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Ultimate Goal
Quality of care and serving the
patients best interests.
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Goals
Understand how to estimate peri-operative CV
risk
Know when to perform stress testingpreoperatively
Learn how to reduce risk perioperatively in
those at higher risk
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55 Years old man with history of hypertension & CAD but
asymptomatic runs for 30 minutes daily, needs inguinal
hernia repair. You are consulted to clear him for surgery.
1) Order Nuclear stress test to evaluate
CAD.
2) Order Regular stress test
3) Order Cardiac catheterization
4) Clear for surgery
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Inflammatory
State
Hypercoagulable
StateStress
State
Hypoxic
State
Triggers
Surgical Trauma
Anesthesia/analgesia
Surgical Trauma
Anesthesia/analgesia
Surgical Trauma
Anesthesia/analgesia
Intubation/extubation
Pain
Hypothermia
Bleeding/anemiaFasting
Anesthesia/analgesia
Hypothermia
Bleeding/anemia
TNF-
IL-1
IL-6
CRP
PAI-1
Factor VII
Platelet reactivity
antithrombin III
catecholamine and
cortisol levelsoxygen delivery
BP
HR
FFAs
relative insulin
deficiency
Coronary artery shear
stress
Plaque fissuring
Oxygen demand
Myocardial
Ischemia
Acute Coronary
Thrombus
Perioperative Myocardial Infarction
Plaque fissuring
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Overview
Risk Assessment
Preoperative Testing
Postoperative Management to Reduce Risk
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Approaches to Risk Assessment
1. ASA/Dripps
2. Goldman Multifactorial Index
3. Detsky Modified Index
4. Revised Risk Index
5. ACC/AHA Task Force
Recommendations
Quantitative
Strategic
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Dripps/ASA ClassificationClass Systemic Disturbance Mortality*
1 Healthy patient with no disease outside of the surgical
process
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Goldman Risk Index
Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac
risk in non-cardiac surgical procedures.N Engl J Med148:2120-2127, 1988.
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Goldman Risk Index
Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac
risk in non-cardiac surgical procedures.N Engl J Med148:2120-2127, 1988.
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J Am Coll Cardiol, 2007; 50:1707-1732
ACC/AHA Guidelines
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Stepwise Approach to the Pre-
operative Evaluation
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Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgery
Operating room
Evaluate and treat
per ACC/AHA
Guidelines
Vigilant perioperativeand postoperative
management
Consider
Operating Room
Low Risk
Surgery
Active
cardiac
conditions
No
Yes
Yes
No
Proceed with
planned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed with
planned surgery
No
Yes
Manage based on
clinical risk factors
No
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Active Cardiac Conditions
Surgery
Acute or recent MI (7Acute or recent MI (7--30 d)30 d)
Unstable coronary syndromeUnstable coronary syndromeDecompensated CHFDecompensated CHF
Significant ArrhythmiasSignificant Arrhythmias
Severe Valvular DiseaseSevere Valvular Disease
High Risk:High Risk:
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Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgery
Operating room
Evaluate and treat
per ACC/AHA
Guidelines
Vigilant perioperativeand postoperative
management
Consider
Operating Room
Low Risk
Surgery
Active
cardiac
conditions
No
Yes
Yes
No
Proceed with
planned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed with
planned surgery
No
Yes
Manage based on
clinical risk factors
No
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Low Risk Surgery Risk < 1%
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
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Low Risk Situations
Reasonable to proceed with surgery
Low risk surgeryLow risk surgeryGood functional capacityGood functional capacity
No cardiac symptomsNo cardiac symptoms
No active cardiac conditionsNo active cardiac conditions
No clinical risk factorsNo clinical risk factors
Low Risk:Low Risk:
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Functional Capacity :
Metabolic Equivalents (METs)
1. Correlates with maximum
oxygen uptake on treadmill
testing
2. Demonstrated predictor of
future cardiac events
2. Poor functional capacity may
hide low threshold cardiac
symptoms
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What is basal O2 consumption
(Vo2)?1) 1.5 ml/kg/min2) 2.5 ml/kg/min
3) 3.5 ml/kg/min4) 4.5 ml/kg/min
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Duke Activity Status Index
1 MET Can you take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the house?
Walk a block or two on level
ground at 2-3 mph or 3.2-4.8km/h?
4 METs Do light work around the house
like dusting or washing clothes?
MET = metabolic equivalent
4 METs Climb a flight ofstairs or walk up a
hill?
Walk on level ground at 4 mph or
6.4 km/h?
Run a short distance?Do heavy work around the house
likescrubbing floors orlifting or
moving heavy objects?
Participate in moderate
recreational activitieslike golf,
bowling, dancing, doubles tennis,
or throwing a baseball or football?
10 METs Participate in strenuoussportslike
swimming, singles tennis, football,
baseball, orskiing?
Resting or basal O2 consumption(Vo2) of a 70 kg, 40 yrs old man is
3.5 mL per kg per min, or 1 MET.
