Preoperative Risk Assessment - Tallahassee, FL
Preoperative Risk AssessmentJoshua D. Lenchus, DO, RPh, FACP, SFHMAssociate Professor of Clinical Medicine and AnesthesiologyUniversity of Miami Miller School of MedicineMiami, FL, USA
Disclosures No financial or other material conflicts of interest
The 2014 ACC-AHA Guidelines for PerioperativeCardiovascular Evaluation (Noncardiac Surgery)
Case57 year old woman is scheduled to undergo alaparoscopic cholecystectomy tomorrow. She has ah/o IDDM-2, also taking metformin, with goodglucose control, and a resting heart rate of 60bpm.She walks 1 mile daily without any problem. Whichof the following is the best recommendation for herpre-operatively?a)b)c)d)Proceed to surgeryBegin beta-blockade, titrating to effectOrder a cardiac stress testConsult cardiology for angiography
Why preoperative evaluation? NOT CLEARANCE Assessment of perioperative risk Used to inform the decision to proceed or the choice of surgery Includes the patient’s perspective Determination of the need for management changes Change medical therapies Perform further cardiovascular interventions Recommendations about postoperative monitoring Identification of cardiovascular conditions or riskfactors requiring longer-term management
Role of the Consultant Review available patient data, history and physicalexamination Determine if further testing is needed to definecardiovascular status Recommend treatment to improve medical condition PREOPERATIVE TESTING RECOMMENDED ONLY IF ITWILL CHANGE SURGICAL CARE OR PERIOPERATIVEMEDICAL THERAPY
General Approach to the Patient-1 History – unstable or severe angina, recent or past MI,decompensated HF, significant arrhythmias, severe vascular dz Comorbid Diseases – pulmonary, diabetes mellitus, renalimpairment, hematologic disorders Medications – Rx, OTC, herbal, nutritional Social history – alcohol, tobacco, illicit drugs
General Approach to the Patient-2 Functional capacity – measured in METs Physical Examination – general appearance, VS, lung andcardiac auscultation Ancillary Studies - ECG may be indicated, bloodchemistries and chest X-ray based on history and physicalfindings
(Un)necessary ancillary testing 9/10 patients undergo at least 1 unnecessary test Why do it? Urban mythMedical liabilityGuideline distrustIgnorance
Coagulation studies Mostly lab error; rarely predict bleeding risk Check thorough history Pregnancy testing Affects management in the proper population Also obtain menstrual bleeding history ECG History is better Stratify risk; establish baseline Not for asymptomatic patients and low-risk procedure CXR History is better Predictor, but doesn’t change management
Step 1: How urgent is the surgical procedure?Steps 1 - 3:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
EMERGENCY Extremely limited time for clinical evaluation Life or limb is threatened if not in the OR within 6hrs URGENT Time for limited evaluation Life or limb is threatened if not in the OR 6-24hrs TIME-SENSITIVE Delay of 1-6wks to allow for E&M will negatively affect outcome Most oncologic procedures ELECTIVE Procedure can be delayed up to 1yr
Disease Specific Approaches1.2.3.4.5.6.7.8.Coronary artery disease (CAD)Decompensated heart failureCardiomyopathyValvular heart diseaseArrhythmias and conduction disordersCardiovascular implantable electronic devicesPulmonary vascular diseaseAdult congenital heart disease
Step 2: Does the patient have ACS?Steps 1 - 3:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Step 3: Perioperative risk assessmentSteps 1 - 3:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Type of Surgery MACE: major adverse cardiac event of death or MI Low surgical risk ( 1%) Cataract surgery Plastic surgery Elevated surgical risk ( 1%) Peripheral vascular diseaseNOTE: prior risk classifications included intermediate.Since recommendations are similar, intermediate andelevated are grouped together.
Revised Cardiac Risk Index (RCRI) Criteria1.2.3.4.5.6.H/o ischemic heart disease angina or CP relieved with NTG remote MI ( 3 -6mos) EKG: pathological Q waves abnormal CST abnormal cardiac cath prior CABG or PCIH/o compensated or prior HFH/o cerebrovascular diseaseDiabetes mellitus (insulin-dependent)Renal insufficiency (SCr 2mg/dL)High-risk surgical procedure0-1 RCRI 1% mortality2 RCRI 2-7% mortality3-4 RCRI 9-18% mortality 5 RCRI 32% mortalityLee, TH. et al. “Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery,” Circulation, 1999; 100: 1043.
