Preoperative Testing: When Is It Appropriate?

Troy LaBounty, MD, FACCDepartments of Medicine and Radiology

University of Michigan

No Disclosures

Case 1

• 60 year-old male with hyperlipidemia and hypertension planned for knee replacement. He has no ischemic or heart failure symptoms. He injured his back several years ago and is wheelchair-bound, so he is sedentary and unable to exercise.

• What testing (if any) would you order:A: Dobutamine echoB: Vasodilator SPECT/PETC: Cardiac catheterizationD: Coronary CT angiogramE: Nothing

Case 2

• 55 year-old female with history of stroke and MI one year ago treated with a stent to the LAD and with an EF of 45% on an echo at the time. She is planned for open cholecystectomy. She has no ischemic or heart failure symptoms at present, although had heart failure at the time of her MI. She is sedentary but regularly takes the stairs to the basement and back without difficulty.

• What testing (if any) would you order:A: Exercise echoB: Exercise SPECT/PETC: Cardiac catheterizationD: Coronary CT angiogramE: Nothing

RF’s for cardiac events (0-1 low-risk, ≥2 high-risk) • High-risk surgery

(intrathoracic, intra-abdominal, or suprainguinal vascular)

• Ischemic heart disease• Heart failure• Stroke/TIA• Pre-op insulin• Pre-op Creatinine >2.0

4 METs:• Climb 1 flight stairs• Walk up hill• Walk at 4 mph

Fleisher, JACC 2014

Case 1

• 60 year-old male with hyperlipidemia and hypertension planned for knee replacement. He has no ischemic or heart failure symptoms. He injured his back several years ago and is wheelchair-bound, so he is sedentary and unable to exercise.

• What testing (if any) would you order:A: Dobutamine echoB: Vasodilator SPECT/PETC: Cardiac catheterizationD: Coronary CT angiogramE: Nothing

Elevated Risk? No

Case 2

• 55 year-old female with history of stroke and MI one year ago treated with a stent to the LAD and with an EF of 45% on an echo at the time. She is planned for open cholecystectomy. She has no ischemic or heart failure symptoms at present, although had heart failure at the time of her MI. She is sedentary but regularly takes the stairs to the basement and back without difficulty.

• What testing (if any) would you order:A: Exercise echoB: Exercise SPECT/PETC: Cardiac catheterizationD: Coronary CT angiogramE: Nothing

Elevated Risk? Yes

Key Points

Preoperative stress testing only indicated if:

• Unstable ischemic or heart failure symptomsor

• High CV risk AND less than moderate (

Case 3

• 53 year-old female with diabetes on insulin, and prior stroke. She is disabled and is not able to exercise regularly. She can walk about 20 feet before stopping due to neuropathic pain. She denies chest pain. She is planned for resection of a spiculated lung mass. She had an echo which showed normal LV function and wall motion.

• What testing (if any) would you order:A: Dobutamine echoB: Vasodilator SPECT/PETC: Cardiac catheterizationD: Coronary CT angiogramE: Nothing

Elevated Risk? Yes

Case 3

2-vessel CAD. Proceed to Surgery?A: YesB: No

McFalls N Engl J Med 2004

CARP Trial: 510 patients scheduled for vascular surgery at multiple VA centers considered at elevated risk undergoing invasive

coronary angiography and with ≥70% stenosis (LM excluded)

Garcia AJC 2008

• 1048 patients undergoing catheterization prior to vascular surgery including both patients in the CARP trial and registry patients not enrolled in the trial.

Pre-Operative Revascularization

Fleisher, JACC 2014

This Case: No indication for RevascularizationNo symptoms

Normal LV functionUrgent Surgery

Case 4

• 75 year-old male planned for hip replacement, with history of tobacco smoking, hypertension, and a prior TIA. He has no ischemic or heart failure symptoms.

• Should you order an ECG?

Fleisher, JACC 2014

• Order ECG?A: YesB: No

Low-Risk Surgery No

Case 5

• 64 year-old female with tobacco use and known CAD with stents to the LCX and RCA a few years ago, with normal LV function at that time. She notes worsening DOE, and can only climb half a flight of stairs before needing to stop. She is planned for a melanoma resection.

• Is testing to measure EF appropriate?:A: YesE: No

Fleisher, JACC 2014

Worsening DOE Yes

Case 6

• 55 year-old female with diabetes, prior stroke, and renal insufficiency preoperative for intestinal resection. She also has HTN well controlled on hctz. She has moderate functional capacity and has no ischemic or heart failure symptoms. Her blood pressure is well controlled.

• Should she be started on a beta-blocker? A: YesB: No

POISE Study Group, Lancet 2008

POISE Trial: Metoprolol vs. Placebo in Patients Undergoing Noncardiac Surgery

5.8

6.9

3.12.3

0

2

4

6

8

CV Death, MI, or CardiacArrest HR 0.83

Total Mortality HR 1.33

MetoprololPlaceboP

erce

ntP=0.04

P=0.03

• 8351 patients with or at risk of CV disease randomized to metoprolol or placebo

• Metoprolol cohort had higher mortality and risk of stroke

Case 7

Fleisher, JACC 2014

No indication for chronic beta-blocker No

Fleisher, JACC 2014

Case 8

• 45 year-old male with a bicuspid aortic valve and moderate aortic stenosis on an echo 2 year ago. He is planned for hernia surgery. He has no cardiovascular symptoms and the murmur sounds unchanged.

• Should an echo be performed prior to surgery? A: YesB: No

Fleisher, JACC 2014

Moderate stenosis or regurgitation and

>1 year since echo Yes

Take-Home Points

• Few patients need stress testing pre-operatively -Unstable ischemic/heart failure symptoms -Elevated CV risk AND less than moderate (