1. Cardiac Issues With Noncardiac Surgery Joseph F. Winget, MD FACC Clinical Assistant Professor University of Vermont Medical School Champlain Valley Cardiovascular Associates, P.C.

2. Objectives Preoperative risk assessment Anticoagulation and antithrombotic issues Postoperative Management Endocarditis prophylaxis

3. Disclosures None

4. Surgery or not? 87 year old white female with known critical AS fall and breaks her hip. No CHF, MI, syncope Stable and relatively independent before the fall. LVEF 65% 82 year old white male with known CAD. Stable angina pectoris. Catheterization shows occluded LAD which was fed by collaterals No CHF AODM and HTN Severe worsening spinal stenosis and weakness LVEF 50%

5. Preoperative cardiac issues How healthy is the patient? How active is the patient? How risky in the planned surgery? Is preoperative cardiac testing necessary? What preventive measures can be taken to reduce cardiac risk?

6. L’Italien JACC 1996;27:779

7. JACC 2002; 39:542

10. JACC 2002 39:542

11. Is testing predictive of outcomes? Circ 1997; 95: 53

12. Cardiac event rates and dobutamine echocardiography JAMA 2001; 285:1865

13. Who to test? Intermediate risk patients undergoing intermediate or high risk surgery Testing does not add additional information in low risk or high risk patient groups.

14. What test? Well validated –Exercise or pharmacologic echocardiography –Exercise or pharmacologic Cardiolite Not well validated –CTA –MRI –Cardiac angiography*

15. Therapies to reduce perioperative cardiac complications Revascularization –Percutaneous revascularization –CABG Medical therapy

16. Benefit of CABG Circ 1997; 96: 1882

17. McFalls E et al. N Engl J Med 2004;351:2795-2804 Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery

18. McFalls E et al. N Engl J Med 2004;351:2795-2804 Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization

19. Medical therapy to lower risk Lindenauer, PK JAMA. 2004 May 5; 291(17)2092

20. Beta blocker use? NEJM 1996; 335:1713

21. Beta blocker use?

23. Recommendations Revascularization for appropriate clinical indications Maximize adjuvant medical therapy –Aspirin –Statin –Beta blocker Close perioperative follow-up –Prolonged telemetry monitoring

24. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242 Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater

25. Surgery or not? 87 year old white female with known critical AS fall and breaks her hip. No CHF, MI, syncope Stable and relatively independent before the fall. 82 year old white male with known CAD. Stable angina pectoris Catheterization shows occluded LAD which was fed by collaterals No CHF AODM Severe worsening spinal stenosis and weakness

28. Cardiac Issues in noncardiac surgery Establish patient risk Assign procedural risk Test intermediate risk patients undergoing intermediate or high risk surgery Optimize medical therapy Revascularization when clinically indicated ACC/AHA Guidelines JACC 2007; 50: 1707-1732

29. Anticoagulation / Antiplatelet Agents 55 year old male s/p CABG in 2000. Drug eluting stent placed to native vessel in August of 2008. Needs colonoscopy Can plavix and aspirin be safely stopped? 70 year old white female with chronic AF needs shoulder surgery History of CVA Warfarin 5 mg daily Does the patient need some form of bridging preoperatively?

30. Anticoagulation / Antithrombotic Issues Anticoagulants – warfarin –Atrial fibrillation –Venous thrombosis –Prosthetic heart valves Antithrombotic agents – clopidogrel –Bare metal stents vs. drug eluting stents

31. Do you need to stop antiplatelet / anticoagulation therapy? Procedural risk for bleeding –Low risk for bleeding Athrocentesis Cataract surgery Dental cleaning / extraction Cutaneous surgery

32. CHADS score - AF Circulation 2004; 110:2287JAMA 2001; 285:2864

33. Atrial fibrillation Bridge –AF and prosthetic valves –AF and significant LV dysfunction (EF<40%) –AF and any prior thrombotic event (CVA, TIA, arterial emboli) –“high risk” patients No bridging –Low risk patients

34. How to bridge Stop warfarin for 48 hours Start lovenox at 1mg/kg SQ BID for 6 doses Stop lovenox the morning before surgery

35. Prosthetic heart valves Bioprosthetic valves –All, if in atrial fibrillation Mechanical valves –All, regardless of rhythm

36. Venous thrombosis Deep venous thrombosis Pulmonary emboli Hypercoagulable states –Factor V Leiden –Protein C / S deficiencies –Lupus anticoagulant

37. How to Bridge Stop warfarin Start replacement therapy once INR < 2.0 –IV heparin –SQ low molecular weight heparin - lovenox

38. Coronary stents

40. Recommendations – stent patients Bare Metal Stents –Delay elective procedures for at least 1 month and preferably 6 months –Restart clopidogrel as soon as possible –Loading dose? Drug eluting stents –Delay elective procedures for 1 year –Continue aspirin –Restart clopidogrel as soon possible –Loading dose?

41. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242 Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion

42. Improved cardiac care for noncardiac surgery? Yes, we can!

44. Perioperative Medication Management Beta Blockerscontinue Alpha agonistscontinue Calcium blockerscontinue prn ACE / ARBstop preoperatively start when stable Statinscontinue Diureticsas needed

45. Endocarditis prophylaxis 70 year old female with rheumatic valvular heart disease and Bjork-Shiley MVR in 1984 needs dental work. Are antibiotics required?

46. SBE prophylaxis Antibiotics –All Prosthetic valves –Prior bacterial endocarditis –Cyanotic congenital heart disease (CHD) –Any repair CHD with prosthetic material * No Antibiotics –Uncomplicated valvular heart disease –Pacemakers or defibrillators –Hypertrophic cardiomyopathy Circ 2007; 115