or-pre-operative-risk/
ACS NSQIP MICA Includes adjusted odds ratios for different surgical sites Target complications:Cardiac arrest1. “chaotic cardiac rhythm requiring initiation of basic or advanced lifesupport”Myocardial infarction ( 1 of the following:)2. Documented EKG findings of MIST elevation of 1mm in 1 contiguous leadsNew LBBBNew Q-wave in 2 contiguous leadsTroponin 3xnml in setting of suspected cardiacarrest
ACS NSQIP Surgical Risk Calculator Calculates risk of:1.2.3.4.5.6.7.8.9.10.MACEDeathPNA,VTEARFReturn to ORUnplanned intubationDischarge to rehab/nursing home,Surgical infectionUTI
Cardiac Risk Stratification: ACS .surgicalriskcalculator.com
RCRIACS NSQIP CalculatorCreatinine 2H/o heart failureIDDMThoracic, Intra-abdominal, or vascularH/o ischemic heart diseaseH/o CVA or TIAARFH/o heart failure within 30 daysDMCPT codePrevious Cardiac eventASA statusAgeWound classAscitesSepsisVentilatorDisseminated cancerSteroid useHTNPrevious MISexDOESmokerCOPDDialysisBMIEmergence
The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) LOE and COR Table & Nomenclature
Steps 4 and 5: Procedure-specific risk assessmentSteps 4 - 7:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Step “5a”: Functional capacity determinationSteps 4 - 7:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Estimated Energy Requirements for VariousActivities2007 WRITING COMMITTEE MEMBERS, et al. Circulation 2009;120:e169-e276
Step 6: Poor/unknown functional capacitySteps 4 - 7:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Stress Testing for Ischemia and Functional Status Recommendations: Test of choice is exercise ECG testingoProvides estimate of functional capacityoDetects myocardial ischemia through ECG changes andhemodynamic response
Step 7: Surgery or alternative strategiesSteps 4 - 7:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Back to the case57 year old woman is scheduled to undergo a laparoscopiccholecystectomy tomorrow. She has a h/o IDDM-2, alsotaking metformin, with good glucose control, and a restingheart rate of 60bpm. She walks 1 mile daily without anyproblem. Which of the following tests would beappropriate?a) Resting ECGb) 2D transthoracic echocardiogramc) Cardiac stress testd) Coronary angiographye) None of the above
Supplemental Preoperative Evaluation Includes ECG Assessment of LV function Exercise Stress Testing for Myocardial Ischemia and FunctionalCapacity Pharmacological Stress TestingNoninvasive Radionuclide DSE Special Situations
Supplemental Preoperative Evaluation Preop resting 12-lead EKG Known CHD, significant arrhythmia, PAD, cerebrovascular dz, structural HD,but not those undergoing low-risk surgery (IIa-B)Considered for asymptomatic patients without CHD, but not low-risk (IIb-B)Routine use in asymptomatic patients undergoing low-risk procedures (III-B) Preop LV function assessment Dyspnea of unknown origin (IIa-C)CHF with worsening dyspnea or other change in clinical status (IIa-C)Clinically stable, previously noted LV dysfunction, 1yr since last echo (IIb-C)Routine evaluation (III-B)
Preoperative stress testing recommendations
Exercise or Pharmacological Stress Test?Choice of stress: Patient’s ability to exercise Baseline EKG (i.e. BBB or paced)Choice of drug: Adenosine and Dipyridamole causebronchospasm, transient AV block,hypotension, and are inhibited byxanthine use Dobutamine causes elevated BPand/or HR, increasing ischemia,and is inhibited by beta-blocker Regadenoson is contraindicated inhigh grade AV block or sinus nodedysfunction
Pharmacological Stress Testing Noninvasive Reasonable (Class IIa) for patients at elevated risk and have poorFC (either DSE or pharm stress MPI) (LOE B)No Benefit (Class III) for routine screening for patients undergoinglow-risk noncardiac surgery (LOE B)
Special SituationsIf patient has a resting ECG that impairs diagnosticinterpretation1. LBBBLV hypertrophy with “strain pattern”Digitalis effect2. Concomitant stress imaging with TTE or MPI may beappropriate3. Pharm stress MPI is suggested for LBBB
Coronary Revascularization Management Class I:1.Revascularization before noncardiac surgery is recommended incircumstances in which revascularization is indicated according toexisting CPGs. (Appendix 3) Unprotected Left Main Disease3 Vessel CAD with or without proximal LAD Disease2 Vessel Disease with Proximal LAD Disease1 Vessel Disease with Proximal LAD disease Class III: No Benefit/Harm1.It is not recommended that routine coronary revascularization beperformed before noncardiac surgery to reduce perioperative cardiacevents
Perioperative Percutaneous Coronary Intervention Performing PCI before noncardiac surgery should be limitedto:1.2.Patients with Left Main disease who can’t get bypass surgery withoutundue riskPatients with unstable CAD who are candidates for emergent orurgent revascularizations (NSTEMI, STEMI) CARP Trial (Coronary Artery RevascularizationProphylaxis) Showed no difference in perioperative and long term cardiac outcomeswith or without preoperative CABG or PCI in patients with CADException: Left Main Disease, LVEF 20%, Severe ASMcFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with documented coronary arterydisease: results of the CARP trial. Eur Heart J. 2008;29:394-401.
