1. Dr. Sonia Anand McMaster University
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery
Dr. Sonia Anand
McMaster University

2. Epidemiology of Noncardiac Surgery
Nearly 30 million patients have noncardiac surgical procedures annually in the United States
Approximately 25% of these are major intra-abdominal, thoracic, vascular and orthopedic procedures

3. Pre-Op Risk Assessment =

4. Overview Guidelines- reflect evidence synthesis and consensus
Evidence as of October 2007
Important Decision points:
Urgent vs Elective Surgery
High risk surgery vs intermediate vs low
Active Cardiac Condition vs non-active

5. The Search For High Risk

6. Methods for Assessing Risk Pre-Operatively
Patient Based
High risk conditions
Functional Capacity
Surgery Based
Vascular Surgery
Emergency surgery
Intervention Based
Medications
Revascularization

7. Six Independent predictors of cardiac risk
ischemic heart disease
congestive heart failure
3) cerebrovascular disease
4) high risk surgery (AAA, orthopedic sx)
5) pre-operative insulin tx for diabetes
6) preoperative creatinine for creat > 2 mg/dL
Lee et al

8. Active/Major Cardiac Conditions
Unstable Coronary Conditions
Decompensated CHF
Significant arrhythmias (i.e. 3⁰HB, new Vtach)
Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????

9. Non-Active Cardiac Factors
Intermediate Risk
Hx of CHD
History of prior CHF
Hx of stroke
Diabetes
Renal insufficiency
Minor Risk*
Age > 70
Abnormal ECG
Nonsinus rhythm
Uncontrolled systolic BP
* Not associated with cardiac risk

10. Functional Capacity
Functional status has shown to be a reliable periop and long-term predictor of cardiac events
Functional status determined based on ability to do ADL’s
MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest
Periop risk is increased if person cannot > 4 METS

11. 10 MET 1 MET 4 MET Moderate recreational golf, dancing, baseball
DO light house work i.e. Washing dishes
Strenuous sports swimming, basketball
Climb a flight of stairs
Run a short distances
Eat, dress
10 MET
1 MET
4 MET

12. The Trump Card: Functional Capacity
Perioperative cardiac risk is increased in patients unable to exercise 4 METs
Functional capacity can be estimated in the office
Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs
Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs
Swimming and singles tennis exceeds 10 METs

13. Surgery Risk Type Type Cardiac risk examples High > 5%
Aortic, peripheral vasc sx
Intermediate risk
1-5%
Intraperitoneal
Intrathoracic
Carotid End
Head and neck
Orthopedic Sx
Prostate Sx
Low
<1%
Endoscopic procedures
Superficial
Cataract Sx
Breast Sx
Ambulatory Sx

14. Surgery-Specific Risk: High Risk*
Major emergency surgery
Vascular surgery including: aortic surgery, infra-inguinal bypass
Prolonged surgery with large fluid shifts or blood loss
* Reported risk of cardiac death or nonfatal MI >5%

15. Stepwise Approach Step 1: Determine urgency of surgery
Step 2: Active cardiac condition?-→test
Step 3: Undergoing low-risk surgery? < 1%*
Step 4: Good functional capacity?
* Combined morbidity and mortality < 1% even in high risk patients

16. The Catheterization Questions to Ask Yourself
Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now?
Am I willing to send the patient to CABG?
Am I doing this just to know the anatomy?

