9/6/ % 25% 25% 25%

(1)

Risky (Factor) Business:

Preoperative Evaluation for

the Primary Care Physician

David M Schneider, MD David M Schneider, MD Faculty Physician, Santa Rosa Family Faculty Physician, Santa Rosa Family

Medicine Residency Medicine Residency

9/6/12 9/6/12

Objectives

By the end of this conference, attendees will be able to:

1. Identify minimum functional level for perioperative

safety.

2. State which lab tests should be done

preoperatively on a routine basis.

3. State at least one step in preop cardiac evaluation.

4. Identify at least 1 low risk surgery.

5. State which pts should definitely get preop β

-blockers.

6. Remember at least 1 fact about the movie Risky

Business.

Case 1

You are called at 0200 by a surgeon to

see a pt with abdominal pain. The

surgeon tells you the pt is an 86

surgeon tells you the pt is an 86 yo

yo white

white

male with

male with CHF with

CHF with RLQ abdominal pain,

RLQ abdominal pain,

tenderness at

tenderness at McBurney’s

McBurney’s point, and a

point, and a

fever to 100.2. CBC shows WBC of 15.1.

Case 1

Case 1 -- continued

continued

Surgeon: “Please clear this pt for surgery.

I think I should wait until the morning and

have

have cardiology do an echo.”

cardiology do an echo.”

What do you do?

86

86 yo

yo M w/H/O CHF &

M w/H/O CHF & Appy

Appy

sx

sx//sx

sx –

– echo?

echo?

33% 33%

33% _1._1.

Yes

Yes—

—echo only

echo only

2.

Yes

Yes—

—echo + Cardio

echo + Cardio eval

eval

3. 3.

No

“Clearance for Surgery”

Does “clear for surgery” mean there are

no risks?

Your task is to Your task is to find the risksfind the risks..

Risks vary based on many factors.Risks vary based on many factors.

Your other key tasks:

Optimize medical condition Optimize medical condition of the surgical of the surgical

pt pt..

Propose strategies to reduce risk & Propose strategies to reduce risk &

complications. complications.

(2)

“Clearance for Surgery”

“Clearance for Surgery” –

– 2

2

As a medical consultant, generally

As a medical consultant, generally avoid

avoid

the phrase “clear for surgery.”

Cardiologists & surgeons felt it was important Cardiologists & surgeons felt it was important

to clear pt for surgery, anesthesiologists did to clear pt for surgery, anesthesiologists did not.

not.

It is the

It is the anesthesiologist’s duty to

anesthesiologist’s duty to

recommend type of anesthesia

recommend type of anesthesia –

– not

not

yours.

Anesthesiologists felt it was unimportant for Anesthesiologists felt it was unimportant for

consultant to recommend type of anesthesia, consultant to recommend type of anesthesia, cardiologists & surgeons disagreed.

cardiologists & surgeons disagreed.

AnesthAnalg AnesthAnalg 1998;87:8301998;87:830--66

What Should You Consider in

Preop

Preop Evaluation?

Evaluation?

My approach = the 4 C’s:

CConditioning (general condition of pt)onditioning (general condition of pt)

CCardiacardiac

CChest (lungs)hest (lungs)

CClots (VTE prophylaxis)lots (VTE prophylaxis)

What Should You Consider in

Preop

Preop Evaluation?

Evaluation?

My approach = the 4 C’s:

CConditioning (general condition of pt)onditioning (general condition of pt)

CCardiacardiac

Conditioning

1 MET = metabolic demand at rest.

Increased

Increased perioperative

perioperative risk in pts unable

risk in pts unable

to perform at

to perform at 4 METs

4 METs..

Walk up 2 flights Walk up 2 flights of stairs.of stairs.

Run “a short distance.”Run “a short distance.”

Walk up a hill 1 Walk up a hill 1 –– 2 blocks.2 blocks.

Carry 2 bags of groceries up 1 flight of stairs.Carry 2 bags of groceries up 1 flight of stairs.

Walk 2 Walk 2 –– 4 blocks (flat).4 blocks (flat).

Simple questions on history.

AmJCardiol

AmJCardiol 1989;64:6511989;64:651--4; Circulation 2009;120:e1694; Circulation 2009;120:e169--e276; e276; ArchIMArchIM 1999;159:2185

1999;159:2185--92; Chest 2001;120:114792; Chest 2001;120:1147--5151

Risky Business Trivia

Bob

Bob Seger’s

Seger’s 1

1

stst

Billboard

Billboard--Charted Song

Charted Song

1 2 3 4

25% 25% 25% 25%

1.

Old Time Rock &

Roll

2.

Ramblin

Ramblin’

’ Gamblin

Gamblin’

’

Man

3.

