Avoiding Thor’s Thunderbolt!
The Urologist’s Role in Managing the Peri-operative Risk of Cardio-Ischemic
and Embolic Events
Philip J. Walther, MD, PhD, MBA, FACS Professor of Urologic Surgery Duke U. School of Medicine
Disclosures: None Off-Label Recommendations: None
Philip J. Walther, MD, PhD, MBA, FACS
Myocardial Infarction Evolving Diagnostics
• 1970’s: Primarily Sxs and EKG changes • 1980’s: Developing cardiac biomarkers
– LDH –isoenzymes, CPK and then CPK-MB • 1990’s: Onset of troponin Dxtics, but criteria for
ischemic Sx and EKG ∆ still dominant • 2000’s: Greater sensitivity: 4th and 5th Gen
– 2017: 5th Gen cTnT just approved by FDA • Impact of Better Dx & Rx: ↓ mortality rate
– Fewer have STEMI than N-STEMI MI’s
Major Peri-Operative Cardiac Complications
• Account for at least 1/3 of perioperative deaths. • Challenge: Ischemic Sx masked by patient’s
obtundation (Eg. Narcotics) or misinterpreted coinciding symptoms (abd. incisional pain)
• Impact: • Substantial morbidity & prolonged hospitalization • Increased medical cost • Affects intermediate and long-term prognosis.
Deceppe E, et al: Canad. J. Cardiology 2017; 33, 17-32
Revised Cardiac Risk Index Computation: Components (1 point / component present)
Lee TH, et al: Circulation 100: 1043-9, 1999
Revised Cardiac Risk Index Validation Cohort
RCRI Class
Index Sum
Major Cardiac Complication
Rate* (%) I 0 0.4 II 1 0.9 III 2 6.6 IV >2 11.0
*V.Fib/Cardiac arrest, Complete heart block, acute MI, or Pulmonary Edema
Lee TH, et al: Circulation 100: 1043-9, 1999
Ann Internal Med 2011; 154: 523-8
Perioperative MI (PMI) after Non-Cardiac Surgery:
Characteristics and Short-Term Prognosis
• Of those who had MI, 65% did not have ischemic Sx
• 30-Day Mortality: – PMI-11.6%; no PMI-2.2%
• With ischemic Sx: 9.7% • Without ischemic Sx: 12.5%
• 8.3% had elevated cardiac markers only Devereaux PJ et al:
Ann Internal Med 2011; 154: 523-8
VISION Investigators JAMA 2012; 307:2295-304
• Prospective cohort study (15,133 pts) • Troponins drawn daily (POD 1,2,3)
– NOTE: 4th Gen cTnT was utilized • Clinical outcomes reviewed: 30-day
mortality was determined.
Postoperative Troponin and 30-Day Mortality
• Peak Troponin level correlated with risk of death within 30 d VISION Investigators
JAMA 2012; 307:2295-304
Kaplan-Meier Estimates of 30-Day Mortality Based on Peak Troponin T Levels
MINS
• Many surgical patients sustain myocardial injury perioperatively that will not satisfy diagnostic criteria for MI, but portend diminished survival outcomes.
• (M)yocardial (I)njury after (N)on-cardiac (S)urgery- defined as: myocardial injury detected by troponin -caused by ischemia (that may or may not result in necrosis), has prognostic relevance, and occurs with 30 days of surgery.
VISION Investigators. Anesthesiology 2014; 307:564-78
MINS: Clinical Outcomes
• Eight % of patients suffered MINS • 52.8% would not have fulfilled universal
definition of MI. • Only 15.8% of MINS experienced ischemic
symptoms. • Conclusion: MINS is common and is
associated with substantial mortality.
