Preoperative Cardiac Evaluation: Risk Stratification & Prevention of Cardiovascular Complications Cardiology Management Challenges in daily Clinical Practice
SHA 24 & GHA 10 Riyadh Feb. 13, 2013 Hasan El-Sayed, MD PhD King Faisal Hospital King Abdul-Aziz Specialist Hospital Taif
Purpose of the preoperative medical evaluation “The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. No test should be performed unless it is likely to influence patient treatment.� Fleisher, L. A. et al. Circulation 2007;116:e418-e499
Purpose of the preoperative medical evaluation “A critical role of the consultant is to determine the stability of the patient’s cardiovascular status and whether the patient is in optimal medical condition, within the context of the surgical illness.” “The consultant must also bear in mind that the perioperative evaluation may be the ideal opportunity to affect the long-term treatment of a patient with significant cardiac disease or risk of such disease.” Fleisher, L. A. et al. Circulation 2007;116:e418-e499
Goals of the preoperative medical evaluation Identify medical conditions that may increase the risk of perioperative complications Optimize these conditions, as possible Recommend preoperative testing only if it aids in risk stratification of patients or influences management Recommend postoperative measures that may reduce the risk of complications
Perioperative Cardiac Care Preoperative cardiac evaluation – Revised cardiac risk index (RCRI) – Preoperative cardiac testing
Strategies to reduce postoperative cardiac complications – – – –
Beta blockers Statins Revascularization (CARP trial) Anti-platelet agents (especially in patients with drugeluting coronary stents) – Other
Perioperative Cardiac Care: Background Worldwide, ~100 million adults undergo noncardiac surgery annually Up to 1/2 have coronary artery disease (CAD) or risk factors for it. Therapies for CAD allow persons to live longer…and develop conditions for which surgery may be considered to treat/cure diseases (e.g., cancer) or improve quality of life (e.g., joint replacement)
Perioperative Cardiac Care: Background >50,000 perioperative myocardial infarctions and >1 million cardiac complications occur annually in the USA. More than half of postoperative deaths are caused by cardiac events. Perioperative cardiac complications prolong hospital course of stay by a mean of 11 days. – Fleischmann KE. Am J Med. 2003;115:515-20.
Estimated cost perioperative cardiac complications (USA) = $20 billion/year – Mangano DT. Anesthesiology. 1990;72:153-84.
Case A 70 year old male is admitted to the hospital for left knee surgery. A preoperative medical evaluation is requested by the orthopedic surgeon. He is fairly active and walks approximately one mile daily with rare angina and can climb 2 flights of stairs in his home without difficulty. His past medical history is notable for CAD with prior MI and subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus. Current medications: aspirin 325 mg qd, simvastatin 20 mg qd, glyburide 5 mg bid, atenolol 25 mg qd, and lisinopril 10 mg qd. Vital signs on admission are pulse 84 and blood pressure 162/90. Cardiopulmonary examination is unremarkable. ECG is notable for pathologic q waves in leads 1 and AVL.
Preoperative Cardiovascular Questions for the medical consultant 1)
Does the patient require additional cardiac testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to surgery?
2)
What is the estimated cardiac risk?
3)
What can be done to decrease cardiac risk for those at high or intermediate risk?
Preoperative Medical Evaluation When should I consider cancelling or delaying surgery? – Decompensated or uncontrolled disease status (e.g., decompensated heart failure, symptomatic severe valvular stenosis, uncontrolled arrhythmia) – Uninvestigated symptoms or signs that may increase the risk of perioperative complications (e.g., uninvestigated angina)
Cardiac Risk* Stratification for Noncardiac Surgical Procedures Risk Stratification
Procedure Examples
High Risk (Vascular Surgery)
Aortic and other major vascular surgery Peripheral vascular surgery
(reported cardiac risk more than 5%)
Intermediate Risk (reported cardiac risk 1% to 5%)
Low Risk (reported cardiac risk less than 1%)
Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery
*Combined incidence of cardiac death and nonfatal myocardial infarction.