Get Out of Denver

4.

(3)

Does Age Matter?

Maybe.

Older studies found Older studies found ↑↑risk w/risk w/↑↑age.age.

Recent studies found Recent studies found ↑↑mortality & pulmonary mortality & pulmonary

morbidity w/advancing age. morbidity w/advancing age.

Other studies have not found Other studies have not found ↑↑mortality.mortality.

After adjusting for other morbidities, After adjusting for other morbidities, impact of impact of

age is relatively small. age is relatively small.

Avoid ageism:

Avoid ageism: age alone is not a reason

age alone is not a reason

to withhold surgery.

NEJM 1977;297:845

NEJM 1977;297:845--50; 50; AnnSurgAnnSurg 1982;195:901982;195:90--6; 6; EffClinPractEffClinPract 2001;4:1722001;4:172--7; 7; AnnIM 2006;144:581AnnIM 2006;144:581--95; 95; JAMA JAMA 1989;261:1909

1989;261:1909--15; 15; AnnIM 2001;134:637AnnIM 2001;134:637--43; 43; MedClinNorthAmMedClinNorthAm 1993;77:3271993;77:327--3333

Speaking of General Condition

What about labs?

Which Should Be Ordered as

Routine

Routine Preop

Preop Lab?

Lab?

20% 20% 20% 20% 20% _1._1.

CBC

2.

Coag

Coag Studies

Studies

3.

Basic

Basic Chem

Chem Panel

Panel

4. 4.

EKG

5. 5.

Other

“Routine”

“Routine” Preop

Preop Testing

Testing

CBC

Electrolytes,

Electrolytes, glc

glc, Cr

, Cr

EKG

CXR

PT/PTT

Preop

Preop Testing

Testing vs

vs None

None

Ambulatory surgery pts:

Ambulatory surgery pts: no difference

no difference in

in

perioperative

perioperative adverse events.

adverse events.

Cataract surgery:

Cataract surgery: no difference

no difference..

Cholecystectomy

Cholecystectomy (teaching hospital):

(teaching hospital):

2.1% of tests abnormal & potentially

significant, 0.66% resulted in action,

0.16%

benefitted from

benefitted from preop

preop management

management

changes.

AnesthAnalg

AnesthAnalg 2009;108:4672009;108:467--75; Cochrane Database 75; Cochrane Database SystSyst Rev. 2012;3:CD007293; Rev. 2012;3:CD007293; ArchIM

ArchIM 1987;147:11011987;147:1101--55

Preop

Preop Testing

Testing vs

vs None

None –

– 2

2

Elective surgery:

60% of tests not needed; 60% of tests not needed; 0.22%0.22%

w/abnormality possibly affecting

w/abnormality possibly affecting periopperiop

management, none of these were acted on & management, none of these were acted on &

no adverse consequences no adverse consequences..

Elective surgery, asymptomatic pts: 4.2% of Elective surgery, asymptomatic pts: 4.2% of

tests abnormal (18.8% predictable by H&P), tests abnormal (18.8% predictable by H&P), 29.4% of these (1.2% of all pts) prompted 29.4% of these (1.2% of all pts) prompted more

more evaleval0.26%0.26%of all pts required of all pts required treatment,

treatment, no surgeries delayed, no surgeries delayed, no no association between lab abnormality and association between lab abnormality and adverse outcome

adverse outcome..

JAMA 1985;253:3576

(4)

Preop

Preop Testing

Testing vs

vs None

None –

– 3

3

Review of studies of

Review of studies of preop

preop testing:

testing:

Normal test does not reduce chance of Normal test does not reduce chance of postoppostop

complications

complications for nearly all tests evaluated.for nearly all tests evaluated.

Exceptions:Exceptions:

••+ LR 3 + LR 3 –– 4 (small increase in likelihood of disease 4 (small increase in likelihood of disease if test is +) only for

if test is +) only for electrolytes, electrolytes, HgbHgb, renal , renal function.

function.

••Clinical evaluation Clinical evaluation predicts most abnormalities.predicts most abnormalities.

••PreopPreop management changed by test result in only management changed by test result in only 0

0 –– 3% of cases.3% of cases.

MedClinNorthAm

MedClinNorthAm 2003;87:72003;87:7--40; http://omerad.msu.edu/ebm/Diagnosis/Diagnosis6.html 40; http://omerad.msu.edu/ebm/Diagnosis/Diagnosis6.html

What About

What About Coags

Coags?

?

Unexpected & clinically significant bleeding Unexpected & clinically significant bleeding

disorders are unusual. disorders are unusual.

Most bleeding disorders are evident on Most bleeding disorders are evident on

history history..

