Perioperative Cardiac Risk Assessment & Management for Noncardiac Surgery
STEVEN L. COHN, MD, FACP, SFHM
PROFESSOR EMERITUS
DIRECTOR-MEDICAL CONSULTATION SERVICE JACKSON MEMORIAL HOSPITAL
UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE
Disclosures
• Nothing relevant (except royalties from): • UpToDate (multiple topics)
• McGraw Hill (Perioperative Medicine-Just the Facts)
• Springer (Perioperative Medicine)
Objectives
• Review the American College of Cardiology (ACC) guidelines and algorithm for preoperative risk assessment
• Discuss various risk calculators and cardiac tests
• Evaluate risk reduction strategies (coronary revascularization & medical therapy)
Purpose of Preop Medical Consultation
• Identify risk factors and assess severity & stability
• Provide a clinical risk profile for informed and shared decision-making
• Make recommendations for any management changes, need for further testing, or specialty consultation
• NOT to CLEAR FOR SURGERY!
• Pt is in his/her OPTIMAL MEDICAL CONDITION for surgery.
Definitions of Urgency & Risk Urgency
• Emergency: <6 hours
• Urgent: 6-24 hours
• Time sensitive: can delay 1-6 weeks
• Elective: can delay up to 1 year
• ------------------------------------------------------------------------
Risk (combined surg & pt characteristics)
• Low risk: <1% MACE
• Elevated: >1% MACE
• Use RCRI, MICA, or ACS-SRC to calculate risk
Revised Cardiac Risk Index (RCRI) (Lee et al, Circulation 1999;100:1043-1049)
• 4315 pts, >50 y/o, LOS >2 days
• 6 independent predictors: high-risk surgery, hx ischemic heart disease, CHF, CVA, DM Rx with insulin, preop creat >2.0
# of risk factors % major cardiac complications
0 - 0.4-0.5% (in-hospital)
1 - 0.9-1.3%
2 - 4-7% >3 - 9-11%
Separates low vs high risk Underestimates risk-AAA/vasc surg
LOW
ELEVATED
Cardiac Risk Calculator (MICA) (http://www.surgicalriskcalculator.com/miorcardiacarrest)
• Used NSQIP database - multivariate logistic regression • Developed from 2007 data - 211,410 pts;
• Validated with 2008 data - 257,385 pts
• 5 predictors of MI/card arrest (30-day outcomes)
1) Type of surgery
2) Dependent functional status
3) Abnormal creatinine (>1.5 mg/dl)
4) ASA class
5) Increasing age • Risk calculator had better discriminative or
predictive ability for MI/CA than RCRI or VSGNE-CRI
Gupta, Circulation 2011
Database RCRI VSG Risk calculator
2007 0.747 0.884
2008 0.874
Vasc surg 0.591 0.71 0.746
ACS NSQIP Surgical Risk Calculator (30-day outcomes)
http://riskcalculator.facs.org
Bilimoria et al. J Am Coll Surg 2013
BNP/NT-proBNP
BNP pg/mL
NT-proBNP pg/mL
30-d death/MI
<92 <300 4.9%
>92 >300 21.8%
Can J Cardiol 2017; 33:17-32 Anesthesiology 2015; 123:264-71
Recommended by Canadian Cardiovascular Society Guidelines for patients: • >65 yrs old, 45-64 yrs old with CV disease, RCRI>1
• Elevated BNP/NT-proBNP preop, postop, or both, is associated with increased postop death/MI
• Adding preop BNP to RCRI improves risk prediction.
Clinical Risk Factors
• CAD • Isch Sx/NYHA, prior MI/timing, CABG/PCI, elevated
biomarkers
• HF • Decompensated + depressed LV funct worst;
• Sx > asympt; syst (EF<30-40%) > diastolic
• Valvular disease • Type (stenotic>regurg), severity, symptoms
• Arrhythmias • Hemodynamic effects, underlying structural heart disease
2014 ACC/AHA ALGORITHM
ACC/AHA 2014: Periop Cardiac Assessment for CAD
Step 1
Step 2
Step 3
Step 6
Need for emergency noncardiac surgery?
ACS?
Estimate risk of MACE (combined clin/surg risk –
RCRI or ACS-NSQIP)
Moderate or greater (>4METS) functional capacity
(<4METS) Will further testing impact decision
making or periop care?
Clinical risk stratification &
proceed to surgery
Evaluate & treat according to GDMT
Proceed to surgery
(no further testing)
Proceed to surgery
(no further testing)
No
No
No or unknown
Yes
Yes
Yes
Yes
Pharmacologic stress testing
Fleisher et al. JACC 2014
Low risk (<1%)
Elevated risk
Step 4
Step 5
No Proceed to surgery (GDMT) or
alternative strategies
Yes
Coronary revascularization (as per clinical practice guidelines)
Abnormal
Step 7
Valve dis HF Arrhythmias as per GDMT
Which Test? (if indicated)
• (Exercise if possible) • Aerobic but need to achieve target heart rate
• Pharmacologic (if unable to exercise) • DSE: fewer false positives, incr HR/BP, more physiologic • Dipyridamole/adenosine nuclear: with LBBB; -COPD/bronchospasm • PPV 15-20%; NPV 95-99%
• Cardiac CTA?