Eagle, K. A. et al. Circulation 2002;105:1257-1267
Stepwise Approach to Preoperative Cardiac Assessment Need for emergency noncardiac surgery
Yes
Operating room
Vigilant perioperative and postoperative management
No Active cardiac conditions
Yes
Evaluate and treat as per Guidelines
Consider Operating Room
No
Low Risk Surgery
Yes
Proceed with planned surgery
Yes
Proceed with planned surgery
No
Asymptomatic and good functional capacity No
Manage based on clinical risk factors
Clinical Risk Factors
•History of heart disease •Compensated or prior CHF •Cerebrovascular disease •Diabetes Mellitus •Renal Insufficiency
Proceed Cautiously
Asymptomatic but poor/unknown functional capacity
3 or more clinical risk factors*
Vascular Surgery
Consider Testing
Intermediate risk surgery
Manage based on clinical risk factors
1 or 2 clinical risk factors*
Vascular Surgery
No clinical risk factors*
Intermediate risk surgery
Proceed with planned surgery with HR control or consider non-invasive testing
Proceed with planned surgery
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal insufficiency, cerebrovascular disease
1) Does the patient require additional cardiac
testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to surgery? No – proceed to surgery without additional cardiac testing. When to consider: – Angina that has not been investigated – High risk patients undergoing moderate or high risk surgery with poor functional status, if it will alter management
Revised Cardiac Risk Index 1) 2) 3) 4) 5) 6)
High risk surgery (major vascular, intraabdominal, or intrathoracic) Ischemic heart disease (h/o MI, Q waves, angina, use of nitrates, or positive stress test) Congestive heart failure Cerebrovascular disease (prior stroke or TIA) Insulin-treated diabetes mellitus Renal insufficiency (serum creatinine >2.0 mg/dL)
Lee TH et al. Circulation. 1999; 100: 1043-1049.
Preoperative Cardiac Risk Stratification: Revised Cardiac Risk Index Class
Number of predictors
Major cardiac events, % *
All cardiac events, % **
I
0
0.4 (0.1-0.8)
0.5 (0.05-1.5)
II
1
1.0 (0.5-1.4)
0.9 (0.3-2.1)
III
2
2.4 (1.3-3.5)
6.6 (3.9-10.3)
IV
≥3
5.4 (2.8-7.9)
11.0 (5.8-18.4)
•*Major cardiac events = cardiac arrest, MI (fatal or non-fatal) •**All cardiac events = cardiac arrest, MI (fatal or non-fatal), pulmonary edema, or complete heart block. Lee TH. Circulation. 1999;100:1043-9.
1)
What is ‟estimated cardiac risk” of our patient? ‟His past medical history is notable for CAD with prior MI and subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus.”
– RCRI score = 2 – ~5-10% risk of perioperative cardiac complications
Perioperative Cardiac Events: Pathophysiology Cardiac death – Myocardial infarction (MI), fatal arrhythmia, or heart failure
MI – Majority of MIs are due to atherosclerotic plaque rupture thrombosis – Perioperative MI Limited available data is conflicting – Datwood MM. Int J Cardiol. 1996;57-37-44. – Cohen MC. Cardiovasc Pathol. 1999;8:133-9. – Landesberg G. J Cardiothorac Vasc Anesth. 2003;17:90-100.