Most common reasons for Most common reasons for ↑↑PTT are mild PTT are mild

factor XII deficiency & lupus anticoagulant

factor XII deficiency & lupus anticoagulant——

neither is

neither is assoc’dassoc’d w/bleeding or w/bleeding or postoppostop complications.

complications.

JAMA 1985;253:3576

JAMA 1985;253:3576--81; 81; BrJAnaesth 2011;106:1BrJAnaesth 2011;106:1--3; 3; ClinApplThrombHemostClinApplThrombHemost 2004;10:1952004;10:195––204; 204; ArchIMArchIM 1995;155:1409

1995;155:1409––15; 15; JThrombHaemostJThrombHaemost 2006;4:7662006;4:766––73; JAMA 1986;256:75073; JAMA 1986;256:750--3; 3; CanJAnaesthCanJAnaesth. 2006;53(6 . 2006;53(6 Suppl

Suppl):S12):S12--20; 20; MedClinNorthAmMedClinNorthAm 2003;87:72003;87:7--4040

What About

What About Coags

Coags?

? –

– 2

2

History or questionnaire is at least as

accurate as lab tests to predict clinically

significant bleeding.

Routine

Routine Preop

Preop Testing

Testing

Routine

preoperative testing in

asymptomatic patients is

asymptomatic patients is not

not

indicated

(even PT/PTT).

Selective

preop

preop testing based on likelihood

testing based on likelihood

of underlying condition that might affect

perioperative

perioperative management.

management.

HOWEVER: know your local

surgeons

’

patterns and practices. You are not likely

to change them, so make sure your pts get

the care they need.

Assessment of Cardiac Risk

Cardiovascular complications are the most

common & serious

common & serious perioperative

perioperative

complications.

Pts > 40 Pts > 40 yoyo (unselected): 1.4% (unselected): 1.4% periopperiop MI.MI.

Pts w/some CV risk factors: 3.2% Pts w/some CV risk factors: 3.2% periopperiop MI.MI.

Pts w/PAD: RR 3.1 for allPts w/PAD: RR 3.1 for all--cause mortality, 5.9 cause mortality, 5.9

for CV mortality, 6.6 for death d/t CAD. for CV mortality, 6.6 for death d/t CAD.

1/3 of

1/3 of periop

periop deaths are due to cardiac

deaths are due to cardiac

causes.

Chest 2006;130:584

Chest 2006;130:584––596; NEJM 2001;345:1677596; NEJM 2001;345:1677––82; 82; AnnIMAnnIM 2011;154:5232011;154:523--8; Anesthesiology 1998; 88:5728; Anesthesiology 1998; 88:572––578; 578; AmJSurg

AmJSurg 1997;174:7551997;174:755--8; 8; MedClinNorAmMedClinNorAm 2001;85:11512001;85:1151--69; N EJM 1995;333:175069; N EJM 1995;333:1750-- 6; ; N EJM 1992;326:3816; ; N EJM 1992;326:381--6; 6; http://www.uptodate.com/contents/estimation

http://www.uptodate.com/contents/estimation--ofof--cardiaccardiac--riskrisk--priorprior--toto--noncardiac noncardiac--surgery?source=search_result&search=preop+eval&selectedTitle=1~150#H21 surgery?source=search_result&search=preop+eval&selectedTitle=1~150#H21

Assessment of Cardiac Risk

Assessment of Cardiac Risk –

– 2

2

30 million surgeries/yr in US.

>8 million w/CV risk factors or CAD.>8 million w/CV risk factors or CAD.

50,000

50,000 periop

periop MI’s.

MI’s.

Most (74%) occur within 48 hrs of surgery.Most (74%) occur within 48 hrs of surgery.

Most pts (65%) did not have ischemic Most pts (65%) did not have ischemic sxsx..

Difficult to diagnose.Difficult to diagnose.

1010--41% mortality.41% mortality.

Prevention is important.Prevention is important.

Chest 2006;130:584

Chest 2006;130:584––596; NEJM 2001;345:1677596; NEJM 2001;345:1677––82; 82; AnnIMAnnIM 2011;154:5232011;154:523--8; Anesthesiology 1998; 88:5728; Anesthesiology 1998; 88:572––578; 578; AmJSurg

AmJSurg 1997;174:7551997;174:755--8; 8; MedClinNorAmMedClinNorAm 2001;85:11512001;85:1151--69; N EJM 1995;333:175069; N EJM 1995;333:1750-- 6; ; N EJM 1992;326:3816; ; N EJM 1992;326:381--6; http://www.uptodate.com/contents/estimation

(5)

Revised Cardiac Risk Index

(RCRI)

20 years after the original Goldman risk

index, a simplified method for determining

cardiac risk in

cardiac risk in noncardiac

noncardiac surgery.

surgery.

