Evaluation of the Cardiac Patient Before NonCardiac Surgery
Evaluation of the Cardiac Patient Before Non-Cardiac Surgery Saturday, April 10, 2016 Department of Anesthesiology u. Ottawa. ca Département d’anésthesiologie
Disclosure of competing interests • No financial CI • No professional CI • Member CCS Guidelines Panel u. Ottawa. ca
Objectives Using the 2014 ACC/AHA Guidelines as a framework, the learner will: • Identify patients at risk for major adverse cardiac events following surgery • Propose a rational approach to preoperative investigation • Select therapies proven to reduce risk of major adverse cardiac events • Contrast ACC/AHA and ESC/ESA guidance u. Ottawa. ca
Where to find this stuff • 2014 ACC/AHA Guideline on perioperative … – J Am Coll Cardiol 2014; 64(22): e 77– 137 – Circulation 2014; 30(24): e 278 -333 • 2014 ESC/ESA Guidelines on non-cardiac surgery … – Eur Heart J 2014; 35(35): 2383 -431 – Eur J Anaesthesiol 2014; 31(10): 517 -73 ($) • Twitter @glbryson u. Ottawa. ca
T 1. Class and Level Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
2014 ACC/AHA New Sections • Valvular Heart Disease – ECHO within a year for mod-severe disease or change (IC) – Consider valve repair/replacement (IC) • Implantable Electric Devices – Have an individualized plan! (IC) • Pulmonary vascular disease – Continue meds (IC) • Use a validated risk tool (IIa. B) u. Ottawa. ca
2007/2009 ACC/AHA Guidelines Lee A. Fleisher et al. Circulation. 2007; 116: e 418 -e 500 Copyright © American Heart Association, Inc. All rights reserved. u. Ottawa. ca
2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
When I say risk, you say. . ? • 2007 ACC/AHA two-step risk evaluation – Surgical risk (low, intermed, vasc) – “Clinical risk factors” • 2014 ESC/ESA two-step method • 2014 ACC/AHA indicates “combined clinical surgical risk” – Low risk <1% MACE – Elevated risk >1% MACE u. Ottawa. ca
Are risk models the same? Characteristic Derived Validated Data collected RCRI N = 2, 900 N = 1, 400 Prospective ASC-NSQIP N = 1, 414, 000 Unclear Retrospective Variables MACE outcomes Biomarkers Procedures 6 Five Routine Mixed, 48 h stay 22 Two Clinical indication All NSQIP Lee TH. Circulation 1999; 100: 1043 -49 Bilimoria KY. J Am Coll Surg 2013; 217: 833 e 842. u. Ottawa. ca
An example • 70 male • Colectomy for CA colon • STEMI 5 years ago, – RCA BMS placed – Angina-free, active (8 METS) • DM 2, oral meds • Otherwise well u. Ottawa. ca
Revised Cardiac Risk Index Risk Factor High risk surgery Events Risk Factors (%) 95% CI 0 0. 4 0. 05 – 1. 5 History of CAD 1 0. 9 0. 3 – 2. 1 History of CHF 2 6. 6 3. 9 – 10. 3 History of stroke 3 11. 0 5. 8 – 18. 4 Diabetes mellitus Cr > 177 u. Ottawa. ca Lee TH. Circulation 1999; 100: 1043 -49
ACS-NSQIP Risk Predictor u. Ottawa. ca http: //riskcalculator. facs. org/Patient. Info
ACS Surgical Risk Calculator u. Ottawa. ca http: //riskcalculator. facs. org/Outcome
ACS Surgical Risk Calculator u. Ottawa. ca http: //riskcalculator. facs. org/Outcome
2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
2014 ACC-AHA Guidelines Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
T 5. Supplemental Investigations 12 Lead LVEF Fancy Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
CPG - Revascularization Left main 3 Vessel 2 Vessel + badness Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
T 6. Perioperative Therapy Revascularization B-blockers Other Stuff Antiplatelet CIED Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
Beta-blockers are a mess Continue Intermediate-high risk tests Known IHD ischemia ≥ 3 Risk Factors ≥ 2 Risk Factors or ASA ≥ 3 Don’t start without titrating Atenolol or bisoprolol u. Ottawa. ca ACC/AHA ESC/ESA IB IB IIb. C IIb. B IIIB IIb. B
DECREASEing the effect Outcome All Trials RR (95%CI) DECREASE RR (95%CI) OTHERS RR (95%CI) Non-fatal MI 484/11, 963 (4. 0%) 0. 66 (0. 57 to 0. 85) 0. 22 (0. 03 to 1. 45) 0. 72 (0. 59 to 0. 86) Stroke 68/11, 611 (0. 6%) 1. 79 (1. 09 to 2. 95) 1. 86 (1. 09 to 3. 16) 1. 33 (0. 30 to 5. 93) Mortality 324/11, 963 (2. 7%) 0. 96 (0. 62 to 1. 47) 0. 42 (0. 15 to 1. 22) 1. 30 (1. 03 to 1. 63) Wijeysundera DN. Circulation. 2014; 130: 2246 -2264 u. Ottawa. ca
T 7. Anesthetic management RA v GA NTG TEE PAC Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
Antiplatelet Rx and PCI Lee A. Fleisher et al. Circulation. 2014; 130: e 278 -e 333 u. Ottawa. ca Copyright © American Heart Association, Inc. All rights reserved.
New DAPT recommendations u. Ottawa. ca Levine GN. Circulation 2016: doi 10. 1161/CIR. 0000000404
Summary • • • Combined medical-surgical risk Surgery w MACE < 1% needs NOTHING Functional capacity remains key assessment Beta-blockers in evolution Anti-platelet agents in evolution – ASA reconsidered after POISE 2 – Wait following newer stents down to 6 mo. • No longer just about CAD u. Ottawa. ca
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