1. Update on Perioperative Medicine
Hugo Quinny Cheng, MD
Division of Hospital Medicine
University of California, San Francisco

2. Update on Perioperative Medicine
Who needs a preoperative cardiac stress test?
What are the benefits and risks of -blockers?
Can statins prevent postoperative MI?
When can patients with stents go to the OR?
How should chronic anticoagulation be managed?
Should arthroscopy patients get DVT prophylaxis?
Is preoperative smoking cessation beneficial?

3. Preoperative Stress Testing
A 65 y.o. man with a history of coronary artery disease and long-standing diabetes will undergo radical prostatectomy. He had a myocardial infarction in 2003, but now has no cardiac symptoms.
Meds: lovastatin, atenolol, glyburide, benazepril, ASA
Exam: BP=115 / 70 HR=60; normal heart & lung exam
ECG: NSR, LVH, otherwise normal

4. 65 y. o. man s/f radical prostatectomy
65 y.o. man s/f radical prostatectomy. History of remote MI and long-standing diabetes. He is currently asymptomatic.
Stress test prior to surgery
No stress test is needed
Make him carry a copy of Harrison’s up a flight of stairs

5. “New Standard” Cardiac Risk Index
Predictors:
Higher risk operation*
Ischemic heart disease
Congestive heart failure
Diabetes requiring insulin
Creatinine > 2 mg/dL
Stroke or TIA
Predictors Complications** % %
2 4%
3 or more 9%
* Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery
** Defined as MI, pulmonary edema, cardiac arrest, complete heart block
Lee, et al. Circulation, 1999

6. Control HR & go to OR (IIa)
2007 ACC/AHA Guideline
Good Functional Capacity?
Go to OR
yes
≥ 3 predictors
1 or 2 predictors
no predictors*
no or ?
Go to OR
Control HR & go to OR (IIa)
Vascular surgery?
Consider stress test if results will change management (IIa) no
yes or
(IIb)
* CAD, CHF, DM, CKD, CVA/TIA

7. 770 vascular patients with 1 or 2 of following:
Age > 70, MI, angina, CHF, DM, stroke / TIA, Cr > 1.8
No stress test (n = 384)
Stress test (n = 386)
34 with extensive ischemia (9%); 12 had PCI or CABG
352 with no or limited ischemia
1.8%
30-day CV Death or MI
2.3%
1.1%
15%
Poldermans et al. JACC, 2006

8. Extensive Ischemia Predicts High Risk
101 patients undergoing vascular surgery, all with ≥ 3 risk predictors and stress test showing extensive ischemia
Poldermans, et al. JACC, 2007

9. Reducing Risk with Medical Management
A 75 y.o. woman will undergo hemicolectomy next week. She has a history of diabetes and a remote stroke, but no current cardiovascular symptoms.
Start a -blocker
Start a statin
Start both -blocker & statin
No new medications needed

10. Cardiac Mortality & Nonfatal MI (%)
patients undergoing vascular surgery - All had ischemic potential on dobutamine echo - Randomized to beta-blocker or standard care 40
Cardiac Mortality & Nonfatal MI (%) 7 14 21 28 10 20 30
Days after Surgery
Bisoprolol
Standard Care
Poldermans, et al. NEJM, 1999

11. POISE: PeriOperative Ischemia Evaluation
8351 patients with s/f major noncardiac surgery
CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery
Not already taking -blocker
Metoprolol XL (immediately preop until 30 days postop)
Placebo
Patients followed for 30 days after surgery:
1° Endpoint: cardiac mortality & nonfatal arrest or MI
Poise Study Group. Lancet, 2008

12. Poise Study Group. Lancet, 2008
POISE: Results
Metoprolol XL:
Reduced cardiac events (mostly nonfatal MI)
but
Increased risk of stroke & total mortality
Poise Study Group. Lancet, 2008

13. POISE: Treatment Protocol
2-4 h OR
0-6 h
12 h
1st dose Metoprolol 100 mg XL*
2nd dose Metoprolol 100 mg XL*
3rd & daily dose Metoprolol 200 mg XL*^
* Study drug held for SBP < 100 or HR < 50
^ Daily dose reduced to 100 mg if persistent bradycardia or hypotension