Derived & validated in original study (1999).Derived & validated in original study (1999).

Validated at another institution (2010).Validated at another institution (2010).

Limitations:

Less accurate for vascular Less accurate for vascular noncardiacnoncardiac

surgery,

surgery, espesp AAA.AAA.

Predicts cardiac, but not allPredicts cardiac, but not all--cause, mortality cause, mortality

(it’s a

(it’s a cardiaccardiacindex index –– duh!).duh!).

Circulation 1999;100:1043

Circulation 1999;100:1043--9; 9; AnnIM 2010;152:26AnnIM 2010;152:26--35; 35; ; CMAJ 2005;173:627; CMAJ 2005;173:627--3434

RCRI

RCRI –

– 2

2

Easy to use.

ACC/AHA finally incorporated RCRI into

its algorithm for

its algorithm for preop

preop eval

eval..

Easy to remember.

RCRI Mnemonic

D

R

C

©

Which is NOT Part of the RCRI

(DR C

44

)?

1 2 3 4 25% 25% 25% 25% 1. 1.

Diabetes

2. 2.

Dysrhythmia

3. 3.

CAD

4. 4.

Cerebrovascular

Dz

RCRI Mnemonic

D

R

C

RCRI Mnemonic

D

Diabetes requiring insulin

iabetes requiring insulin

R

Risky surgery

isky surgery

(intrathoracic, (intrathoracic, intraperitonealintraperitoneal, , vascular)

vascular)

C

CAD (including + test, EKG, etc)

AD (including + test, EKG, etc)

C

CHF

HF

C

Cerebrovascular

erebrovascular dz

dz hx

hx

C

Cr > 2.0

r > 2.0



David M. Schneider, MDDavid M. Schneider, MD

Circulation 1999;100:1043 Circulation 1999;100:1043--99

(6)

RCRI Interpretation

Count the risk factors to estimate cardiac

mortality

mortality!!

0 0 0.4%0.4% [<1%][<1%] 1 1 1.0%1.0% [1%][1%] 2 2 2.4 2.4 –– 6.6%6.6% [5%][5%] 3 or more 3 or more 5.4 5.4 –– 11.0%11.0% [10%][10%]

Some later studies had higher death rates,

but similar predictive value of increasing

RCRI score.

Circulation 1999;100:1043

Circulation 1999;100:1043--9 ; CMAJ 2005;173:6279 ; CMAJ 2005;173:627--3434

RCRI Predicts CV Morbidity,

Too

VFib

VFib/Cardiac arrest

/Cardiac arrest

Complete heart block

MI

Pulmonary edema

Risky Business Trivia 2

Curtis Armstrong Played Joel’s

Friend Miles in

Risky Business

.

His Next Role?

1 2 3 4

25% 25% 25% 25% 1.

1. GoovGoov ((Clan of Cave Clan of Cave Bear

Bear))

2.

2. Herbert Quentin Herbert Quentin “Burt” Viola “Burt” Viola ((MoonlightingMoonlighting))

3.

3. Booger (Booger (Revenge of Revenge of Nerds

Nerds))

4.

4. Ronnie (Ronnie (ConeheadsConeheads))

Steps to

Steps to Eval

Eval of CV Risk in Surgical

of CV Risk in Surgical

Pts

ACC/AHA updated guideline, 2009.

A bit cumbersome, but mostly

manageable.

Mnemonic for Steps in ACC

Algorithm

E

A

R

L

II

(i.e., “early”

(i.e., “early” eval

eval for CV

for CV dz

dz))



(7)

Mnemonic for Steps in ACC

Algorithm

E

Emergency?

mergency?

A

Active cardiac conditions?

ctive cardiac conditions?

R

Risk of surgical procedure

isk of surgical procedure

L

Limitation (functional capacity)

imitation (functional capacity)

IIndex (RCRI)

ndex (RCRI)



David M Schneider, MDDavid M Schneider, MD

Circulation 2009;120:e169 Circulation 2009;120:e169--e276e276

In Other Words…

5 steps:

1.

1. Is surgery an emergency?Is surgery an emergency? 2.

2. Does pt have active cardiac conditions?Does pt have active cardiac conditions? 3.

3. Is it a low risk surgery?Is it a low risk surgery? 4.

4. Does pt have good functional capacity?Does pt have good functional capacity? 5.

5. What clinical or surgeryWhat clinical or surgery--related risk factors related risk factors

does pt have by the RCRI? does pt have by the RCRI?

Step 1

Does the surgery need to be done

emergently?

Yes Yes go to OR!go to OR!

••PerioperativePerioperative surveillance.surveillance.