VISION Investigators. Anesthesiology 2014; 307:564-78
JAMA 2017; 317: 1642-51
• 21,842 participants • Outcome: Death within 30 d.: 266 (1.2%) • Protocol: • cTnT drawn postop: At 6-12 hr, D1, 2, 3 • If >14 ng/L, assessed for:
– Ischemic features (Sxs, EKGs) – Excluding sepsis, PE, AF
Post-Operative Complications Troponin Occurrence and 30-Day Mortality
Complication % Occurrence Deaths (% of Occurrence)
MINS 17.9 4.1 Major Bleeding 14.2 4.5 Sepsis 4.1 9.3 New Atrial Fib 1.2 10.6 Stroke 0.3 15.9 Pulmonary embolus 0.4 4.3 DVT 0.3 2.6 Pneumonia 1.8 9.4
VISION Study Investigators. JAMA 2017;317:1642-51
Post-Operative Complications Troponin Occurrence and 30-Day Mortality
VISION Study Investigators. JAMA 2017;317:1642-51
Brain (B-Type) Natriuretic Peptide (BNP)
• Synthesized as Pro-BNP. Released by cardiomyocytes with multiple stimuli: – Ischemia, stretch, inflammation,
neuroendocrine stimuli. – Inhibits renin ↓ Aldosterone
production Natriuresis – Causes vasodilation
Brain (B-Type) Natriuretic Peptide (BNP)
• Strongly prognostic of cardiac injury and decompensation. – N-terminal peptide (NT-ProBNP and BNP very
similar in prognostic value.) • Blood test is inexpensive.
Peri-Op Cardiac Risk Assessment /
Management for Elective Non-Cardiac Surgery: Canadian Cardiovascular Society Guidelines 2017
(Duceppe, 2017: Can. J. Card.)
Patient Population: (Surgery requiring overnight admission) • Age: 18-44 yrs + known
signif. CV (SigCV) disease* • Age: ≥ 45 yrs
Risk Stratification with Revised Cardiac Risk (Lee) Index
If: • ≥ 65 yrs and RCRI ≥ 1, • 45-64 yrs with Sig CV,
Draw BNP/NT-proBNP (Neg. / Threshold- NT-pro: <300 mg/L
BNP <92 mg/L)
If NOT: No further testing
necessary
If Neg: No
additional Routine Postop
monitoring
If Pos:
• EKG in PACU (? Troponin) • Daily troponin x 48-72 hrs • Consider in-hospital shared-
care management
* Sig. CV Disease: Known CAD,
CBVD, PAD, CHF, Severe PHTN,
Severe obstructive intra-cardiac abnormality
Anesth Analg 2014; 119:1053-63
• Retrospective, case-controlled study • Site: Paris, France • All patients aged >18 years who underwent
major vascular surgery 2005-8 • Note: All patients had 30d of enoxaparin
Therapy Intensification (TI) for Post-Operative Troponin Elevation
• Focus on 4 major drug groups: – Anti-platelet agents – Beta-blockers – ACE inhibitors – Statins
• 66 pts with Pos. cTp: – 43 had TI; 23- no change
Fourcrier A, et al.: Anesth Analg 2014; 119:1053-63
Therapy Intensification (TI) for Post-Operative Troponin Elevation
Fourcrier A, et al: Anesth Analg 2014; 119:1053-63
Gettysburg, 1863
THE “GOOD OLD DAYS”
SURGEON
THE “GOOD OLD DAYS”
Gettysburg, 1863 • Surgical therapeutic objectives
were straightforward. • Since the “tools of the trade” were
few (scalpel, saw, and thread), outcome expectations were limited.
• The surgeon was a HERO – when the patient lived!
• No one kept track of complications; they kept track of “SAVES”.
NOT the “GOOD OLD DAYS” Anymore!!
• Joint Commission inspections & mandates provide a regulatory framework for constant surveillance of physician practice patterns
• National Surgical Quality Improvement Program (NSQIP)
• Plaintiff Bar Filing Malpractice Torts
EVERY BUSY SURGEON’S NEMESIS
EMBOLUS
CMS considers Venous Thromboembolism
a preventable complication!!!
NOT the “GOOD OLD DAYS” Anymore!!
• Payors are now monitoring physician performance (scorecards”): – Complications – Length of Stay – Re-admission rates – Deaths!
• Since CMS considers venous thromboembolism a preventable complication, it becomes a major cost to the hospital– and ….
• SURGEON PRACTICE PATTERNS BECOME AN ISSUE!
DVT Occurrence Correlates in Tandem with No. of Risk Factors
Anderson FA, Spencer FA. Circulation 2003; 107:I9-I16
Risk of VTE in Perioperative Period
Bahl V, Et al: Ann Surg 2010; 251: 344
Radical Cystectomy: A Setup for VTE?
