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Pre-operative Cardiovascular Evaluation: Guidelines and More Eric A. Brody MD, FACC Medical Director, NA Cardiology and Medical Services Associate Professor of Clinical Medicine University of Arizona Medical Center
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Objectives Review Algorithm for Pre-op risk assessment for current guidelines Define the roles of the cardiac/medical consultant for the non-cardiac surgery patient Discuss “clearance” Review the 10 commandments of the cardiac/medical consultant
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Mechanisms of Perioperative MI Unique postoperative conditions lend themselves to AMI –Volume loss/Fluid Shifts –Anemia –Anxiety/Pain –Tachycardia –Temperature fluctuations –Coagulation cascade MVO 2 Shear Stresses Excess Catechols Platelet Activation
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What Causes Perioperative MI? Surgery Patient Volume Shifts Anemia Medication withdrawal Temperature fluctuation Acidosis Underlying CAD Hypertension Tachycardia Anxiety/Pain Hemostasis Myocardial Infarction
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Treatment of Peri-operative MI Medical Therapy Beta Blockers Ca+ Channel. Blockers ACE inhibitors/ARB Antithrombotic Therapy UFH/LMWH Anti-thrombins Thrombolysis Interventional Therapy PCI/Stent Antiplatelet Therapy ASA GP2b3a Thienopyridines
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Role of the Medical Consultant Identify co-morbidities which may complicate surgery Airway/anaesthesia issues Functional status of the patient Clarify pre-op medications Peri-procedural cardiac risk
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What is “Cleared”? Questions to answer. Patients condition is optimized prior to surgery?? Benefits outweigh risk of surgery?? OK to proceed?? Medical Legal considerations removed???
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What is “Cleared”? My preference- one of 2 options –“Patient is considered ______________ (low, moderate or high) risk for peri-op cardiovascular complications based on current ACC/AHA guidelines” -” My recommendations for perioperative care include…..” -”Patient requires additional testing to better clarify perioperative cardiac risk.”
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http://www.americanheart.org/
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ACC/AHA Perioperative Guidelines Updates: October 2007 Last revision: 2002 Significant changes to previous guidelines Dramatic change in perioperative evaluation algorithm. JACC 2007: vol. 50 (17)
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2007 Update
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Perioperative Guidelines Algorithm Need for Emergency non- cardiac Surgery? Step 1 Operating Room Perioperative Surveillance and postop. Risk stratification. Risk Factor management Yes No Step 2
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Perioperative Guidelines Algorithm Active Cardiac Conditions Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Yes
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Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease Unstable or Severe Angina (class III or IV) or recent MI >7 days but < one month
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Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Significant Arrhythmias High grade AV block Mobitz II AVB Third degree AVB Symptomatic Vent. Arrhythmias/Bradycardia SVT/Afib with uncontrolled rate (>100/min) Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease
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Active Cardiac Conditions: Patients require evaluation and treatment before non- cardiac surgery Severe Valvular Heart disease Severe Aortic Stenosis Critical Mitral Stenosis Unstable Coronary Syndromes Decompensated CHF Significant Arrhythmias Severe Valvular Heart disease
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Perioperative Guidelines Algorithm Active Cardiac Conditions Step 2 Evaluate and Treat per ACC/AHA guidelines Consider Operating Room Yes No Step 3
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Perioperative Guidelines Algorithm Low Risk non- cardiac Surgery? Step 3 Proceed with planned surgery Yes Endoscopic Superficial Breast Most ambulatory surgeries Cataracts/ocular Low Risk Surgeries
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Perioperative Guidelines Algorithm Low Risk non-cardiac Surgery? Step 3 Proceed with planned surgery No Step 4
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Perioperative Guidelines Algorithm Good Functional Capacity without symptoms (>4 mets) Step 4 Proceed with planned surgery Yes
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Assessing Functional Capacity 1 Met 4 mets ADL’s Eat, Dress or Toilet Walk Indoors Walk 1-2 blocks, level ground Light House Work
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Assessing Functional Capacity 4 mets >10 mets Climb 1 flight stairs or walk uphill Walk 4 mph Run a short distance Heavy Housework Strenuous Sports Moderate sports
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Assessing Functional Capacity
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Another Way to look at This!! No Clinical Risk Factors and Low or intermediate risk surgeries with good functional capacity may proceed directly to the OR.