••PostopPostop risk stratification & management.risk stratification & management.

No No go to step 2.go to step 2.

Which Active Cardiac Condition is

NOT a Contraindication to

Surgery?

25% 25% 25%

25% _1._1.

Unstable angina

2.

Decompensated

Decompensated CHF

CHF

3.

Symptomatic Aortic Stenosis

4.

2

2°

°AV

AV Blk

Blk Type I (

Type I (Wenkebach

Wenkebach))

Step 2

Are there “active cardiac conditions”?

AAcute/unstable coronary syndromescute/unstable coronary syndromes

BBlocks/arrhythmiaslocks/arrhythmias

CCHFHF

SSevere evere sstenosestenoses

Yes

evaluate & treat per ACC

guideline.

No

go to step 3.

Active Cardiac Conditions

A

Acute/unstable coronary syndromes

cute/unstable coronary syndromes

Unstable or severe angina (NYHA/CCS III or Unstable or severe angina (NYHA/CCS III or

IV). IV).

Acute or recent MI (within 30 days).Acute or recent MI (within 30 days).

May include “stable” angina in patients who May include “stable” angina in patients who

are unusually sedentary. are unusually sedentary.

(8)

Grading Angina

Canadian CV SocietyCanadian CV Society 1.

1. Sx only w/strenuous Sx only w/strenuous

activity activity 2. 2. Sl limitationSl limitation——sx sx w/vigorous activity w/vigorous activity 3.

3. Mod limitationMod limitation——sx sx

w/everyday living w/everyday living activities activities

4.

4. Severe limitationSevere limitation——sx sx

w/any activity or @ w/any activity or @ rest rest NYHANYHA 1. 1. No limitation No limitation of of activity activity——no sx w/ no sx w/ ordinary activity ordinary activity 2. 2. Sl limitationSl limitation——sx sx w/ordinary activity w/ordinary activity 3.

3. Mod limitationMod limitation——sx sx

w/less

w/less--thanthan--ordinary ordinary activity

activity

4.

4. Severe limitationSevere limitation——sx sx

w/any activity or @ w/any activity or @ rest

rest

Active Cardiac Conditions

Active Cardiac Conditions –

– 2

2

B

Blocks/significant arrhythmias:

locks/significant arrhythmias:

HighHigh--grade AV block.grade AV block.

••MobitzMobitz II AV block.II AV block.

••ThirdThird--degree AV heart block.degree AV heart block.

Symptomatic ventricular arrhythmias.Symptomatic ventricular arrhythmias.

SupraventricularSupraventricular arrhythmias (including atrial arrhythmias (including atrial

fib) w/uncontrolled ventricular rate (HR > 100 fib) w/uncontrolled ventricular rate (HR > 100 @ rest).

@ rest).

Newly recognized ventricular tachycardia.Newly recognized ventricular tachycardia.

Symptomatic bradycardia.Symptomatic bradycardia.

Active Cardiac Conditions

– 3

3

Decompensated

C

Congestive heart failure

ongestive heart failure

NYHA class IVNYHA class IV

Worsening or new onset HFWorsening or new onset HF

Severity of CHF

NYHA

Class I Class I -- symptoms of HF only at activity symptoms of HF only at activity

levels that would limit normal individuals. levels that would limit normal individuals.

Class II Class II -- symptoms of HF with symptoms of HF with ordinary ordinary

exertion. exertion.

Class III Class III -- symptoms of HF with symptoms of HF with less than less than

ordinary exertion. ordinary exertion.

Class IV Class IV -- symptoms of HF at symptoms of HF at rest.rest.

Same scale as NYHA angina grading (or

CCS).

Active Cardiac Conditions

– 4

4

S

Severe valvular disease

evere valvular disease

Severe aortic Severe aortic sstenosistenosis

Symptomatic mitral Symptomatic mitral sstenosis (progressive tenosis (progressive

DOE, exertional

DOE, exertional presyncopepresyncope, HF) , HF)

Step 3

Risk of surgery

Low risk surgery Low risk surgery proceed to OR.proceed to OR.

(9)

Which is a Low Risk Surgery?

1 2 3 4 25% 25% 25% 25% 1. 1.

Mastectomy

2. 2.

Tonsillectomy

3.

Total Knee

Replacement

4. 4.