Plaque rupture or prolonged myocardial oxygen supply-demand mismatch (in setting of CAD)
Perioperative Cardiac Care: Pathophysiology Postoperative period is a hyperadrenergic state i.e., an extreme stress. Also, it is a state of inflammation and hypercoagulability Several studies have linked postoperative myocardial ischemia (assessed by continuous ECG monitoring) to postoperative cardiac events, as well as long-term cardiovascular morbidity and mortality. Hypothesis: – (Relative) tachycardia myocardial O2 supply/demand mismatch shear stress across atherosclerotic plaque plaque rupture thrombus MI Postoperative myocardial ischemia is: – common – almost always clinically silent – associated with relative tachycardia
Devereaux, P.J. et al. CMAJ 2005;173:779-788
Copyright Š2005 Canadian Medical Association or its licensors
For our patient, strong evidence exists to support the use of a prophylactic perioperative beta-blocker to reduce the risk of cardiac complications (i.e., class I recommendation, level A evidence). 1. True 2. False
Perioperative cardiac care: Beta-blockade – landmark trials 200 patients scheduled for noncardiac surgery who had or were at risk for CAD were randomized to receive either perioperative atenolol or placebo. Atenolol was started on the day of surgery and continued for the length of the hospitalization to a maximum of 7 days. No difference in in-hospital cardiac morbidity/mortality (as expected). Prospective follow-up (for 2 years) showed a decrease in both overall mortality and event free survival with perioperative beta-blockade.
Mangano DT et al. N Engl J Med 1996; 335: 1713-20.
Perioperative cardiac care: Beta-blockade – landmark trials 2- year survival = 90%
2- year survival = 79%
Mangano DT et al. N Engl J Med 1996; 335: 1713-20.
Perioperative cardiac care: Beta-blockade – landmark trials 2- year event free survival = 83%
2- year event free survival = 68%
Mangano DT et al. N Engl J Med 1996; 335: 1713-20.
Perioperative cardiac care: Beta-blockade – landmark trials 112 patients scheduled for elective major vascular surgery (AAA repair or lower extremity revascularization) with a positive dobutamine echocardiogram randomized to bisoprolol or placebo. Bisoprolol was started at least 1 week preoperatively, uptitrated if heart rate >60 bpm, and continued for 30 days postoperatively. Dramatic reduction in 30-day postoperative cardiac death and non-fatal MI. Poldermans D et al. N Engl J Med 1999; 341: 1789-94.
Perioperative cardiac care: Beta-blockade – landmark trials Cardiac death or non-fatal MI
Poldermans D et al. N Engl J Med 1999; 341: 1789-94.
Perioperative Beta-blockade… what other studies show! Other trials showing no benefit – POBBLE trial (J Vasc Surg 2005; 41: 602-9.) 103 patients without known CAD undergoing elective vascular surgery. Randomized to metoprolol (fixed dose) or placebo (started on admission, continued for up to 7 days).
– MaVS study (Am Heart J. 2006;152:983-90.) 496 patients undergoing elective vascular surgery. Randomized to metoprolol (fixed dose) or placebo (started on admission, continued for up to 5 days).
– DIPOM trial (BMJ. 2006;332:1482-8.) 921 patients with diabetes undergoing major, non-cardiac surgery. Randomized to metoprolol (fixed dose) or placebo (started 1 day before surgery, continued for up to 8 days).
– Large (>300 hospitals, >7000 patients), retrospective database study confirmed reduced mortality in high and (probably) intermediate risk, but trend towards harm in low risk. (Lindenauer PK et al. N Engl J Med 2005; 353: 348-61.)
Perioperative Beta-Blockade: PeriOperative ISchemic Evaluation (POISE) trial 190 hospitals, 23 countries, 8351 patients enrolled Inclusion: – >45 yrs old, expected hospitalization >24 hours, and: CAD; PVD; prior stroke; hospitalization for CHF within 3 years; major vascular surgery; or any 3 of the following: intrathoracic or intraperitoneal surgery, h/o CHF, h/o TIA, DM, Cr >2.0, >70 yrs old, or emergent/urgent surgery)
Exclusion: â&#x20AC;&#x201C; HR <50 bpm, 2nd or 3rd degree AVB, asthma, on beta-blocker or planned periop beta-blockade, prior ADR with beta-blocker, CABG within 5 yrs and no recurrent angina; low risk surgery; on verapamil.
Primary outcome = cardiac death, non-fatal cardiac arrest or non-fatal MI POISE study group. Lancet 2008;371:1839-47.