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Perioperative Guidelines Algorithm Good Functional Capacity without symptoms (>4 mets) Step 4 Proceed with planned surgery Yes No or Unknown Step 5
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Clinical Risk Factors Ischemic Heart Disease Compensated or Prior CHF DM (insulin requiring) Renal Insufficiency (creat. >2.0) Cerebrovascular Disease Step 5 Lee et al. Circulation. 1999;100:1043- 1049.)
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Revised Cardiac Risk Index Procedure Type Percent AAA Other Vascular Thoracic Abdominal Orthopedic Other
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Perioperative Guidelines Algorithm No Clinical Risk Factors Step 5 Proceed with planned surgery
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Perioperative Guidelines Algorithm 1 or 2 Clinical Risk Factors Step 5 Intermediate Risk Surgery Vascular Surgery Proceed to OR with HR control or Consider Non invasive testing Class IIa, LOE B Class IIb, LOE B
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Cardiac Risk Stratification: High Risk Procedures Reported Cardiac Risk often >5% –Emergent major operations, particularly in elderly patients –Aortic and other major vascular –Peripheral vascular –Anticipated prolonged procedures with large fluid shifts or blood loss
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Cardiac Risk Stratification: Intermediate Risk Procedures Reported cardiac risk generally <5% –Carotid endarterectomy –Major head and neck, especially for CA –Intraperitoneal and intrathoracic –Orthopedic, especially in elderly –Radical prostatectomy
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Perioperative Guidelines Algorithm 3 or more Clinical Risk Factors Step 5 Intermediate Risk Surgery Vascular Surgery Proceed to OR with HR control or consider Non invasive testing Consider Non- invasive testing Class IIa, LOE B
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TYPE of Surgery
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http://www.surgicalriskcalculator.com/miorcardiacarrest On line tool to calculate patient and procedure specific risk for planned surgery
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ACC/AHA Perioperative Guidelines Updates: October 2007 Miscellaneous
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ACC/AHA Perioperative Guidelines Updates: October 2007 Who Needs an ECG?? Undergoing Vascular surgery (one or more clinical risk factors) Class I Undergoing Vascular Surgery (no risk factors) IIa Intermediate risk surgery with established CVD (CAD, PVD, Cerebrovascular disease) Class I Intermediate Risk surgery with one or more clinical risk factors
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ACC/AHA Perioperative Guidelines Updates: October 2007 Who Needs an ECG?? –CLASS III- ECG not needed in asymptomatic patients undergoing low risk surgical procedures.
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Recommendations for Statin Therapy ACC/AHA Perioperative Guidelines Updates: October 2007 Class I- (LOE B) –Patients taking statins should be continued on this therapy at time of non-cardiac surgery
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Best Treatment of Perioperative MI
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Conclusions: Ways to Avoid Cardiac Complications Know the Patient’s History –Prior MI or known CAD –Prior CHF and LVEF –Renal Failure/ baseline Creatinine –History of significant Valvular heart disease Stenosis > regurgitation
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Conclusions: Ways to Avoid Cardiac Complications Know what your surgeons and anesthesiologists did –Speak with them directly to coordinate perioperative care. –Blood loss/serial hematocrits –Fluid resuscitation –Check the post op orders yourself
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Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 Our own insecurities –Long history of “clearance” performed by cardiologists Changing the Culture –Surgeons –Anesthesiologists
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Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 Getting the surgeons to listen to peri-operative recommendations –“ You lost me at ‘Cleared’…..” –Importance of continuing statin therapy and beta blocker therapy in those already taking these medications
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Conclusions: Ways to Avoid Cardiac Complications Know the patients’ medications –Continue Beta Blockers if on these preoperatively –Prophylactic beta blockade is not indicated in all patients
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Challenges for Primary Providers ACC/AHA Perioperative Guidelines Updates: October 2007 The “Business” of stress testing and preoperative evalutation Who’s going to pay?
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Preoperative Evaluation Keep it simple!!
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