Appendectomy

Risks of Surgery

High risk (>5% CV events):

Aortic and other major vascular surgeryAortic and other major vascular surgery

Peripheral vascular surgeryPeripheral vascular surgery

Intermediate risk (1

Intermediate risk (1--5%):

5%):

IntraperitonealIntraperitoneal and intrathoracic surgeryand intrathoracic surgery

Carotid Carotid endarterectomyendarterectomy

Head and neck surgeryHead and neck surgery

Orthopedic surgeryOrthopedic surgery

Prostate surgeryProstate surgery

AmJMed

AmJMed 2005;118,11342005;118,1134--1141; Circulation 2009;120:e1691141; Circulation 2009;120:e169--e276; e276; EurHeartJEurHeartJ 2009;30:27692009;30:2769––812812

Risks of Surgery

Risks of Surgery –

– 2

2

Low risk surgery (<1% CV events)

Low risk surgery (<1% CV events) –

–

generally no additional CV testing

required:

AAmbulatory surgerymbulatory surgery

BBreast surgeryreast surgery

CCataract surgeryataract surgery

DDermerm/Superficial procedure/Superficial procedure

EEndoscopic proceduresndoscopic procedures

Step 4

Functional

Functional L

Limitation:

imitation:

Functional capacity Functional capacity ≥≥4 METs w/o 4 METs w/o sxsxgo to go to

OR. OR.

Functional capacity < 4 METs w/o Functional capacity < 4 METs w/o sxsxgo to go to

step 5. step 5.

••Walk up 2 flights Walk up 2 flights of stairs.of stairs.

••Walk 2 Walk 2 –– 4 blocks (flat).4 blocks (flat).

Step 5

Here is where the RCRI comes in.

Score 0 Score 0 go to OR.go to OR.

Score 1 Score 1 –– 2 2 either:either:

••Surgery w/Surgery w/possible possible ββ--blocker blocker if it will change mgmt.if it will change mgmt.

••ConsiderConsidernoninvasive testing.noninvasive testing.

Score Score ≥≥3:3:

••VascularVascularsurgery surgery considerconsiderfurther testing (if it will further testing (if it will change management) &

change management) & ββ--blockerblocker..

••IntermediateIntermediaterisk surgery risk surgery surgery w/surgery w/possible possible ββ --blocker

blocker OR OR considerconsidernoninvasive testing.noninvasive testing.

RCRI Mnemonic

D

Diabetes requiring insulin

iabetes requiring insulin

R

Risky surgery

isky surgery

(intrathoracic, (intrathoracic, intraperitonealintraperitoneal, , vascular)

vascular)

C

CAD (including + test, EKG, etc)

AD (including + test, EKG, etc)

C

CHF

HF

C

Cerebrovascular

erebrovascular dz

dz hx

hx

C

Cr > 2.0

r > 2.0



David M. Schneider, MDDavid M. Schneider, MD

(10)

Who Should Get

β

--Blocker?

Blocker?

25% 25% 25%

25% _1._1.

62

62 yo

yo F

F

carotid

carotid endarterectomy

endarterectomy

2.

81

81 yo

yo M

M

colonoscopy

3.

44

44 yo

yo F already on

F already on

β

--Blocker

Blocker

Mastectomy

4.

44

44 yo

yo M

M

liver transplant (no GIB)

Surgery w/

β

--blocker

blocker vs

vs More

More

Testing

Insufficient data.

11--2 risk factors:2 risk factors:

••2 studies in 2 studies in vascvasc surgsurg pts showed no difference in pts showed no difference in outcomes.

outcomes.

≥≥ 3 risk factors:3 risk factors:

••Degree of cardiac stress (change in HR, BP, Degree of cardiac stress (change in HR, BP, vascular volume, pain, bleeding, clotting vascular volume, pain, bleeding, clotting tendencies, oxygenation,

tendencies, oxygenation, neurohumoralneurohumoral activation, activation, other) may help determine risk of

other) may help determine risk of periopperiop cardiac cardiac events & need for testing.

events & need for testing.

JCardiothoracVas

JCardiothoracVas AnesthAnesth 2003;17:6942003;17:694--8; JACC 2006;48:9648; JACC 2006;48:964--99

Perioperative

β

--Blockers

Blockers

Conflicting early data:

1996: 1996: PeriopPeriop atenolol atenolol ↓↓mortality & CV mortality & CV

complications for 2 yrs in pts w/CAD or CAD complications for 2 yrs in pts w/CAD or CAD risk.

risk.

••Above study of ? validityAbove study of ? validity——small #’s, risk factors & small #’s, risk factors & meds not identical.

meds not identical.

DECREASE, 1999: DECREASE, 1999: preoppreop bisoprololbisoprolol↓↓MI & MI &

CV events by 90%. CV events by 90%.

••? Validity ? Validity –– small #’s, small #’s, unblindedunblinded, stopped early., stopped early.

