1. No category

Mozow Zuidema, MD, PhD
Staff Cardiologist
Harry S. Truman Memorial Veterans Hospital
No financial disclosures or conflicts of interests
 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?
 Catecholamine surges
 Prothrombotic milieu
 Coronary plaque destabilization
 Blood loss
 Volume shifts
Classification of Recommendations
 Class I: Conditions for which there is evidence, general agreement, or both
that a given procedure or treatment is useful and effective.
 Class II: Conditions for which there is conflicting evidence, a divergence of
opinion, or both about the usefulness/efficacy of a procedure or treatment
 Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
 Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
 Class III: Conditions for which there is evidence, general agreement, or both
that the procedure/treatment is not useful/effective and in some cases may
be harmful.
Level of Evidence
 Level of Evidence A: Data derived from multiple randomized clinical trials
 Level of Evidence B: Data derived from a single randomized trial or
nonrandomized studies
 Level of Evidence C: Consensus opinion of experts
Circulation 2006 114: 1761 – 1791.
What We Knew
Fliesher et al, “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” Circulation. 2007. 116:e418-500.
 The iPhone debuts…for $599
 The final Harry Potter book (Harry Potter and the
Deathly Hallows) is released
 George W Bush was the President
 The Departed won Best Picture
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Figure 1. Stepwise Approach to Perioperative Cardiac Assessment for CAD
Fliesher et al. “2014 ACC/AHA
Guideline on Perioperative
Cardiovascular Evaluation and
Management of Patients Undergoing
Noncardiac Surgery.”
http://content/onlinejacc.org/
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2014: Now,
with
color!!!
Step 1:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Emergent
Life or limb is
threatened if
not in operating
room within
6 hours
Urgent
TimeSensitive
Elective
Life or limb is
threatened if
not in operating
room within
24 hours
Delay of 1-6
weeks for
further
evaluation
would
negatively affect
outcome
Delay for up to
1 year
Step 2:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Step 3:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Class IIa:
 A validated risk-prediction tool can be useful in predicting the risk of
perioperative MACE in patients undergoing non-cardiac surgery
 Class III: No benefit
 For patients with low risk of perioperative MACE, further testing is not
recommended before the planned operation
 RCRI- Revised Cardiac Risk Index
 American College of Surgeons NSQIP Risk Calculator
RCRI
•
6 predictors of complications
•
Major cardiac complications
included:
•
•
•
•
•
•
Myocardial infarction
Ventricular fibrillation
Cardiac arrest
Complete heart bock
Pulmonary edema
Revised Cardiac Risk Index
1. History of ischemic heart disease
2. History of congestive heart failure
3. History of cerebrovascular disease (stroke or transient ischemic attack)
4. History of diabetes requiring preoperative insulin use
0-1 predictors = low risk
5. Chronic kidney disease (creatinine > 2 mg/dL)
•
2+ = high risk
6. Undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery
Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac
arrest:0 predictors = 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%, ≥3 predictors =
>11%
http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/
ACS NSQIP Calculator
•
21 predictors of risk for major cardiac complications
•
NSQIP MICA risk-prediction rule created in 2011
•
525 US hospitals participated
•
> 1 million operations included
•
Outperformed RCRI in discriminative power (esp. with vascular)
•
Calculates risk of:
•
MACE, death, pneumonia, venous thromboembolism, acute renal failure, return to operating
room, unplanned intubation, discharge to rehab/nursing home, surgical infection, urinary
tract infection
•
Predicts length of hospital stay
•
Limitations:
•
•
•
Not validated outside NSQIP
ASA status
Functional status/dependence
http://riskcalculator.facs.org/PatientInfo/PatientInfo
RCRI
ACS NSQIP Calculator
Creatinine > 2
H/o heart failure
IDDM
Thoracic, Intra-abdominal, or
vascular
H/o ischemic heart disease
H/o CVA or TIA
ARF
H/o heart failure within 30 days
DM
RCRI: h/o MI, positive ETT, angina, use of
nitrites, EKG with pathologic Q waves
NSQIP: MI within 6 months, PCI ever,
angina ever, any cardiac surgery (not PPM or
ICDs)
**CAD itself is not a risk factor
CPT code
Previous Cardiac event
ASA status
Age
Wound class
Ascites
Sepsis
Ventilator
Disseminated cancer
Steroid use
HTN
Previous MI
Sex
DOE
Smoker
COPD
Dialysis
BMI
Emergence
Step 4:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Step 5:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Step 6:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Step 7:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Low Risk
 Combined surgical and
patient characteristics
predict a risk of major
adverse cardiac event
(MACE) < 1%
 Ex: Cataracts, plastics
High Risk
 Any procedure with MACE
risk > 1%
 No longer distinguishes
between intermediate and
high risk because
recommendations the
same
 Risk can be lowered by less
invasive approach
(endovascular AAA)
 Emergency procedures
increase risk
 Includes
 ECG: known CAD, significant arrhythmia, PVD, CVD, or other




