perioperative cardiovascular evaluation dr gage 3-22-2004

8/14/2019 Perioperative Cardiovascular Evaluation Dr Gage 3-22-2004

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Perioperative Cardiovascular Evaluationand Management for Noncardiac Surgery

REFERENCES:

Circulation 2002;105:1257-68 OR

J Am Coll Cardiol 2002;39:542-53. http://www.acc.org/clinical/topic/topic.htm#guidelines


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Purpose of Preoperative Cardiac EvaluationPurpose of Preoperative Cardiac Evaluation

Define patients current cardiac status.

Assess and project perioperative CV risk.

Determine if preoperative testing is needed to

define cardiovascular status - recommended onlyif it will change surgical care or perioperativemedical therapy.

Initiate management to minimize cardiac riskover theentire perioperative period, andsubsequently.


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General Approach to the Patient - HistoryGeneral Approach to the Patient - History

Have you ever had any problem with your heart or arteries?

Do you exercise? Typical responses I try to. Translation: No.

Not as much as I should. Translation: No. Im active. Translation: No.

What exercise do you do? Tell me the most physically strenuous thingyou did in the last 2 weeks.

Is there real (exertional) angina, recent or past MI, HF, documented

arrhythmia, pacemaker or ICD? Any history or other indicators of atherosclerotic vascular disease?

CAD risk factors and doses of risk factors

unexplained, inordinate dyspnea


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ExerciseExercise capacity

capacity integrates theintegrates the

physiologic effects of all the patientsphysiologic effects of all the patientscombined cardiac abnormalities.combined cardiac abnormalities.

If history revealsIf history reveals

GOOD EXERCISE CAPACITY,GOOD EXERCISE CAPACITY,

then the patients operative risk is low.then the patients operative risk is low.


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General Approach to the PatientGeneral Approach to the Patient

Physical Examination general appearance,Physical Examination general appearance,

bruits, rales, elevated JVP, heart rate & rhythm,bruits, rales, elevated JVP, heart rate & rhythm,

murmurs of severe AS or MSmurmurs of severe AS or MS

Comorbidity: renal impairment, diabetes,Comorbidity: renal impairment, diabetes,

pulmonary diseasepulmonary disease

Basic Metabolic Panel, CBC, BNP, ECG, CXRBasic Metabolic Panel, CBC, BNP, ECG, CXR

BNP level (precise role in risk assessment andBNP level (precise role in risk assessment andpost-op management remains to be defined)post-op management remains to be defined)


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Q: Which cardiac conditions worry me most?Q: Which cardiac conditions worry me most?

A:A: SevereSevere stenotic (flow-limiting)stenotic (flow-limiting) lesions:lesions: coronary - diseasecoronary - disease severityseverity andand extentextent

AS > MSAS > MS severe pulmonary hypertensionsevere pulmonary hypertension

Regurgitant valvular lesions are rarely a problemperioperatively.

I am less concerned about CHF or arrhythmia in theabsence of ischemia. Both are readily treated and usuallywithout permanent sequelae, unlike MI and death.

AF is, however, a potentially costly (in money andmorbidity) nuisance. Avoid it.


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Patient-specific Clinical Predictors of IncreasedPatient-specific Clinical Predictors of Increased

Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk(ACC/AHA Guidelines)(ACC/AHA Guidelines)

Major Acute coronary

syndromes

Decompensated CHF Significant (?)

arrhythmias

Intermediate Mild (?) angina pectoris Prior MI

Minor Advanced age. Abnormal ECG. Rhythm other than

sinus. Low functional

capacity.

History of stroke. Uncontrolled HTN


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Type of Surgery and Risk - IType of Surgery and Risk - I

Urgency: emergent, urgent/soon, elective Influences not only risk, but also your pre-op testing

(if any) strategy.

HIGH SURGICAL RISK:HIGH SURGICAL RISK: emergent major operations, esp. in elderly aortic and other major vascular surgery peripheral vascular surgery

BIG SURGERY: anticipated prolonged surgicalprocedures associated with large fluid shifts and/orblood loss, and long recovery.


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Type of Surgery and Risk - IIType of Surgery and Risk - II

Intermediate risk:

carotid

head and neckintraperitoneal

intrathoracic

orthopedicprostate

Low risk:

endoscopy

superficial procedurescataract surgery

breast surgery


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poor or unknown functional capacity: cant exercise,dont exercise

known or suspected CAD:angina, prior MI based onhistory or pathological Q waves, CAD-equivalent(peripheral vascular disease), risk factor profile

known or suspected significant AS, MS, pulmonary HTN

high surgical risk procedure: aortic or peripheral

vascular, BIG SURGERY

Preoperative non-invasive testing inPreoperative non-invasive testing in

known or suspected CAD - Which patient?known or suspected CAD - Which patient?