ββ --blocker evidence considered unreliable.blocker evidence considered unreliable. NEJM 1996;335:1713

NEJM 1996;335:1713--20; N EJM 1996;335:176120; N EJM 1996;335:1761--3; 3; AmJMed 2005;118:1413; NEJM AmJMed 2005;118:1413; NEJM 1999;341:17891999;341:1789--94; 94; EurHeartJ

EurHeartJ 2001;22:13532001;22:1353--8; JAMA 2005;294:22038; JAMA 2005;294:2203--9; BMJ 2005;331:3139; BMJ 2005;331:313--2121

Perioperative

β

--Blockers

Blockers –

– 2

2

2006: No benefit in DM pts.

Periop

β

--Blockers

Blockers

↓

in

in--hosp mortality only

hosp mortality only

in high risk pts.

BMJ 2006;332:1482; NEJM 2005;353:349 BMJ 2006;332:1482; NEJM 2005;353:349--6161

POISE Study

Large RCT, 8351 pts w/atherosclerosis or

risk.

High dose metoprolol succinate High dose metoprolol succinate vsvs placebo.placebo.

Hold for HR < 50 or SBP < 100.Hold for HR < 50 or SBP < 100.

Combined endpoint CV death, nonfatal MI, or Combined endpoint CV death, nonfatal MI, or

nonfatal cardiac arrest. nonfatal cardiac arrest.

••16% 16% ↓↓_{in 1}_{in 1°}_{°endpoint, ARR = 1.1%}_{endpoint, ARR = 1.1%}_{NNT = 91.}_{NNT = 91.} ••MI MI ↓↓_{by 27%, ARR = 1.5%}_{by 27%, ARR = 1.5%}_{NNT = 67.}_{NNT = 67.} ••Total mortality Total mortality ↑↑↑↑↑↑↑↑_{33%, NNH = 125.}_{33%, NNH = 125.} ••CVA CVA ↑↑↑↑↑↑↑↑_{117%, NNH = 200.}_{117%, NNH = 200.} ••Hypotension Hypotension ↑↑↑↑↑↑↑↑_{55%, NNH = 19.}_{55%, NNH = 19.}

Lancet 2008;371:1839 Lancet 2008;371:1839--4747

Only 2% in POISE had RCRI

≥

3. ??

benefit.

NNH=293). NNH=293).

Other Other risksrisks::

••PeriopPeriop bradycardia: NNH = 22.bradycardia: NNH = 22.

••PeriopPeriop hypotension: NNH = 17.hypotension: NNH = 17.

••No increased risk of bronchospasm.No increased risk of bronchospasm.

Lancet 2008;372:1962 Lancet 2008;372:1962--7676

(11)

ACC/AHA

ACC/AHA Recs

Recs on

on

β

--Blockers

Blockers

Class I (benefit >> risk), intervention

should be done:

ContinueContinueββ--BlockersBlockers in pts already taking in pts already taking

(LOE C = consensus opinion, limited (LOE C = consensus opinion, limited studies).

studies).

ACC/AHA

ACC/AHA Recs

Recs on

on

β

--Blockers

Blockers –

–

2

Class

Class IIa

IIa (benefit > risk, more studies

(benefit > risk, more studies

needed, reasonable to do intervention),

LOE B (limited info, 1 RCT or some

unrandomized

unrandomized):

):

Beta blockers titrated to HR & BP Beta blockers titrated to HR & BP probablyprobably

recommended for pts undergoing

recommended for pts undergoing vascular vascular

surgery

surgerywho are at high cardiac risk d/t who are at high cardiac risk d/t CAD CAD or cardiac ischemia on preoperative testing or cardiac ischemia on preoperative testing. .

Circulation 2009;120:e169

Circulation 2009;120:e169--e276; JAMA 2001;285:1865e276; JAMA 2001;285:1865––1873; NEJM 1999;341:1789 1873; NEJM 1999;341:1789 ––94; Ann 94; Ann SurgSurg 2009;249:921

2009;249:921–– 66

ACC/AHA

ACC/AHA Recs

Recs on

on

β

--Blockers

Blockers –

–

3

Class

Class IIa

LOE B (limited info, 1 RCT or some

unrandomized

unrandomized):

):

Beta blockers titrated to HR & BP are Beta blockers titrated to HR & BP are

reasonable

reasonablefor patients undergoing for patients undergoing

intermediate

intermediate--risk surgery risk surgery in whom in whom preoperative assessment identifies

preoperative assessment identifies CAD or CAD or

RCRI > 1 RCRI > 1. .