• Cardiac catheterization • Abn NIT, Class III/IV unstable angina, high pretest probability
• Resting 2D Echo • Only for valvular disease or heart failure
Assessment of LV Function
Supplemental Preoperative Evaluation
Recommendations COR LOE It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function.
IIa C
It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function.
IIa C
Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if there has been no assessment within a year.
IIb C
Routine preoperative evaluation of LV function is not recommended.
III: No Benefit
B
?
Noninvasive Pharmacological Stress Testing
Before Noncardiac Surgery
Supplemental Preoperative Evaluation
Recommendations COR LOE It is reasonable for patients who are at an elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo noninvasive pharmacological stress testing (DSE or pharmacological stress MPI) IF it will change management.
IIa B
Routine screening with noninvasive stress testing is not useful for patients undergoing low-risk noncardiac surgery.
III: No Benefit
B
Recommendation COR LOE
Routine preoperative coronary angiography is not recommended.
III: No Benefit
C
Preoperative Coronary Angiography
Perioperative Cardiac Risk Reduction Strategies
Prophylactic Coronary Intervention
• CABG and PCI – no evidence of better outcome vs medical therapy alone (need to consider risk of revascularization)
• RCTs: • CARP (McFalls et al. N Engl J Med 2004;351:2795-2804)
• Stable cardiac disease, elective vascular surgery (510 pts)
• Medical Rx +/- revascularization
• No difference in 30-day MI/death or long-term mortality (22 vs 23%)
• CABG better than PCI
• DECREASE V (Poldermans et al. J Am Coll Cardiol 2007 49:1763-1769)
• Abnormal DSE (5 segments or more) – 101 pts • Medical Rx +/- revascularization • No difference in 30-day MI/death or long-term mortality
• If previously revascularized (survived, asymptomatic), potentially beneficial (CASS)
Coronary Revascularization Prior to Noncardiac
Surgery
Perioperative Therapy
Recommendations COR LOE Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs.
I C
It is not recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events.
III: No Benefit
B
Circulation, 2016
Timing of Noncardiac Surgery after PCI
• Risk of stent thrombosis if DAPT is interrupted Timeframe 6 months irrespective of stent type
Lower with 2nd generation DES
Higher if placed in setting of MI
• Consequences of delaying surgery
• Increased periop bleeding risk if DAPT is continued
Individualize
Urgency of surgery
Type of surgery
Patient clinical risk factors
Risk factors for stent thrombosis
• Patient (ACS, low EF, DM, age) • Procedure (LAD/LM, multiple stents/vessels) • Lesion (bifurcation, length, diameter, multiple)
Management of antiplatelet therapy
• Continue both, stop one, stop both
Timing of Elective Noncardiac Surgery in Pts With Previous PCI (Levine et al, Circulation 2016)
Possibly after 1 month as per ESC
Antiplatelet Agents (cont’d)
Recommendations COR LOE In patients undergoing nonemergency/nonurgent noncardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased bleeding.
IIb B
Initiation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting,… III: No
Benefit
B
…unless the risk of ischemic events outweighs the risk of surgical bleeding. C
Perioperative Therapy
Results
25
Outcome
Aspirin (4998)
Placebo (5012)
HR (95% CI)
P
1O outcome: death or MI
351 (7.0)
355 (7.1)
0.99 (0.86-1.15)
0.92
2O outcome: death, MI, or stroke death, MI, revasc, or VTE
362 (7.2)
402 (8.0)
370 (7.4)
407 (8.1)
0.98 (0.85-1.13)
0.99 (0.86-1.14)
0.80
0.90
3O outcomes: MI
309 (6.2)
315 (6.3)
0.98 (0.84-1.15)
0.85
Safety outcome Major bleeding
230 (4.6)
188 (3.8)
1.23 (1.01-1.49)
0.04
Antiplatelet Therapy • Secondary prophylaxis – continue ASA
• Recent stent – continue DAPT
• Any PCI after completing DAPT – continue ASA (POISE-2 subgroup)
• If surgery mandates discontinuation, stop: • ASA – 3-7 days before surgery
• Clopidogrel – 5-7 days before
• Prasugrel – 7 days before
• Ticagrelor – 5 days before
Irreversible
Reversible
BETA-BLOCKERS
CONTROVERSY:
- Poldermans – question about scientific integrity of DECREASE trials
- POISE – question regarding dosing of metoprolol
Perioperative beta-blockers (RCTs) Author # pts Drug Duration Endpoint Outcome*
Mangano (NEJM 1996)
200 (noncard)
Atenolol (titrated)
<7 days 2 yr death 10 vs 21% RR 0.5
Poldermans (NEJM 1999)
DECREASE-I
112 (vasc;abn
DSE)
Bisoprolol (titrated)
30 days 30 d cardiac
death/MI
3.4 vs 34% RR 0.1
Dunkelgrun (Ann Surg 2009)
DECREASE-IV
1066 (noncard)
Bisoprolol (titrated)
30 days 30 d cardiac
death/MI
2.1 vs 6%
HR .34
Juul (DIPOM)
(BMJ 2006)
921DM
(noncard)
Metoprolol (not titrated)
7 days In-hosp CV
events
21 vs 20%
Brady(POBBLE)
(J Vasc Surg 2005)
103 (vasc)
Metoprolol (not titrated)
7 days 30 day CV
events
32 vs 34%
Yang (MaVS)
(Am H J 2006)
497 (vasc)
Metoprolol (not titrated)
5 days 30 day CV
events
10.1 vs 12%
Devereaux
(POISE)
(Lancet, 2008)
8351 (noncard)
Metoprolol
ER;High-dose
30 days 30 day CV
events:
1° MI, CA, CV death;
2° CVA,death,AF,revasc
1° 5.8 vs 6.9%
CVA: 1 vs 0.5%
Total mort: 3.1 vs 2.3%
*all statistically significant
Periop Beta-Blocker – Efficacy/Safety Mixed results depending on studies in meta-analyses.