14. Poldermans et al. Presented at ESC, 2008
DECREASE III
497 statin naive patients s/f vascular surgery
Fluvastatin XL 80 mg/day
Started > 1 month preop
Continued > 1 mo postop
Placebo
Patients followed for 30 days after surgery:
Clinical Endpoint: cardiac death or nonfatal MI
Poldermans et al. Presented at ESC, 2008

15. Poldermans et al. Presented at ESC, 2008
DECREASE III: Results
Fluvastatin XL:
Reduced the composite outcome of cardiac death & nonfatal MI
No difference in rates of LFT or CPK elevation
Poldermans et al. Presented at ESC, 2008

16. DECREASE-IV
1066 patients with estimated 1-6% risk of postoperatived cardiac complications
Randomized to: Bisoprolol
Fluvastatin XL
Bisoprolol + Fluvastatin
Double placebo
Drugs started average 34 days prior to surgery
Primary endpoint: 30-day CV death or nonfatal MI

17. DECREASE-IV Results
Bisoprolol-treated patients had fewer complications
Trend towards benefit with statins
No safety issues
* P < .002 * *
Dunkelgrun et al. Ann Surg, 2009

18. Perioperative -blockers in 2009
Strong indications:
Already using -blocker to treat angina, HTN, arrhythmia
Patients with ischemic potential having vascular surgery
Possible indications:
Patients with ischemic potential having high-risk nonvascular surgery (e.g., > 5 hours or > 500 cc blood loss)
Multiple risk predictors* in vascular or other high-risk surgery
(*Coronary disease, renal insufficiency, diabetes)
Titrate dose up gradually (rarely start immediately preop)

19. Statins: 2007 ACC/AHA Guideline
Definite indications (class I):
Continue statin if already taking prior to surgery
Probable indications (class IIa):
All vascular surgery patients
Possible indications (class IIb):
At least one risk predictor* in any intermediate risk surgery
*Coronary disease, renal insufficiency, diabetes, CVA/TIA

20. Delaying Surgery After Coronary Stent
A woman falls and suffers a cervical spine fracture. One month ago, she received a sirulimus-eluting stent for stable angina. The neurosurgeon won’t operate unless aspirin and clopidogrel are held for her surgery. Non-operative management in a halo for next 2 months is offered as an alternative.
What do you recommend to the patient & surgeon?

21. Patient with recently placed drug-eluting stent has a c-spine fracture
Patient with recently placed drug-eluting stent has a c-spine fracture. Surgeon won’t operate unless aspirin & clopidogrel are held perioperatively.
Hold ASA & clopidogrel
Hold ASA & clopidogrel but bridge with heparin
Keep her in a halo for next 2 months

22. Does Heparin Bridge Prevent Stent-related Complications?
Prospective study of 103 patients with coronary stent placed within 12 months having noncardiac surgery
Antiplatelet drugs continued or held < 3 days
All patients received heparin drip or enoxaparin
14% of patient stented within 35 days of surgery suffered cardiac death or MI, or needed re-do PCI
Conclusion: High rate of cardiac complications even when bridging anticoagulants used
Vicenzi et al. Br J Anaesth, 2006

23. ACC/AHA Guidelines for PCI
Avoid PCI unless patient has independent indications
Avoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapy
Delay elective surgery in patients with recent PCI
Balloon angioplasty: weeks
Bare metal stent: 4 weeks
Drug eluting stent: 12 months
If clopidogrel must be stopped, try to continue ASA
No evidence for bridging with other agents

24. Managing Perioperative Anticoagulation
Two patients who take coumadin underwent THA. One has atrial fibrillation due to HTN. The other has a mechanical AVR. Neither has a history of stroke or any other comorbidity.
Heparin bridge for AVR only
Heparin bridge for AF only
Heparin bridge for both
Heparin bridge for neither

25. Two patients who take coumadin underwent THA. One has AF due to HTN
Two patients who take coumadin underwent THA. One has AF due to HTN. The other has a mechanical AVR. Neither has a history of stroke any other comorbidity.
Heparin bridge for AVR only
Heparin bridge for AF only
Heparin bridge for both
Heparin bridge for neither