Timing of Elective Non Cardiac Surgery after PCI Class I:1.Elective noncardiac surgery should be delayed: 2.14 days after balloon angioplasty30 days after BMS implantationElective noncardiac surgery should optimally be delayed: 365 days after drug-eluting stent (DES)implantation Class IIa1.When noncardiac surgery is required: A consensus decision among treating clinicians as to the relative risksof surgery and discontinuation or continuation of antiplatelet therapycan be useful.
Timing of Elective Non Cardiac Surgery after PCI Class IIb*1.Elective noncardiac surgery after drug eluting stent implantation may beconsidered: After 180 days if the risk of further delay is greater than risks of ischemiaand stent thrombosis Class III: No Benefit/Harm1.Elective noncardiac surgery should not be performed: Within 30 days after BMS implantation if dual antiplatelet therapy needsto be discontinued Within 12 months after DES implantation if dual antiplatelet therapy needsto be discontinued Within 14 days of balloon angioplasty if aspirin needs to be discontinued
Choosing Appropriate PCI Intervention Urgent Surgery Consider CABG combined with noncardiac surgery Surgery 2-6 weeks with high bleeding risk Consider balloon angioplasty with provisional BMS Surgery in 1-12 months Consider BMS and 4-6 weeks of ASA and P2Y12 inhibitor with continuation ofASA perioperatively Surgery 12 Months or low bleeding risk PCI and DES with prolonged aspirin and P2Y12 platelet receptor-inhibitor
Indications for Preoperative CABGClass III-C (No Benefit, Not Indicated): Routine preoperative revascularizationIf it will change management & elevated risksurgery, then:Class I-B Indication: Significant LM disease Complex CAD 3-vessel disease 2-vessel disease with proximal LAD Survivor of sudden deathClass IIa-B Indication: 2-vessel disease without proximal LAD andextensive ischemia 1-vessel disease with proximal LAD 1-vessel disease with EF 35 - 50%Class IIb-B Indication: 2-vessel disease without extensive ischemia 1-vessel disease without proximal LAD andEF 35%
Antiplatelet Agent Recommendations Class I1.Urgent Non Cardiac Surgery 4-6 weeks after BMS or DES 2.Patient with coronary stent & surgical procedure mandatesdiscontinuation of P2Y12 platelet receptor inhibitor 3.Continue DAPT unless RR of bleeding outweighs benefit ofpreventing stent thrombosisContinue aspirin perioperatively, re-start P2Y12 platelet receptorinhibitor ASAP after surgeryObtain a consensus between surgeon, anesthesiologist,cardiologist & patient to weigh RR of bleeding versuspreventing stent thrombosis when deciding perioperativeantiplatelet management
Antiplatelet Agent Recommendations Class IIbNon-emergent/Non-urgent, Non Cardiac surgery: If patients have not had previous stenting, you may continue aspirinperioperatively when the risk of potential increased cardiac eventsoutweighs the risk of bleeding
Antiplatelet Management Perioperatively
Indications for Beta-Blocker to Reduce MACEClass III-B (Harm, Not Indicated): Do not initiate on day of surgeryIf elevated risk surgery:Class IIb-C Indication: Intermediate-high risk ischemia seenon preoperative testingClass IIb-B Indication: 3 RCRI Criteria 3 RCRI with primary long-termindication (CAD, HF, HTN) Start 1 day preoperativelyClass IIa-B Recommendation: May be continued postoperatively ifclinically safe (SBP 100, HR 55, noacute anemia or Hgb 10)Class I-B Recommendation: May be safely continued if toleratedas chronic therapy
Perioperative Beta-Blocker & MortalityLindenauer, PK et. al. “Perioperative Beta-Blocker Therapy and Mortality After Noncardiac Surgery,” NEJM, 2005; 353: 349.
Perioperative Beta-Blockers & Statins
Indications for Perioperative StatinIf elevated risk surgery:Class IIb-C Indication: Consider initiating if undergoing high risk procedureClass IIa-B Indication: Initiate for vascular surgeryClass I-B Indication: Continue if chronically usingRCRI-based indication was discarded with DECREASE data
Indications for Perioperative Alpha-2 AgonistClass III-B (No Benefit, Not Indicated) Insufficient data to recommend Benefit seen in those also taking beta-blockerWallace, AW, et al. Anesthesiology, 2004; 101(2): 284.Wijeysundera, DN, et al. Cochrane Database Syst Rev, 2009 Oct 7; (4): CD004126
Cardiac Risk Assessment AlgorithmSteps 1 - 3:Steps 4 - 7:MACE major adverse cardiac eventMET metabolic equivalent timeGDMT guideline directed medical therapyCPG clinical practice guideline
Thank youJoshua D. Lenchus, DO, RPh, FACP, SFHMjlenchus@med.miami.eduOffice: 305-585-5215Cell: 954-817-5684
High-risk surgical procedure 0-1 RCRI 1% mortality 2 RCRI 2-7% mortality 3-4 RCRI 9-18% mortality 5 RCRI 32% mortality Lee, TH. et al. “Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery,” Circulation, 1999; 100: 1043.
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