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Clinical Risk Factors
Known Ischemic Heart Disease
Compensated or Prior Heart Failure
Diabetes Renal Insufficiency
Cerebrovascular disease
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Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgery
Operating room
Evaluate and treat
per ACC/AHA
Guidelines
Vigilant perioperativeand postoperative
management
Consider
Operating Room
Low Risk
Surgery
Active
cardiac
conditions
No
Yes
Yes
No
Proceed with
planned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed with
planned surgery
No
Yes
Manage based on
clinical risk factors
No
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Clinical Risk Factors
History of heart diseaseHistory of heart disease
Compensated or prior CHFCompensated or prior CHF
Cerebrovascular diseaseCerebrovascular disease
Diabetes MellitusDiabetes Mellitus
Renal InsufficiencyRenal Insufficiency
Proceed CautiouslyProceed Cautiously
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Manage based on
clinical risk factors
3 or more clinical
risk factors*
1 or 2 clinical
risk factors*
No clinical
risk factors*
Vascular
Surgery
Intermediate
risk surgery
Vascular
Surgery
Intermediate
risk surgery
Proceed with
planned surgery
Proceed with planned surgery with HR control
or consider non-invasive testingConsider Testing
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease
Asymptomatic but
poor/unknown functional
capacity
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Intermediate Risk Surgery Risk < 5%
Carotid endarterectomy
Endovascular AAA repair
Head and neck
Intraperitoneal and intrathoracic
Orthopedic
Prostate
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High Risk Surgery Risk > 5%
Emergent major operations (3-5 times more risk)
Aortic and other major vascular
Peripheral vascular
Anticipated prolonged or associated with large fluid
shifts and/or blood loss
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Overview
Risk Assessment
Preoperative Testing
Postoperative Management to Reduce Risk
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Most preoperative testing assesses for
presence of obstructive CAD and NOT
plaque vulnerability which truly predicts
the risk.
Unfortunately we have no way of
predicting this.
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ACC/AHA Recommendations
Echocardiography:
Dyspnea of unknown origin (Class IIa)
Current or hx of HF and no echo in 12 months
(Class IIa)
12 Lead ECG
Vascular surgery and 1 CRF (class I)
CRFs and intermediate risk surgery (class I)
All vascular surgery (class IIa)
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ACC/AHA Recommendations
Treadmill stress testing
High cardiac risk conditions
3 CRFs, poor functional capacity & vascular
surgery (class IIa)
Nuclear stress testing
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Which test to choose?
Most ambulatory
patients
Abnormal resting
ECG (dig, LVH)
LBBBUnable to exercise
Treadmill Stress Test
Exercise
echo or sestamibi
DSE
Adenosine sestamibi
dipyridamole sestamibi
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Preoperative TestingNegative Predictive Value
96.3
98.699.4
80
85
90
95
100
%
St ECG Dipyramadole Tl Dobutamine Echo
Freedom from MI or DeathFreedom from MI or Death
Eagle et al. JACC 1996;27:910.Eagle et al. JACC 1996;27:910.
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Preoperative Testing
Whenever feasible, an exercise stress test is best
choice
Dipyridamole or adenosine perfusion scan andDSE are reasonable choices if:
unable to exercise
BBB or other resting ECG abnormality
Avoid dipyridamole and adenosine scan ifbronchspasm
Avoid DSE if serious arrhythmias or severe
hypertension
Caveats
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Overview
Risk Assessment
Preoperative Testing
Perioperative Management to Reduce Risk
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60 yrs old man with history of CAD, HTN, DM & Creatinine of
2.5 showed small I W ischemia on nuclear stress test at 10
METS & asymptomatic, needs to have prostatectomy for Ca.
How would you treat?
1) Cardiac cath & PCI as indicated.
2) Cancel surgery & request other Rx option.3) BB with heart rate control perioperative.
4) Give nitrates & CCB & proceed with surgery.
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Perioperative Nitrates?
0
5
10
15
20
25
30
35
Percen
I
che
c
Preop Induc on Inc on E erg. PostOp
ontrol
TNG
Dodds, et al. Anesth. Analg. 1993;76:705-13
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Perioperative Management
Revascularization
Beta blockers
Statins Alpha-2 agonists
Calcium channel blockers
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Revascularization
5859 vets screened prior
to vascular surgery;4669
excluded
510 randomized to: Revascularization (258)
99 CABG
141 PCI
18 not revascularized
252 no revascularization
9 revascularized
143 medical rx
McFalls, et al. NEJM 2004;351:2795-2804
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Intervention is rarely necessary to simply lower
the risk of surgery.
Revascularization (surgery or PCI) should be
considered only if standard indications arepresent.