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Preoperative non-invasive testingPreoperative non-invasive testing

in known or suspected CAD - Which test?in known or suspected CAD - Which test?

rest echocardiography: but little insight into CAD

simple treadmill: exercise capacity

stress or dobutamine echo but dobutamine in aortic aneurysm ???

myocardial perfusion imaging - exercise or

dipyridamole

EXERCISE WHENEVER POSSIBLE.


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Recommendations for Coronary Angiography inRecommendations for Coronary Angiography in

Perioperative EvaluationPerioperative Evaluation (ACC/AHA Guidelines)(ACC/AHA Guidelines)

Class I: Patients with suspected or known CAD Evidence for high risk of adverse outcome based on

noninvasive test results

Angina unresponsive to adequate medical therapy

Unstable angina, particularly when facing intermediate-risk or high-risk noncardiac surgery

Equivocal noninvasive test results in patients at high-clinical risk undergoing high-risk surgery


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Q. When is revascularization (PCI, CABG)Q. When is revascularization (PCI, CABG)

recommended ?recommended ? (ACC/AHA Guidelines)(ACC/AHA Guidelines)

A. Generally only when justified by the usual clinicalA. Generally only when justified by the usual clinical

factors, apart from planned non-cardiac surgery.factors, apart from planned non-cardiac surgery.

No randomized trials document decreased perioperativecardiac events.

No prospective studies have determined optimal period of

delay after PCI before noncardiac surgery. Delay of 2-4 weeks after PCI with stent placement is

supported by observational study.


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Preoperative Therapy with B-BlockersPreoperative Therapy with B-Blockers(ACC/AHA Guidelines)(ACC/AHA Guidelines)

Class I indications

When B-blockers have been required in recent past forangina, symptomatic arrhythmia or hypertension.

Do not withdraw beta-blockade preoperatively. Patients undergoing vascular surgery with ischemia on

preoperative testing

Class IIa

When preoperative assessment identifies untreatedhypertension, known CAD, or major CAD risk factors.

Class III: contraindication to B-blockade


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Start pre-op, titrate to HR 50-60 bpm Short acting beta-blockers provide more flexible

dosing Give orally, if possible, with IV supplementation

when patient is NPO

Preoperative Therapy with B-BlockersPreoperative Therapy with B-Blockers(ACC/AHA Guidelines)(ACC/AHA Guidelines)


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Anesthetic Considerations andAnesthetic Considerations and

Intraoperative ManagementIntraoperative Management (ACC/AHA Guidelines)(ACC/AHA Guidelines)

No study clearly demonstrates improved outcome from : regional versus general anesthesia pulmonary artery catheter

intraoperative nitroglycerin ST-segment monitoring TEE prophylactic intra-aortic balloon pump

Choice of anesthetic and intraoperative monitoring is bestleft to discretion of anesthesia care team.


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Perioperative SurveillancePerioperative Surveillance (ACC/AHA Guidelines)(ACC/AHA Guidelines)

Post operative myocardial ischemia: Strongest predictor of perioperative cardiac morbidity. Often untreated until overt symptoms develop. Diagnosis of perioperative MI has short and long-term prognostic value.

30% to 50% perioperative mortality and reduced long-term survival.

For patients with known or suspected CAD, undergoing high orintermediate risk procedure:

Check ECG at baseline, immediately after procedure, and daily x 2 days.

Check cardiac troponin measurements 24 hours postoperatively and onday 4, or hospital discharge (whichever comes first).

Consider troponion also days 2 & 3.


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Pacemakers & ICDsPacemakers & ICDs

Electrocautery can cause oversensing, resultingin failure to pace or an inappropriate shock froman ICD.

Contact Cardiology.


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ConclusionsConclusions (ACC/AHA Guidelines)(ACC/AHA Guidelines)

Insure good communication between surgeon, anesthesiologist,primary care physician, and consultant.

Further cardiac testing and treatments generally are thesame as in the non-operative setting, considering:

the urgency of the noncardiac surgery patient-specific risk factors surgery-specific factors

Preoperative testing: when surgical risk is high. when patient-specific and surgery-specific risks are intermediate. when results will affect patient management.


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Questions you should always ask yourselfQuestions you should always ask yourself

Is there CAD?

If there is,

how severe? how extensive?

how active?

How big is the

surgery?

Is there severe AS, MS

pulmonary hypertension

perioperative cardiovascular evaluation dr gage 3-22-2004

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