Cardiac Risk Index

24. When evaluating cardiac risk, we suggest clinicians use RCRI over other available clinical risk prediction scores Conditional recommendation, low-quality evidence Speaker: Amal Bessissow Recommendation

25. Reilly et al. (1999) – prospective cohort 600 pts undergoing major noncardiac sx – self-reported functional capacity did not predict CV events aOR, 1.81 ; 95% CI, 0.94-3.46 Wiklund et al. (2000) – prospective cohort, 5939 pts having major noncardiac sx – METs not independently predictive of major cardiac events – data suggest observer bias in estimation of pts METS Given limitations of evidence – primary panel decided not to make recommendation on how to use patient self-reported functional capacity to estimate perioperative cardiac risk Speaker: Amal Bessissow Self-reported functional capacity

26. Individual patient data meta-analysis (Rodseth 2014) 2179 patients – 18 studies Preop NT-proBNP/BNP independently associated with death or nonfatal MI at 30 days – aOR 3.40 (95% CI, 2.57-4.47) p<0.001 Threshold value associated with lowest p value for death and MI – NTproBNP ≥300 ng/l – BNP ≥92 mg/l Speaker: Emmanuelle Duceppe NT-proBNP/BNP

27. Test result Risk estimate 95% CI NT-proBNP <300 ng/L or BNP <92 mg/L 4.9%3.9% - 6.1% NT-proBNP value ≥300 ng/L or BNP ≥92 mg/L 21.8%19.0% - 24.8% Risk of death or MI at 30 days after noncardiac surgery, based on patient’s preoperative NT-proBNP or BNP Speaker: Emmanuelle Duceppe – compared to RCRI, preop NT-proBNP/BNP results improved risk classification in 155 patients in 1000 patient sample – based on risk categories 10-15%, >15% NT-proBNP/BNP

28. We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients ≥65 years of age, 45 to 64 years of age with significant cardiovascular disease, or who have RCRI score ≥1 Strong recommendation, moderate-quality evidence Speaker: Emmanuelle Duceppe Recommendation

29. Considering cost – NT-proBNP/BNP testing restricted to patient groups with baseline clinical risk estimate >5% RCRI score 1 has >5% risk of MI, cardiac arrest, or death 30 days after surgery VISION Study data – 30 day risk of CV death or MI – patients ≥65 years of age, 45-64 years of age with known CV disease have >5% risk – patients without these characteristics have  2.0% risk Compared to cardiac imaging and non-invasive cardiac stress testing – NT-proBNP/BNP inexpensive and avoids need for return visits Speaker: Emmanuelle Duceppe Values and Preferences

30. Hospitals without NT-proBNP/BNP available at core lab can obtain point-of-care instrument to measure NT-proBNP in preop clinic Speaker: Emmanuelle Duceppe Practical Tip

31. 3 studies including 2832 pts – inconsistent association between TTE findings and perioperative ischemic events – Park 2011 1923 pts prospective cohort TTE within 2 weeks before sx Several TTE measurements predictors of major CV events all TTE parameters inferior to NT-proBNP for predicting major CV events (p<0.001) Speaker: Kim Styles Resting Echocardiography

32. We recommend against performing preoperative resting echocardiography to enhance perioperative cardiac risk estimation Strong recommendation low-quality evidence Speaker: Kim Styles Recommendation

33. If patient requires urgent/semi-urgent or elective surgery and clinical exam suggests undiagnosed severe obstructive intra-cardiac abnormality or severe pulmonary HTN, obtain urgent echocardiography before surgery to inform anesthesiologist, surgeon, and medical team of type and degree of disease If clinical assessment suggests patient may have undiagnosed cardiomyopathy then echocardiogram should be obtained to facilitate optimization of long-term cardiac health, physicians should consider urgency of surgery when deciding whether to obtain echocardiogram before or after surgery Speaker: Kim Styles Practical Tips