17. Is pre-op coronary revasc advantageous?
If high risk surgery and patient has active cardiac issue
Functional test and perfusion Imaging and if
L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op
CARP – if none of these – no advantage of revasc

18. Functional Test Exercise test with ECG
If abnormal ECG, Rx perfusion imaging
Adenosine
Dipyridamole
Dobutamine
Dobutamine stress echo

19. Effect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry2 4 6 8 10
No CAD
CAD:
Medical Rx
CABG
(n=314)
Periop MI
Death
3.0
8.5
2.8
0.6
1.1
*** *
Eagle et al. Circulation, 1997

20. Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes
510 VA pts, aged 66 years, with stable CAD, scheduled for elective
AAA repair (33%) or infrainguinal bypass (67%), randomized to
Revasc (PCI 59%, CABG 41%) or conservative management. 25 20 15 10 5
Post-Op MI
30 Day
2.7 Year
Mortality
Mortality
Revascularization
Conservative Mgmt
McFalls, E. CARP Trial;AHA 2004

21. Get Out of Jail Free Cards
If the patient has been revascularized within 5 years (stent or CABG) and has no change in symptoms and no active major issues, they do not need any further testing or stratification.
If the patient has had a coronary evaluation within 2 years and no change in symptoms, they are at acceptable risk for surgery.

22. High Risk Patients & Revascularization Pre-Op
101 pts with extensive ischemia randomly assigned to pre-op revascularization
or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up. 50 40 30 % 20
2VD in 12 (24%),
3VD in 33 (67%),
Left main in 4 (8%). 10 7 14 21 28 3 6 9 12
Days since surgery
Months since surgery
Poldermans, D. JACC 2007; 49(17): 1763

23. The Effect of Percutaneous Revascularization Above Optimal Medical Therapy: COURAGE
2287 Pts w/myocardial ischemia and CAD randomized to PCI with
optimal medical therapy (PCI group) and 1138 to medical therapy alone.
1.0
0.9
0.8
0.7
0.6
0.5 1 2 3 4 5 6 7
Years
Survival Free of Death/MI
Medical therapy
PCI + Medical therapy
Boden, W. NEJM 2007; 356:1503

24. STENTS
If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after
If received DES....
1) postpone sx until > 12 months,
2) do sx on both asa+clop
3) do sx on single ap tx

25. Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended

26. Medical tx 1) beta blockers-if on keep them if not....
2) Statins continue, ? Start -need randomized trials

27. Statins Improve Survival After Vascular Surgery
100 pts randomized 20 mg atorvastatin or placebo for 45 days.
Vascular surgery ~ 30 days after randomization. F/U 6 months
Primary Endpoint
CV death +
NFMI+
Ischemic stroke+
Unstable Angina
Durazzo, AES. JVS 2004:39(5):975

28. Statins Improve Long-Term Survival After Vascular Surgery
Retrospective review of 446 consecutive infrainguinal bypass surgeries 20 40 60 80
100
1.00
.75
.50
.25
Time (months)
Survival
Statin (+)
p < 0.004
Statin (-)
Ward, RP. Int J Card 2005; 104(3):264

29. Statin Intensity & Operative Outcomes
359 vascular surgery pts, statin dose were recorded. Myocardial ischemia & HR
variability were assessed by 72-h 12-lead ECG. TNT measured on day 1, 3, 7,
and discharge. Cardiac events included cardiac death or NFMI
at 30 days and follow-up mean 2.3 years
Statin therapy % of Max Recommended

30. Other Issues DVT/PE prophylaxis
Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B)
No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes
Routine troponin monitoring not recommended

31. Surveillance for Perioperative Myocardial Infarction
ECGs
All intermediate and high-risk patients should get a post-op ECG.
As need for signs or symptoms of ischemia
Troponin / CK
In patients with signs or symptoms of ischemia
Do not do screening biomarkers

32. High Risk Features Severe obstructive or restrictive pulmonary disease
Diabetes
Renal impairment
Anemia, polycythemia, thrombocytosis

33. PCI pre-op
ST-elevation MI
Unstable angina
Non ST elevation MI

34. 2007 ACC/AHA Perioperative Guidelines

35. Take Home Messages
Unstable syndromes require management prior to surgery. Look for
Unstable angina
Signs of heart failure
Stenotic valve lesions
Ventricular arrhythmias
Functional tolerance is the best single predictor of outcome
Be very specific in your history (one step at at time, regular or slow pace, etc)
If patient on beta blockers & statins continue them, more trials to mandate them
PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.