significant structural heart disease,
Echo: Assessment of LV function for dyspnea of unknown
origin, known CHF with change in clinical status, stable
patients with prior LV dysfunction if >1 yr since last EF
assessment
Exercise Stress Testing for Myocardial Ischemia and
Functional Capacity: for patients with elevated risk and
unknown or poor (<4 METS) functional capacity if it will
change management
Pharmacological Stress Testing (MPS/DSE): for patients with
elevated risk and poor functional capacity
Special Situations
 If your patient has a resting ECG that impairs
diagnostic interpretation during exercise
 LBBB
 LV hypertrophy with “strain pattern”
 Digitalis effect
 Exercise stress echo or exercise MPI may be
appropriate – prefer pharmacologic stress, DSE or
pharmacologic stress MPI
 Pharm stress MPI is suggested for LBBB
 Borderline or mild
reversible perfusion
defect?
 Class I:
Revascularization before noncardiac surgery
is recommended in circumstances in which
revascularization is indicated according to
existing CPGs. (Appendix 3)
1.




Unprotected Left Main Disease
3 Vessel CAD with or without proximal LAD
Disease
2 Vessel Disease with Proximal LAD Disease
1 Vessel Disease with Proximal LAD disease
 Class III: No Benefit/Harm
1.
It is not recommended that routine
coronary revascularization be performed
before noncardiac surgery to reduce
perioperative cardiac events
 Performing PCI before noncardiac surgery should be
limited to:
 Patients with Left Main disease who can’t get bypass surgery
without undue risk
 Patients with unstable CAD who are candidates for emergent
or urgent revascularizations (NSTEMI, STEMI)
 CARP Trial (Coronary Artery Revascularization
Prophylaxis)
 Showed no difference in perioperative and long term cardiac
outcomes with or without preoperative CABG or PCI in
patients with CAD
 Exception: Left Main Disease, LVEF < 20%, Severe AS
McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in
patients with documented coronary artery disease: results of the CARP trial. Eur Heart J. 2008;29:394-401.
 Class I:
1. Elective noncardiac surgery should be delayed:

14 days after balloon angioplasty

30 days after BMS implantation
2.
Elective noncardiac surgery should optimally be
delayed:

365 days after drug-eluting stent (DES)implantation
 Class IIa
1. When noncardiac surgery is required:

A consensus decision among treating clinicians as to the
relative risks of surgery and discontinuation or continuation
of antiplatelet therapy can be useful.
 Bare Metal Stents
 Drug eluting stents
 Delay elective
 Delay elective
procedures for at least 1
month and preferably 6
months
 Restart clopidogrel as
soon as possible
 Consider re-loading
dose
procedures for 1 year
 Continue aspirin
 Restart clopidogrel as
soon possible
J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944
Figure Legend:
Algorithm for Antiplatelet Management in Patients With PCI and Noncardiac Surgery
Colors correspond to the Classes of Recommendations in Table 1. *Assuming patient is currently on DAPT. ASA indicates aspirin;
ASAP, as soon as possible; BMS, bare-metal stent; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; and PCI, percutaneous
coronary intervention.
From: 2014 ACC/AHA Guideline on
Perioperative
Cardiovascular
Evaluation and Management of
Copyright
© The American
College of Cardiology.
Patients Undergoing Noncardiac Surgery:
Report
of the American College of Cardiology/American Heart
AllArights
reserved.
Association Task Force on Practice Guidelines
 Antithrombotic agents – clopidogrel
 Bare metal stents vs. drug eluting stents
 Anticoagulants – warfarin
 Atrial fibrillation
 Venous thrombosis
 Prosthetic heart valves
 Procedural risk for bleeding
 Low risk for bleeding
 Athrocentesis
 Cataract surgery
 Dental cleaning / extraction
 Cutaneous surgery
 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
 Deep venous thrombosis
 Pulmonary emboli
 Hypercoagulable states
 Factor V Leiden
 Protein C / S deficiencies
 Lupus anticoagulant
 Stop warfarin for 48 hours
 Start lovenox at 1mg/kg SQ BID for 6 doses
 Stop lovenox the morning before surgery
 OR IV heparin until 4 hours prior to surgery
 Maximize adjuvant medical therapy
 Aspirin
 Statin
 Beta blocker
 Close perioperative follow-up
 Prolonged telemetry monitoring, consider ICU
monitoring
 Antibiotics
All Prosthetic valves
2. Prior bacterial
endocarditis
3. Cyanotic congenital
heart disease (CHD)
4. Any repair CHD with
prosthetic material *
1.
 No Antibiotics
 Uncomplicated valvular
heart disease
 Pacemakers or
defibrillators
 Hypertrophic
cardiomyopathy
Circulation 2007; 115.
Fliesher et al. “2014 ACC/AHA
Guideline on Perioperative
Cardiovascular Evaluation and
Management of Patients Undergoing
Noncardiac Surgery.”
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Figure 1. Stepwise Approach to Perioperative Cardiac Assessment for CAD
Colors correspond to the Classes of Recommendations in Table 1.