Perioperative beta-blockade: POISE trial Randomized to metoprolol XL vs. placebo – 1st dose metoprolol XL = 100mg, given 2-4 hours preop – If HR > 80 bpm or SBP >100 mmHg at any time 1st 6 hours after surgery, another dose of metoprolol 100mg administered. – Daily dosage metoprolol 200mg thereafter x30 days – If HR < 45 bpm or SBP <100 mmHg consistently, decrease metoprolol to 100mg qd
POISE study group. Lancet 2008;371:1839-47.
Perioperative Beta-Blockade: POISE trial Metoprolol
Placebo
HR
p value
Primary outcome
244 (5.8%)
290 (6.9%)
0.84 (0.70-0.99)
0.0399
Non-fatal MI
152 (3.6%)
215 (5.1%)
0.70 (0.57-0.86)
0.0008
Stroke
41 (1.0%)
19 (0.5%)
2.17 (1.26-3.74)
0.0053
Total mortality
129 (3.1%)
97 (2.3%)
1.33 (1.03-1.74)
0.0317
POISE study group. Lancet 2008;371:1839-47.
Perioperative Cardiac Care: Beta-Blockadeâ&#x20AC;Śbottom line For patients chronically receiving betablockers ď&#x192; continue perioperatively Which patients may benefit from prophylactic beta-blockade, if any, is uncertain. â&#x20AC;&#x201C; Guidelines: High/Intermediate risk patients are likely to benefit To be started days to weeks before surgery with dose titration to achieve resting heart rate < ~70 bpm
Perioperative Cardiac Care: What about the other cardiac meds? In general: – Continue uninterrupted including the morning of surgery: Beta-blockers Calcium channel blockers Centrally acting alpha agonists (e.g., clonidine) Nitrates Digoxin
– Hold morning of surgery, resume postop: ACE-I, ARB (if using for CHF or baseline BP is low – risk of intraop hypotension) Diuretics
Perioperative Cardiac Care: Statins Pathophysiology of perioperative MI is believed to be similar to non-perioperative MI (i.e., plaque rupture in many cases) Pleiotropic effects of statins are well known â&#x20AC;&#x201C; Anti-inflammatory, stabilize vulnerable atherosclerotic plaques, reduce platelet aggregation, improve endothelial vasodilation
Perioperative cardiac care: Statins Retrospective studies – Case control study of patients undergoing major vascular surgery 4 fold reduction in perioperative morality in patients who received perioperative statins. – Poldermans D et al. Circulation 2003; 107: 1848-51. – Large cohort study of patients undergoing major noncardiac surgery Reduced crude mortality rates in patients who received perioperative statins. Benefit was greatest in patients at highest risk (RCRI ≥4). – Lindenauer PK. JAMA 2004; 291: 2092-99.
Single, small, RCT comparing 45 days of perioperative atorvastatin (irrespective of serum cholesterol) to placebo. – 69% relative risk reduction in composite endpoint (death, nonfatal MI, stroke, unstable angina) with atorvastatin. Durazzo AE et al. J Vasc Surg 2004; 39: 967-75.
Perioperative Cardiac Risk Reduction: Statin Therapy Available data is encouraging and suggests benefit, risk is largely unknown Bottom line: â&#x20AC;&#x201C; Insufficient data to recommend routine perioperative statin use. â&#x20AC;&#x201C; Consider continuing statin therapy perioperatively, particularly in high-risk patients.
Perioperative Cardiac care: Prophylactic Revascularization Background Expert groups and practice guidelines recommend preoperative revascularization only if indicated for reasons independent of the non-cardiac surgery, but substantial variability in practice patterns exists. Observational studies (CASS and BARI) have suggested that recent (<5 years) coronary revascularization reduces the risk of cardiac complications for subsequent non-cardiac operations – –
Eagle KA. Circulation 1997; 96: 1882-7. Hassan SA. Am J Med 2001; 110: 260-6.
Increased rates of in-stent thrombosis perioperative MI and cardiac death when non-cardiac surgery performed in the immediate period following PCI – –
Kaluza GL. J Am Coll Cardiol 2000; 35: 1288-94. Wilson SH. J Am Coll Cardiol 2003; 42: 234-40.