Outcome Beta-blocker use
Ischemia Beneficial
MI Beneficial
CVA Harmful based primarily on POISE;
neutral/possible harm without POISE
Hypotension
& bradycardia
Harmful
Total mortality Possibly beneficial without POISE;
detrimental with POISE
Perioperative Therapy
Perioperative Beta-Blocker Therapy
Recommendations COR LOE Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically.
I BSR
It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started.
IIa BSR
In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers.
IIb CSR
In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery.
IIb BSR
These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s
systematic review. See the ERC systematic review report, “Perioperative beta blockade in noncardiac surgery: a
systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of
patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.
Perioperative Beta-Blocker Therapy (cont’d)
Recommendations COR LOE In patients with a compelling long-term indication for beta-blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit.
IIb BSR
In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery.
IIb BSR
Beta-blocker therapy should not be started on the day of surgery. III: Harm
BSR
What they don’t tell you:
- Bisoprolol and atenolol may be better than metoprolol
- BB should probably be started at least 1 week before surgery
- BB were beneficial in several large observational studies
Perioperative Therapy
Perioperative Statins: RCTs
Study # pts Surgery Statin Started Outcome
Durrazo 100 vasc Atorvastatin 20 mg
2 wks preop
↓ composite endpoint UA,CVA,MI,CV death (8 vs 26%) at 6 mos
DECREASE III
497 vasc Fluvastatin XL 80 mg
>30 days preop
↓ isch (11 vs 19%) MI/CV death (5 vs 10%) at 30 days
DECREASE IV
1066 Interm risk
Fluvastatin XL 80 mg
>30 days preop
Statistically insignificant ↓ MI/CV death (3 vs 5%) at 30 days
Perioperative Statins: Newer Observational Studies
Study # pts Surgery Outcome
London
(2016)
180,478 pts
Prop cohort
48243 statin
48243 control
NCS All-cause 30d mortality: 0.82 [.75-.89] NNT: 244
Mod-high intensity statin better; discontinuation worse
Any complic: 0.82 [.79-.86]; Card: 0.73; Resp: 0.75
High intensity statin incr renal injury: 1.18 [1.02-1.37]
Berwanger
(2015)
VISION
15,478
Matched
2845 statin
4492 control
NCS Composite: all-cause mort,MINS,CVA@30d: 0.83 [.73-.95]
Mort: .58; CV mort: .42; MINS: .86;
NS for MI, CVA
STATINS
What they don’t tell you:
- Which statin? Longer-acting to prevent withdrawal, more potent statin
- What dose? Moderate to high
- When to start it? Unclear – may have some benefit early on
- Downside? No evidence of harmful effects (rhabdo/LFTs)
Recommendations COR LOE
Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery. I B
Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery. IIa B
Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures.
IIb C
OTHER MEDICAL THERAPY
POSTOP TROPONIN MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY (MINS)
MANAGE
PRACTICE POINTS • RISK ASSESSMENT – ACC algorithm
• Low vs elevated risk (RCRI, MICA, ACS) • If elevated & <4METS, stress testing only if it changes mgmt
• INTERVENTIONS • Prophylactic revascularization is rarely necessary just to get a
patient through surgery
• MED MANAGEMENT • NCS may be OK if >3 but<6 mos after newer DES - try to
continue ASA or DAPT • Beta-blocker data remains controversial • Statins are potentially helpful
• COMMUNICATION/COLLABORATION • Team approach - shared decision-making • Patient, surgeon, anesthesiologist, consultant
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• UpToDate (multiple topics)
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