26. Thromboembolic Risks with Non-rheumatic Atrial Fibrillation
CHADS-2 Score:
1 point for CHF, HTN, Age > 75, DM
2 points for Stroke/TIA
Score 0 - 2: < 5% annual stroke risk Score 3 - 4: 5-10%
Score 5 - 6: > 10%
Annual Stroke Risk
Albers et al. Chest, 2001

27. Thromboembolic Risks with Mechanical Valves
Annual Incidence
Cannegieter, et al. Circulation, 1994

28. Effect of Mechanical Valve Location & Design on Thromboembolic Risk
Aortic RR = 1.0
Mitral RR = 1.8
Valve Design:
Caged Ball RR = 1.0
Tilting Disk RR = 0.7
Bi-leaflet RR = 0.6
Cannegieter, et al. Circulation, 1994

29. Perioperative Anticoagulation: 2008 ACCP Guidelines
Atrial Fibrillation
Mechanical Valve
Recommend
CHADS2 = 5-6, recent CVA, or rheumatic AF
Any MVR; older (caged-ball or tilting disc) AVR; recent CVA
Full dose heparin bridge
CHADS2 = 3-4
Bileaflet AVR plus one additional stroke risk factor
Full or low dose heparin
CHADS2 = 0-2
Bileaflet AVR without AF or other stroke risk factor
Low dose or no heparin
Full dose = therapeutic dose of heparin IV or LMWH SC
Low dose = DVT prophylaxis dose of heparin SC or LMWH SC

30. DVT Prophylaxis Which DVTs matter?
Symptomatic versus asymptomatic
Proximal versus distal
2008 American College of Chest Physicians:
Weights DVT risk greater than bleeding risk
Treats asymptomatic DVT as important

31. RCT of LMWH in Knee Arthroscopy
Background: ACCP guidelines recommend LMWH if additional risk factors for DVT are present.
Study Design: ~1300 patients randomized to compression hose or LMWH x 7 days after knee arthroscopy. All patients underwent screening ultrasound.
Results: Combined incidence of death or any clot reduced in patients receiving LMWH (0.9% vs 3.2%). Almost all clots were either asymptomatic or distal. Non-significant trend for increased bleeding.
Conclusions: LMWH superior to compression hose after knee arthroscopy (NNT = 43). Impact on symptomatic DVT small.
Camporese et al. Ann Intern Med, 2008.

32. Preoperative Smoking Cessation
A middle-aged man will undergo repair of a ventral hernia in 1 month. He currently smokes one pack of cigarettes per day. How do you counsel him?
Quit smoking now to prevent postoperative complications.
It’s always good to quit, but it’s too late to affect your risk of complications.
Don’t stop smoking! You will actually increase your surgical risk by quitting!

33. Effect of Smoking Cessation
Time since quitting
p < .001
Complication Rate (%)
Warner, Anesthesiology 1984

34. Preoperative Smoking Cessation Counseling
RCTs of Preoperative Smoking Cessation Counseling:
120 patients undergoing arthroplasty in 6-8 weeks
117 patients undergoing various operations in 4 weeks
60 patients undergoing colorectal resection in 2-3 weeks
Intervention: Smoking cessation counseling at weekly meetings (or by telephone) & offer free nicotine replacement products
Outcomes: Postop complications, especically wound related (e.g., dehiscence, infection, hematoma)

35. Smoking Cessation 6-8 Weeks Before TKA or THA
Moller et al. Lancet, 2002

36. Smoking Cessation 4 Weeks Before Surgery
Lindstrom et al. Ann Surg, 2008.

37. Smoking Cessation 2-3 Weeks Before Colorectal Surgery
Sorensen, et al. Colorectal Dis, 2003

38. Take Home Points Reserve stress testing for higher risk patients
-- Limited ischemia ok, but extensive ischemia = high risk
Start -blocker cautiously & only in high risk patients
Delay surgery in patients with recent stent placement
Individualize thrombotic risk assessment when managing perioperative anticoagulation
Consider LMWH for knee arthroplasty patients
Smoking cessation for ≥ 4 weeks may be beneficial