34. Coronary CTA VISION (Sheth 2015) Prospective cohort - 955 patients Results blinded unless left main disease identified Preop CCTA predicted CV death and nonfatal MI beyond RCRI – extensive disease: aHR 3.76 (95% CI, 1.12-12.62) – CCTA overestimated risk amongst patients who did not suffer primary outcome compared to RCRI, preop CCTA results in inappropriate risk classification in 81 patients in 1000 patient sample – based on risk categories of 15% Speaker: PJ Devereaux Coronary CT Angiography

35. We recommend against performing preoperative coronary CT angiography to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence Speaker: PJ Devereaux Recommendation

36. Limited data - 4 studies (508 patients) – only 2 studies performed risk adjusted analysis Carliner 1985 – treadmill exercise – 200 pts prospective cohort – no significant association between ECG exercise change and death or MI Sgura 2000 – supine bicycle – 149 pts prospective cohort, vascular surgery – no significant association between exercise induced ST depression and death or MI Speaker: Vikas Tandon Exercise Stress Testing

37. We recommend against performing preoperative exercise stress testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence Speaker: Vikas Tandon Recommendation

38. Colson 2012 1725 patients undergoing major elective abdominal or thoracic surgery CPET weak independent predictor of mortality at 5 yrs 3 studies looked at CPET association with 30 day outcomes 706 patients inconsistent results across studies no study evaluated if CPET improved risk reclassification in addition to clinical evaluation Speaker: Vikas Tandon Cardiopulmonary Exercise Testing

39. We recommend against performing preoperative cardiopulmonary exercise testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence Speaker: Vikas Tandon Recommendation

40. Several studies, mostly small sample size and small number of events Low quality of evidence – most retrospective, few reported risk adjusted associations No study adequately assessed incremental value of stress tests over well-established perioperative cardiac risk factors (e.g., RCRI) Speaker: Vikas Tandon Pharmacological stress echocardiography and radionuclide imaging

41. We recommend against performing preoperative pharmacological stress echocardiography Strong recommendation, low-quality evidence and Speaker: Vikas Tandon Recommendations

42. We recommend against performing preoperative radionuclide imaging to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence, respectively Speaker: Vikas Tandon Recommendations

43. Panel believed that cost and potential delays associated with stress tests should be taken into account given absence of evidence of overall absolute net improvement in risk reclass Speaker: Vikas Tandon Values and Preferences

44. Perioperative cardiac risk modification

45. Smoking cessation Meta-analysis smoking cessation RCTs (Thomson 2014) CV events after surgery – 4 trials – 653 patients – no impact of preoperative smoking cessation on major CV events – RR 0.58 (95% CI, 0.17-1.96) – only 16 events Speaker: Paul MacDonald Perioperative Risk Modification

46. Meta-analysis smoking cessation RCTs (Thomson 2014) Smoking cessation at time of surgery – 12 trials – 1867 patients – Brief intervention: RR 1.30 (95% CI, 1.16-1.46) – Intensive intervention: RR 10.76 (95% CI, 4.55-25.46) Smoking cessation at 12 month – 5 trials – 836 patients – Brief intervention: RR 1.09 (95% CI, 0.68-1.76) – Intensive intervention: RR 2.96 (95% CI, 1.57-5.55) Speaker: Paul MacDonald Smoking Cessation

47. We recommend discussing and facilitating smoking cessation before noncardiac surgery Strong recommendation low-quality evidence Speaker: Paul MacDonald Recommendation

48. Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk Speaker: Paul MacDonald Values and Preferences

49. Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk Speaker: Paul MacDonald Values and Preferences

50. POISE 2 (2014) – RCT 10,010 noncardiac Sx patients – with known vascular disease or risk factors Initiation stratum (5628 pts) – ASA 200 mg vs placebo preop and ASA 100 mg daily vs placebo x 30 days postop Continuation stratum (4382 pts) – ASA 200 mg vs placebo preop and ASA 100 mg daily vs placebo x 7 days postop ASA had to be stopped ≥3 days preop (median 7 days) Systematic monitoring troponin postop Speaker: Paul MacDonald ASA Initiation / Continuation