Perioperative Cardiac Care: Prophylactic Revascularization CARP trial Randomized controlled trial conducted at 18 VA medical centers. 510 patients with stable CAD (â&#x2030;Ľ70% stenosis in at least one major coronary artery) scheduled for vascular surgery (AAA repair [1/3] or lower extremity bypass surgery [2/3]) randomized to prophylactic revascularization (CABG [~40%] or PCI [~60%]) or none. Medical therapy (including beta-blockade and statins) was equivalent in the 2 groups McFalls EO et al. N Engl J Med 2004; 351: 2795-804.
Perioperative cardiac care: Prophylactic revascularization CARP trial
No difference in 30-day rates of MI, stroke, limb loss, or dialysis No difference in longterm mortality
McFalls EO et al. N Engl J Med 2004; 351: 2795-804.
Regarding Perioperative Anti-Platelet management: 1. 2.
3.
4. 5. 6.
Hold aspirin and clopidogrel for 7 days preop and resume as soon as possible postop Hold clopidogrel for 7 days preop and resume as soon as possible postop; continue aspirin (uninterrupted) perioperatively Hold aspirin for 7 days preop and resume as soon as possible postop; continue clopidogrel (uninterrupted) perioperatively Do not hold aspirin/clopidogrel and perform surgery Cancel surgery, interruption of anti-platelet agents is not safe More information is needed
PCI: general PTCA alone – Relatively high rates of acute (during or immediately after procedure) and subacute (within 30 days) thrombosis or restenosis – Uncommonly used because of these limitations
PTCA vs. Coronary stents (Bare metal and drugeluting [DES]) Acute (hours) thrombosis: up to 10% <1% Subacute (days) thrombosis: 5% 0.5-1% Restenosis: 30-40% (PTCA) vs. 20-30% (bare-metal) vs. <10% (DES) Late thrombosis: DES
Drug-eluting coronary stents
Schuchman M. N Engl J Med 2007; 356: 325-8
Drug-Eluting Coronary Stents Dual anti-platelet therapy reduces the risk cardiac events following DES Premature discontinuation may lead to in-stent thrombosis ď&#x192; MI, cardiac death. Increasing reports of late (>1 month) thrombosis led to recent ACC/AHA recommendation of 12 months dual antiplatelet therapy following DES Elective procedures should be deferred at least until 12 months course of dual antiplatelet therapy complete (or procedure may performed without interruption of antiplatelet therapy).
Surgery in the elderly Persons age 65 years and older are the fastest growing segment of the western population. Advances in medicine, particularly therapies for cardiovascular disease, allow persons to live longer…and develop conditions for which surgery may be considered to treat/cure diseases (e.g., cancer) or improve quality of life (e.g., joint replacement). Surgeons and anesthesiologists rely on medical consultants to assist with perioperative care In general, perioperative data on elderly populations is limited
Age and overall perioperative complications, length of stay and nursing home placement Large, prospective cohort study of nonemergent, non-cardiac major surgery: – Increased risk of overall postop complications with increased age (RRI 2.3 for 70-79yrs and 3.1 for >80 yrs, compared to 50-59 yrs) – Mean length of stay ~2 days longer for >80 yrs compared to 50-59 yrs – >80yrs more likely to be discharged to nursing facility (39% vs. 16%) Polanczyk CA. Ann Intern Med 2001;134:637-43.
Major postoperative complications and in-hospital mortality in patients undergoing noncardiac surgery
Polanczyk, C. A. et. al. Ann Intern Med 2001;134:637-643
Surgery in the elderly â&#x20AC;&#x201C; Take home points Advanced age is associated with increased postoperative complications, longer recovery times, and some age-specific morbitidities (most notably, delirium). In general, chronic medical comorbidities, rather than chronologic age, are more important determinants of perioperative morbidity and mortality. Reported perioperative morbidity and mortality rates in elderly persons undergoing a variety of surgical procedures (eg, abdominal, cardiac, vascular, orthopedic, etc) are favorable.