Perioperative Cardiovascular Evaluation And Management For Noncardiac Surgery

Perioperative Cardiovascular Evaluation and 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

Purpose of Preoperative Cardiac Evaluation   



Define patient’s current cardiac status. Assess and project perioperative CV risk. Determine if preoperative testing is needed to define cardiovascular status - recommended only if it will change surgical care or perioperative medical therapy. Initiate management to minimize cardiac risk over the entire perioperative period, and subsequently.

General Approach to the Patient - History  

“Have you ever had any problem with your heart or arteries?” “Do you exercise?” Typical responses …   





  

“I try to.” “Not as much as I should.” “I’m active.”

Translation: “No.” Translation: “No.” Translation: “No.”

“What exercise do you do? Tell me the most physically strenuous thing you 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

Exercise capacity integrates the physiologic effects of all the patient’s combined cardiac abnormalities. If history reveals GOOD EXERCISE CAPACITY, then the patient’s operative risk is low.

General Approach to the Patient 



 

Physical Examination – general appearance, bruits, rales, elevated JVP, heart rate & rhythm, murmurs of severe AS or MS Comorbidity: renal impairment, diabetes, pulmonary disease Basic Metabolic Panel, CBC, BNP, ECG, CXR BNP level (precise role in risk assessment and post-op management remains to be defined)

Q: Which cardiac conditions worry me most? A:

 



Severe stenotic (flow-limiting) lesions:  coronary - disease severity and extent  AS > MS  severe pulmonary hypertension

Regurgitant valvular lesions are rarely a problem perioperatively. I am less concerned about CHF or arrhythmia in the absence of ischemia. Both are readily treated and usually without permanent sequelae, unlike MI and death. AF is, however, a potentially costly (in money and morbidity) nuisance. Avoid it.

Patient-specific Clinical Predictors of Increased Perioperative Cardiovascular Risk (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

Type 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:    

emergent major operations, esp. in elderly aortic and other major vascular surgery peripheral vascular surgery BIG SURGERY: anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss, and long recovery.

Type of Surgery and Risk - II 

Intermediate risk: carotid head and neck intraperitoneal intrathoracic orthopedic prostate



Low risk: endoscopy superficial procedures cataract surgery breast surgery

Preoperative non-invasive testing in known or suspected CAD - Which patient? 



 

poor or unknown functional capacity: can’t exercise, don’t exercise known or suspected CAD: angina, prior MI based on history 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 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.

Recommendations for Coronary Angiography in Perioperative Evaluation (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 intermediaterisk or high-risk noncardiac surgery Equivocal noninvasive test results in patients at highclinical risk undergoing high-risk surgery

Q. When is revascularization (PCI, CABG) recommended ? (ACC/AHA Guidelines) A. Generally only when justified by the usual clinical factors, apart from planned non-cardiac surgery. 





No randomized trials document decreased perioperative cardiac 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.

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

Class I indications  When B-blockers have been required in recent past for angina, 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 untreated hypertension, known CAD, or major CAD risk factors. Class III: contraindication to B-blockade

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

  

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

Anesthetic Considerations and Intraoperative Management (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 best left to discretion of anesthesia care team.

Perioperative Surveillance (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 or intermediate risk procedure:  Check ECG at baseline, immediately after procedure, and daily x 2 days.  Check cardiac troponin measurements 24 hours postoperatively and on day 4, or hospital discharge (whichever comes first). Consider troponion also days 2 & 3.

Pacemakers & ICDs 



Electrocautery can cause oversensing, resulting in failure to pace or an inappropriate shock from an ICD. Contact Cardiology.

Conclusions (ACC/AHA Guidelines) 

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



Further cardiac testing and treatments generally are the same 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.

Questions 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