51. Death or nonfatal MI at 30 days – HR 0.99 (95% CI, 0.86–1.15) p=0.92 All-cause mortality – HR 1.05 (95% CI, 0.74–1.49) p=0.78 Cardiac death – HR 1.00 (95% CI, 0.63–1.60) p=0.99 MI – HR 0.98 (95% CI, 0.84–1.15) p=0.85 Major bleeding – HR 1.23 (95% CI, 1.01–1.49) p=0.04 Speaker: Paul MacDonald POISE-2 Results

52. We recommend against initiation of ASA for prevention of perioperative cardiac events Strong recommendation, high-quality evidence We recommend against continuation of ASA to prevent perioperative cardiac events, except in patients with a recent coronary artery stent and patients undergoing carotid endarterectomy Strong recommendation, high-quality evidence Speaker: Paul MacDonald Recommendations

53. Discontinue ASA at least 3 days before noncardiac surgery to reduce risk of major bleeding Perioperative ASA continuation may be reasonable for some surgical interventions to prevent local thrombosis – e.g., free flap, acute limb ischemia In patients with indication for chronic ASA, restart ASA when bleeding risk related to surgery has passed – i.e., 8 days after major noncardiac surgery When patient suffers myocardial injury or thrombotic event after surgery in absence of bleeding, there may be net value to re-starting ASA sooner after surgery than 8-10 days Speaker: Paul MacDonald Practical Tips

54. Systematic review 2014 All cause mortality (14 trials, n=10,785) – β-blocker 3.0%, no β-B 2.3%, RR 1.30 (1.03-1.63) Cardiac mortality (12 trials, n=10,648) – β-blocker 1.7%, no β-B 1.3%, RR 1.25 (0.92-1.71) Myocardial infarction (14 trials, n=10,785) – β-blocker 3.4%, no β-B 4.7%, RR 0.72 (0.59-0.86) Stroke (9 trials, n=10,545) – β-blocker 0.8%, no β-B 0.4%, RR 1.86 (1.09-3.16) Results consistent without inclusion of POISE Speaker: Joel Parlow β-blocker Initiation

55. POISE 8,351 patients - Noncardiac surgery, long-acting metoprolol vs placebo MI – β-blocker 4.2% vs no β-B 5.7%, p=0.002 Mortality – β-blocker 3.1% vs no β-B 2.3%, p=0.03 Stroke – β-blocker 1.0% vs no β-B 0.5%, p=0.005 Unclear if earlier initiation or preoperative dose titration would be practical or safer Speaker: Joel Parlow β-blocker Initiation

56. We recommend against β-blocker initiation within 24 hours before noncardiac surgery Strong recommendation, high-quality evidence Speaker: Joel Parlow Recommendation

57. Very low quality evidence regarding risk or benefit of continuing chronic β-blocker Wallace, 2010 (1996-2008, n=12,105) retrospective observational study in noncardiac surgery, with highly variable dosing all cause 30-day mortality: – continuation: aOR 0.74 (95% CI, 0.51-1.05) p=0.09 – withdrawal: aOR 3.57 (95% CI, 2.31-5.52) p<0.0001 Speaker: Joel Parlow β-blocker Continuation

58. Among patients taking β-blocker chronically, we suggest continuing β-blocker during the perioperative period Conditional recommendation, low-quality evidence Practical Tip If patient’s systolic blood pressure is low before surgery, physicians should consider decreasing or holding dose of β-blocker before surgery Speaker: Joel Parlow Recommendation