• Of GU cancer cases, highest rate of VTE • Independent risk for VTE • Contemporary VTE incidence: 2.9-24.4% • In pelvic surgeries, Gyn and Gen Surg
literature suggests that risk extends beyond discharge date.
Findings: • 6% were diagnosed with VTE (DVT only- 2.9%; PE only-
1.7%; Both-1.4%) • 55% were diagnosed after initial discharge (65% of PE, 50%
of DVT) • Of pts with VTE, 30-day mortality rate was 6.4%
J. Urol 191: 943, 2014
Observational retrospective study: 1,037 cystectomy patients Source: NSQIP data base of ACS
Timeframe of surgery: 2005-2011
Timing of Postoperative VTE Events
VanDlac AA, et al. J. Urol 191: 943, 2014
Median and Mean Time: 14d &15.2d, respectively
DVT Prophylaxis: Changing Patterns of Care-Need for New Paradigm?
• Large clinical experience (outside GU) has demonstrated risk of thromboembolism for several weeks after surgery (multiple abdominal sites)
• “Utilization Review” initiatives in late 1990’s: – Impact: substantially shorter postoperative hospital stays. – When used, postop inpatient DVT prophylaxis (SCD’s, ?
pharma) had a substantially shorter duration of use => potentially adverse outcomes
• Time for new paradigm? (Post-discharge prophylaxis!!) But if so, extent of duration?
• All 332 pts: Everyone- Enoxaparin 40 mg qd (starting 10-14 hrs preop) for 6-10 d => then randomized.
• Randomization: Placebo vs. Drug for 19-21 d. • Compression stockings but no SCD’s • All pts had venograms at 25d (after not earlier for
Sxs)
New Engl. J. Med. 346: 975, 2002
Prospective, Double-blind, Placebo-controlled Randomized Trial
DVT Prophylaxis-Postoperative Ortho LMWH (Enoxaparin) vs. Placebo
• Study: 100 pts undergoing hip surgery • Regimen: Randomization. Enoxaparin 30 mg
bid starting 12 hr postop x 14d (or discharge) • Monitoring: Daily 125I-Fb scans (confirmed by
venography if positive)
Turpie AGG, et al. et al. New Eng. J. Med. 315: 925, 1986
DVT Prophylaxis-Postoperative LMWH (Enoxaparin) vs. Placebo
Turpie AGG, et al.: New Eng. J. Med. 315: 925, 1986
(10.8%) (51.2%) ( 5.4%) (23.1%)
Caprini Method
of Risk
Stratifi-cation
Bahl V, et al: Ann Surg
2010; 251: 344
Bahl V, Et al: Ann Surg 2010; 251: 344
SHOCKING!!!
• 10,966 AUA members queried; 11% responded. • Question: FAMILIAR WITH RECOMMENDATIONS of the
AUA Best Practice Statement? • Yes 50.7% • No 19.4% • Unaware of AUA-BPS 29.9%
49.3% Sterious S, et al.: J. Urol. 190: 992 (2013)
DVT Prophylaxis: Technique
• Mechanical: – Early ambulation – Graduated compression stockings – Intermittent (sequential) pneumatic compression (SCD’s)
• Pharmacologic: – Low-dose unfractionated heparin (LDUF-H) – Indirect Factor X inhibitors:
• Low molecular weight heparin (WMWH)- Ex., enoxaparin • Synthetic- fondaparinux
– Vitamin K antagonists (VKA)- warfarin – Oral therapies: Factor IIa & Xa inhibitors (dabigatran,rivaroxaban) – Developmental: Anti-sense anti-Factor XI inhibitors
Stratifying Patient Risk of DVT: Intrinsic Patient Risk AND Type of Procedure
Risk Stratification
AUA Best Practice Statement-DVT Prophylaxis, 2008
Risk-Adapted VTE Prophylaxis: AUA-Best Practice Statement
*If patient >150 kg, consider Enoxaparin 40 mg q12h
AUA-BPS DVT Prophylaxis, 2008
“In selected very high-risk pts, consider post-discharge enoxaparin”