1. Jason E. Davis, MD PERI-OPERATIVE CARDIAC RISK REDUCTION, A-FIB/MI MANAGEMENT

2.  ~27 million non-cardiac surgeries per year  1 – 1.5 million for pt’s w/ known cardiac disease  3 – 4 million for pt’s with 3 or more risk factors for coronary artery disease (DM, smoking, etc)  Past 50 years in surgery  Dramatic changes in procedures  Improvements to survival SURGERY AS A CONTROLLED INJURY

3.  Predictable responses  Body doesn’t differentiate surgery from injury  Fight or flight, mobilization of energy stores  “Physiological Narrowing”  20 years old and healthy generally tolerates stressors better than pt 80 years old  Graded neuro-endocrine response  Bigger surgery, bigger response SURGERY AS A CONTROLLED INJURY

4. Anterior Pituitary – ACTH – Growth hormone – Prolactin – Endorphin Posterior Pituitary – Arginine vasopressin Adrenals – Cortisol – Epinephrine (rises until 3 hrs) – Norepinephrine (until 3 days) PREDICTABLE RESPONSES

5.  Analgesia  Hypercoagulability (control of blood loss)  Mobilization of metabolic substrates (glucose)  Conservation of fluid, electrolytes POST-INJURY/SURGERY DEFENSES

6. Altered hemodynamics – Hypertension – Fluid and metabolite shifts – Tachycardia – Hypercoagulability – DVT, pulmonary embolus – Myocardial Ischemia – Congestive heart failure – Tachyarrhythmia Hypokalemia Hypomagnesemia Immune suppression Infectious complications Hyperglycemia CONSEQUENCES & COMPLICATIONS

7.  Defining overall risk  PMH = Opportunity to Prevent, Plan, Adapt  Highest risk for complications  First 3 days post-operatively  Corresponds to injury + response SEQUENCE OF EVENTS

8.  American Society of Anesthesiologists risk stratification and classification scheme  Class 1: Normal healthy patient  Class 2: Patient with mild systemic disease  Class 3: Severe systemic disease, limits function  Class 4: Incapacitating, constant threat to life  Class 5: Moribund, unlikely to survive +/- surgery  Class 6: Brain-dead organ donor PATIENT SELECTION

9.  American Society of Anesthesiologists risk stratification and classification scheme  Class 1: Mortality 0 – 2%  Class 2: Mortality 0.5 – 3%  Class 3: Mortality 5 – 10%  Class 4: Mortality 75%  Elective vs. Emergent: 2 – 3x risk  Also: Magnitude, Duration… PATIENT SELECTION

10.  High Risk factors  Acute/recent MI  Unstable coronary dx  De-compensated CHF  Significant arrhythmias  Severe valvular disease EAGLE’S CARDIAC RISK ASSESSMENT HTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/EGLSCRDCRSKASMNT.HTM

11.  Intermediate Risk factors  Mild angina  History of MI, compensated CHF  Renal insufficiency, DM  Minor Risk Factors  Advanced age  Abnormal EKG  Low functional capacity EAGLE’S CARDIAC RISK ASSESSMENT HTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/EGLSCRDCRSKASMNT.HTM

12. Eagle’s cardiac risk assessment – >70 years age – History of angina – History of ventricular dysfunction – Diabetes on therapy – Abnormal Q-waves on EKG ACC-AHA Criteria – Functional Capacity (I – IV) – Graded by “Metabolic Equivalents” (>4 METS = lower risk) Detsky’s Modified risk index Goldman criteria FURTHER PRE-OP PLANNING HTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/ACAHPRPRTVCRDCRSKAS MNT.HTM

13. Beta-Blockers – Chronic users (AM w/ sip of water) – High risk non-users prescribed pre-op Remember neuro-endocrine response Anticoagulants – soon as outweighs bleeding – Coumadin Interim heparin – Aspirin, Plavix Statins – mixed literature CONTINUATION OF MEDICATIONS

14. Pre-operative – Pre-emptive anesthesia (local, systemic) – Appreciate pt’s entire risk -- not just surgical! Intra-operative – Product of underlying problems x surgical stress Post-operative – Pain control – Fluid balance, early mobilization – Tx co-morbid conditions ATTENUATION OF STRESS RESPONSE

15. Anesthetic selection – Local +/- sedation – Regional (epidural, spinal, etc) – General Temperature control – National initiatives to 37C Improved bloodflow Decreased neuro-endocrine ANESTHETIC FACTORS (COLLABORATIVELY ADDRESSED WITH ANESTHESIA COLLEAGUES)

16. Recognition – Irreg rhythm, tachycardia +/- CP, SOB, hypotension Diagnosis – EKG, new onset often secondary to ischemia Treatments – Attempt to normalize B-blocker > Diltiazem > Digoxin – Rate control (often same meds) – Anticoagulation soon as poss Prevent propagation thrombus ATRIAL FIBRILLATION

17.  Recognition  Tachycardia, hypotension, chest pain, new onset a-fib, shortness of breath, mental status change  Diagnosis  EKG, Troponin/CKMb, CXR (assess alt causes)  Treatment  B-blocker, nitrates, heparin, morphine, asa, statins  Cardiology consult PRN MYOCARDIAL ISCHEMIA

18.  Lehigh Valley Heart Specialists  Nurse available on-call  Contact:  Lehigh Valley Heart Care Group  Fellow available on-call  Contact: LVHN CARDIOLOGY CONSULTS

19.  Consider whole pt  Surgery (controlled injury) + co-morbidities  Risk reduction  Pt stratification  Clearance, medications  Coordination of care  MI: dx, decrease work, decrease pain, +O2  A-fib: ‘break’, rate, anticoag. SUMMARY

20. THANK YOU.