59. POISE-2, 2014: n=10,010 noncardiac surgery with known vascular disease or risk factors 30-day mortality: clonidine 1.3% vs placebo 1.3% – HR 1.01 (95% CI, 0.72–1.44, p=0.94) Nonfatal MI: clonidine 6.6% vs placebo 5.9% – HR 1.11 (95% CI, 0.95-1.30, p=0.18) Hypotension: clonidine 47.6% vs placebo 37.1% – HR 1.32 (95% CI 1.24-1.40, p<0.001) Bradycardia: clonidine 12.0% vs placebo 8.1% – HR 1.49 (95% CI, 1.32–1.69, p<0.001) Nonfatal cardiac arrest: clonidine 0.3% vs placebo 0.1%, HR 3.20 (95% CI, 1.17–8.73, p=0.02) Speaker: Joel Parlow α2-Agonist Initiation

60. We recommend against preoperative initiation of α 2 -agonist for prevention of perioperative cardiovascular events Strong recommendation, high-quality evidence Speaker: Joel Parlow Recommendation

61. Systematic review of RCTs (Wijeysundera 2003) 5 trials (692 patients) Death and MI: RR 0.35 (95% CI, 0.15-0.86) Death: RR 0.40 (95% CI, 0.14-1.16) – Only 17 events MI: RR 0.25 (95% CI, 0.05-1.18) – Only 5 events Very low quality of evidence – only half studies blinded, only one with allocation concealment – possible publication bias – implausible treatment effects and large CI Speaker: Sadeesh Srinathan Calcium Channel Blocker Initiation

62. We suggest against initiation of calcium channel blockers for prevention of perioperative cardiovascular events Conditional recommendation, low-quality evidence Speaker: Sadeesh Srinathan Recommendation

63. Only three small RCTs – total 188 patients ACEI/ARB continuation associated with increase intraoperative hypotension – pooled RR 2.53 (95% CI, 1.08-5.93) Only one trial reported on CV events – too few events to draw conclusion Other perioperative trials showed association between hypotension and postoperative risk of death, MI and stroke Speaker: Sadeesh Srinathan ACEI / ARBs Continuation

64. We recommend withholding ACEI/ARB starting 24 hours before noncardiac surgery in patients treated chronically with ACEI/ARB Strong recommendation, low-quality evidence Speaker: Sadeesh Srinathan Recommendation

65. Weight was accorded to absence of demonstrated benefit and substantial increase in risk of intraoperative hypotension associated with perioperative continuation of ACEI/ARB Speaker: Sadeesh Srinathan Values and Preferences

66. Since risk of hypotension is greatest within 24 hours of surgery, physicians should consider restarting ACEI/ARB on day 2 after surgery in patients on chronic ACEI/ARB therapy, if patient is hemodynamically stable Speaker: Sadeesh Srinathan Practical Tip

67. Meta-analysis of RCTs (Sanders 2013) 3 trials – 178 patients All-cause mortality – RR 0.73 (95% CI, 0.31-1.75) Nonfatal MI – RR 0.47 (95% CI, 0.15-1.52) Very few events Speaker: Sadeesh Srinathan Statin Initiation

68. Panel members felt evidence was too weak to support a recommendation Speaker: Sadeesh Srinathan Statin Initiation

69. Xia 2015 -Single RCT -550 patients undergoing noncardiac surgery with stable CAD -Rosuvastatin 20 mg or placebo 2h preop -MI at 30 days – Statin: 10/275 (3.6%) – Placebo: 22/275 (8.0%) – RR 0.45 (95% CI, 0.22-0.94) p=0.03 Speaker: Sadeesh Srinathan Statin Continuation

70. We recommend continuing statin therapy perioperatively in patients who are on chronic statin therapy Strong recommendation, moderate-quality evidence Speaker: Sadeesh Srinathan Recommendation

71. Coronary artery revascularization before noncardiac surgery RCT (n=426) CEA with no apparent evidence of CAD Pre-op cath/revasc vs no cath All-cause mortality at 30 days – intervention 0% vs control 1.0%, p=0.24 MI at 30 days – intervention 0% vs control 4.3%, p=0.01 Few events, large effect sizes Illuminati 2015 Speaker: Michelle Graham