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PCI before anticipated surgery
Acute MI
High Risk ACS
High risk anatomy
Stent and continued
Dual-antiplatelet rx
Bleeding risk of
anticipated surgery
Balloon
angioplasty
Bare-metal
stent
Drug-eluting
stent
14 to 29Days
30 365Days
> 365Days
Low
Not low
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Timing of Surgery After PCI
Balloon
angioplasty
Bare-metal
stent
Drug-eluting
stent
< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days
DelaySurgery
with ASADelay Delay
Surgery
with ASA
Surgery
with ASA
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Perioperative Management
Revascularization
Beta blockers
Statins Alpha-2 agonists
Calcium channel blockers
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Postoperative Mortality ReductionBeta-Blockers
8
14
21
0
3
10
0
5
10
15
20
25
Pl ce Ate l l
6 t
1 Ye r
2 Ye r
200 pts undergoing
non-cardiac surgery
Random assignmentto:
IV followed by oral
atenolol or
Placebo
Double-blind follow-up over 2 years
Mangano, et al. NEMJ 199 ;335:1713.
Mortality
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Postoperative Cardiac Events In HighRisk Patients
Bisoprolol n=59Placebo n=53
Poldermans et al. NEJM 1999;341:1789.Poldermans et al. NEJM 1999;341:1789.
173 patients
undergoing vascularsurgery with positive
DSE
Randomized to BB
1 week pre-op or
placeboFollowed for 30
days
1 7 1 7
3 .45
1 0
1 5
0
25
P l ac e bo B i s opr o l o l
B e ta B loc ad e
ardiac ea t
N o n a ta l M
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Perioperative Beta Blockers
AHA/ACC Recommendations: 2006 UpdateBeta blockers required in recent past to control symptoms of angina orpatients with symptomatic arrhythmias or hypertension
Patients at high cardiac risk owing to the finding of ischemia on
preoperative testing who are undergoing vascular surgeryPatients undergoing vascular surgery and with identified CAD
Vascular surgery and multiple cardiac risk factors
Moderate or high risk surgery and multiple cardiac risk factors
Key Point: if known or suspected CAD and
undergoing moderate or high risk surgery, use a
beta blocker!
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Perioperative Management
Revascularization
Beta blockers
Statins Alpha-2 agonists
Calcium channel blockers
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Perioperative Statins?
100 patients pre-op before
vascular surgery
Random assignment:
Atorvastatin 20 mg
Placebo
Started 30 days preoperatively
Follow-up 6 month
Endpoint:
Cardiac death Non-fatal MI
USA
Stroke
J Vasc. Surgery 2004;39:967
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Perioperative Statins
Hindler, et al. Anesthesiology 2006;105:1260-72
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Perioperative Statins
44% reduction in mortality after all types of
surgery.
59 % after vascular surgery alone
Hindler, et al. Anesthesiology 2006;105:1260-72
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Perioperative Management
Revascularization
Beta blockers
Statins Alpha-2 agonists
Calcium channel blockers
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Perioperative Alpha-2 Agonists
Clonidine prophylaxis in patients with or at
risk of CAD undergoing noncardiac surgery
reduced perioperative ischemia significantly.
(P=0.01) & mortality up to 2 yrs was also
reduced (P=0.035)
Wallace et al (PDBT)
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Perioperative Management
Revascularization
Beta blockers
Statins Alpha-2 agonists
Calcium channel blockers
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Preoperative Hgb and Mortality
0
2
4
6
8
10
12
14
R
e
tive
Ris
r
taity
6.0-6.9 .0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 >12
Pre He in
N
Carson, et al. Lancet. 1996;348:1055-60
Study of Untreated Anemia
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Perioperative Hypothermia
1 4
6 3
2 4
7 9
0
1
2
3
4
5
6
7
8
C
ar
iac
or
i
it
y
(
ercent)
Mor i ity V
Nor other ia Hy other ia
300 pts undergoing
general surgery
Randomized,
double blinded
assignment to
routine care or
supplementalwarming
Frank SM JAMA 1997;227(14)
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Inflammatory
State
Hypercoagulable
StateStress
State
Hypoxic
State
Triggers
Surgical Trauma
Anesthesia/analgesia
Surgical Trauma
Anesthesia/analgesia
Surgical Trauma
Anesthesia/analgesia
Intubation/extubation
Pain
Hypothermia
Bleeding/anemiaFasting
Anesthesia/analgesia
Hypothermia
Bleeding/anemia
TNF-
IL-1
IL-6
CRP
PAI-1
Factor VII
Platelet reactivity
antithrombin III
catecholamine and
cortisol levelsoxygen delivery
BP
HR
FFAs
relative insulin
deficiency
Coronary artery shear
stress
Plaque fissuring
Oxygen demand
Myocardial
Ischemia
Acute Coronary
Thrombus
Perioperative Myocardial Infarction
Plaque fissuring
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Key Point:
Beta blocker if able
Limit hypothermia Aggressive post-operative pain control
Avoid significant anemia
Avoid Sympathetic Stimulation in those at Risk!
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THANK YOU