72. Coronary artery revascularization before noncardiac surgery 510 patients undergoing vascular surgery Randomized to revascularization vs medical Tx – left main disease ≥50% excluded Mortality at median of 2.7 yrs – coronary revascularization group 22% – no-revascularization group 23% RR, 0.98; 95% CI, 0.70 to 1.37; P=0.92 Surgery delayed 54 days vs 18 days Speaker: Michelle Graham CARP trial (McFalls 2004)

73. Recommendation For patients with stable coronary artery disease undergoing noncardiac surgery, we recommend against preoperative prophylactic coronary revascularization Strong recommendation, low-quality evidence Speaker: Michelle Graham

74. Values and preferences Absence of clearly demonstrated benefit – inconsistent results between trials Surgical delays Increase in costs Risk of bleeding with dual antiplatelet therapy Speaker: Michelle Graham

75. Practical tips CCS Class III-IV or unstable angina – Coronary revascularization preop seems prudent individual risk-benefit assessment required in patients who require urgent/semi-urgent noncardiac surgery – Patients undergoing PCI should have noncardiac surgery delayed until risk of stopping dual antiplatelet therapy outweighed by risk of delaying noncardiac surgery Speaker: Michelle Graham

76. Monitoring for perioperative cardiac events

77. Pulmonary artery catheters Systematic review of 8 trials (2667 patients) (Shah 2005) All-cause mortality – PAC: 92/1389 (6.6%) – No PAC: 101/1318 (7.7%) – Pooled OR 0.84 (95%CI, 0.63-1.13) One trial showed increased risk pulmonary embolus – PAC: 8/997 (0.8%) – No PAC: 0/997 (0%) – p=0.004 Speaker: Michelle Graham

78. Recommendation We recommend against using pulmonary artery catheters in patients undergoing noncardiac surgery Strong recommendation, moderate-quality evidence Speaker: Michelle Graham

79. POISE Trial (8351 patients) 65% of patients suffering a perioperative MI do not experience ischemic symptoms – 2/3 of perioperative MIs would go unrecognized without periop troponin monitoring Presence or absence of signs/symptoms does not change risk 30-day mortality – symptomatic MI: aOR 4.76 (95% CI, 2.68-8.43) – asymptomatic MI: aOR 4.00 (95% CI, 2.65-6.06) Speaker: Emmanuelle Duceppe Troponin Monitoring

80. Prospective international cohort study 15,065 noncardiac surgery patients with at least overnight stay in hospital, TnT measured postop days 1,2,3 MINS Criteria = peak TnT  0.03 ng/ml due to myocardial ischemia – MINS: 9.8% death at 30 days – No MINS: 1.1% death at 30 days Speaker: Emmanuelle Duceppe VISION Study (Botto 2014)

81. 84% MINS asymptomatic – undetected without troponin monitoring Asymptomatic perioperative TnT elevations adjudicated as myocardial injuries due to ischemia – that did not fulfill Universal Definition of MI – were also associated with increased risk of 30-day mortality – aHR, 3.30; 95% CI, 2.26–4.81 Speaker: Emmanuelle Duceppe VISION Study (Botto 2014)

82. Meta-analysis of postop troponin (Levy 2011) 14 studies – 3,318 patients Postop troponin elevation associated with all- cause mortality at 12 months – aOR 6.7 (95% CI, 4.1-10.9) Speaker: Emmanuelle Duceppe Troponin Monitoring

83. We recommend obtaining daily troponin measurements for 48 to 72 hours after noncardiac surgery in patients with baseline risk >5%* for cardiovascular death or nonfatal MI at 30 days after surgery Strong recommendation, moderate-quality evidence * Patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥1, age 45 to 64 years with significant cardiovascular disease, or age ≥65 years Speaker: Emmanuelle Duceppe Recommendation

84. Prospective cohort study (Rinfret 2004) 3564 patients, age ≥50 years old, major noncardiac surgery ECG done in recovery room and on day 1, 3 and 5 postop New ischemic findings independent predictor of subsequent major cardiac events – aOR 2.19 (95% CI, 1.22–3.93) p=0.009 Speaker: Kim Styles Postoperative ECG

85. We suggest performing postoperative ECG in post- anesthetic care unit in patients with baseline risk >5%* for CV death or nonfatal MI Conditional recommendation, low-quality evidence Speaker: Kim Styles Recommendation * elevated preop NT-proBNP/BNP measurement or, if there is no preop NT-proBNP/BNP measurement, in those who have RCRI score ≥1, age 45 to 64 years with significant CV disease, or age ≥65 years

86. 3 prospective cohort studies (740 patients) Ischemia defined as – ≥1mm of horizontal or down-sloping ST depression or ≥2mm ST elevation for ≥60 seconds Longer duration more predictive of postop adverse outcomes In vascular surgery pts and pts with or at risk of CAD, – ischemic changes predicted postop cardiac events Speaker: Kim Styles Postoperative Telemetry

87. With troponin screening, additional benefit of postoperative telemetry monitoring has not been established Telemetry is associated with substantial resources and costs Panel members felt evidence was too weak to support recommendation regarding postop telemetry monitoring Speaker: Kim Styles Postoperative Telemetry

88. Meta-analysis RCTs or observational studies (Grigoryan 2013) 18 studies – 9096 patients with hip fracture Intervention: – inpatient systematic multidisciplinary approach to hip fracture management involving orthopedic surgeon and geriatrician Shared-care models reduced in-hospital and long- term mortality – In-hospital: RR 0.60 (95% CI, 0.43-0.84) – Long-term mortality: RR 0.83 (95% CI, 0.74-0.94) Speaker: PJ Devereaux Postoperative Shared-Care Management

89. We suggest shared-care management of patients with baseline risk >5%* for CV death or nonfatal MI Conditional recommendation, low-quality evidence Speaker: PJ Devereaux Recommendation *elevated preop NT-proBNP/BNP measurement, or if there is no preop NT-proBNP/BNP measurement, in those who have RCRI score ≥1, age 45 to 64 years with significant CV, or age ≥65 years

90. Management of perioperative cardiac complications

91. ASA and statin in patients suffering myocardial injury after noncardiac surgery Prospective cohort study (Devereaux 2011) 415 noncardiac surgery patients who suffered postop MI ASA and statin at discharge reduced 30-day mortality – ASA : aOR 0.54 (95% CI, 0.29-0.99) – Statin: aOR 0.26 (95% CI, 0.13-0.54) Speaker: PJ Devereaux Postoperative Management of Complications

92. 66 MINS patients and 132 matched non-MINS patients (controls) among MINS patients – 43 received therapeutic intensification of ≥1 of 4 cardiac medications (ASA, statin, beta-blocker, ACE-I) – 23 patients did not receive therapeutic intensification after MINS MINS patients not receiving therapeutic intensification had – HR, 1.77; 95% CI, 1.13-2.42 MINS patients receiving therapeutic intensification had – HR, 0.63; 95% CI, 0.10-1.19 Speaker: PJ Devereaux Retrospective propensity matched cohort study (Foucrier 2014)

93. We recommend initiation of long-term ASA and statin in patients who suffer myocardial injury or myocardial infarction after noncardiac surgery Strong recommendation, moderate-quality evidence Speaker: PJ Devereaux Recommendation

94. Speaker: Joel Parlow x

95. New Canadian Guidelines provide evidence- based recommendations on perioperative cardiac assessment and management for patients undergoing noncardiac surgery Significant changes from prior guidelines Shift of emphasis from preoperative noninvasive cardiac testing to increased use of biomarkers and postoperative monitoring of patients at risk and management of cardiac complication Conclusions

96. Questions?