Circulation 2009;120:e169--e276; JAMA 2001;285:1865e276; JAMA 2001;285:1865––1873; NEJM 1999;341:1789 1873; NEJM 1999;341:1789 ––94; Ann Surg 94; Ann Surg 2009;249:921

2009;249:921–– 66

ACC/AHA

ACC/AHA Recs

Recs on

on

β

--Blockers

Blockers –

–

4

Class

Class IIa

LOE C (consensus opinion, limited

studies):

Beta blockers titrated to HR & BP are Beta blockers titrated to HR & BP are

reasonable

reasonablefor pts in whom preoperative for pts in whom preoperative assessment for

assessment for vascular surgery vascular surgery identifies identifies high cardiac risk, as defined by

high cardiac risk, as defined by RCRI > 1RCRI > 1..

ACC/AHA

ACC/AHA Recs

Recs on

on

β

--Blockers

Blockers –

–

4

Class

Class IIb

IIb

The usefulness of beta blockers is The usefulness of beta blockers is uncertainuncertain

for pts who are undergoing either for pts who are undergoing either

intermediate

intermediate--risk procedures or vascular risk procedures or vascular surgery

surgery in whom preoperative assessment in whom preoperative assessment identifies a

identifies a single clinical risk factor single clinical risk factor in the in the absence of coronary artery disease. (LOE C) absence of coronary artery disease. (LOE C)

The usefulness of beta blockers is The usefulness of beta blockers is uncertainuncertain

in patients undergoing

in patients undergoing vascular surgery with vascular surgery with no clinical risk factors

no clinical risk factorswho are not currently who are not currently taking beta blockers. (LOE B)

taking beta blockers. (LOE B)

Summary on

β

--Blockers

Blockers

Continue

β

--Blockers

Blockers in pts already taking

in pts already taking

them.

Probably:

Pts w/Pts w/CADCADon on preoppreop testing (or testing (or knownknownhxhx) )

undergoing

undergoing vascularvascularsurgery.surgery.

Consider:

Pts w/known Pts w/known CAD or RCRI > 1 CAD or RCRI > 1 undergoing undergoing

intermed

intermedrisk surgery.risk surgery.

(12)

How to Use

β

--Blockers

Blockers

β

--1 selective preferred.

1 selective preferred.

Atenolol may be superior to metoprolol.Atenolol may be superior to metoprolol.

••1 study did not differentiate between metoprolol 1 study did not differentiate between metoprolol tartrate

tartrate (regular) & succinate (sustained release).(regular) & succinate (sustained release).

••Other study included pts on both metoprolol forms.Other study included pts on both metoprolol forms.

••POISE used metoprolol succinate.POISE used metoprolol succinate.

BisoprololBisoprolol more selective, no comparative more selective, no comparative

data. data.

BMJ 2005;331:932

BMJ 2005;331:932--8; Anesthesiology 2011;114:8248; Anesthesiology 2011;114:824--36; NEJM 1999;341:178936; NEJM 1999;341:1789--94; 94; JACC2010;56:1922

JACC2010;56:1922--9; Am 9; Am HeartJHeartJ 2006;152:9832006;152:983--90; Lancet 2008;371:183990; Lancet 2008;371:1839--4747

When to Give

β

--Blockers

Blockers

Begin

Begin po

po

β

--Blockers

Blockers at least

at least 7

7 –

– 30 days

30 days

before

surgery, if possible, to enhance

efficacy.

IV

β

--Blockers

Blockers (atenolol > metoprolol) may

(atenolol > metoprolol) may

be given shortly before surgery.

Who Should Get

Who Should Get Preop

Preop EKG?

EKG?

1 2 3 4 25% 25% 25% 25% 1. 1.

Nobody

2. 2.

Everybody

3. 3.

57

57 yo

yo M smoker +

M smoker +

low risk

low risk surg

surg

4.

Known CAD +

intermed

intermed risk

risk surg

surg

Who Should Get

Who Should Get Preop

Preop EKG?

EKG?

Class I

Recommended for pts Recommended for pts RCRI RCRI ≥≥11who are who are

undergoing

undergoing vascularvascularsurgical procedures LOE surgical procedures LOE B).

B).

Recommended for pts w/known Recommended for pts w/known CHD, PAD, or CHD, PAD, or

cerebrovascular

cerebrovascular diseasediseasewho are undergoing who are undergoing

intermediate

intermediate--riskrisksurgical procedures (LOE C).surgical procedures (LOE C).

Class

Class IIa

IIa

Reasonable in persons with Reasonable in persons with no clinical risk no clinical risk

factors

factorswho are undergoing who are undergoing vascularvascularsurgical surgical procedures. (LOE B).

procedures. (LOE B).

Maybe

Maybe Preop

Preop EKG?

EKG?

Class

Class IIb

IIb

Preoperative resting 12Preoperative resting 12--lead ECG lead ECG may be may be

reasonable

reasonable in patients with in patients with RCRI RCRI ≥≥11who are who are undergoing

undergoing intermediateintermediate--riskriskoperative operative procedures (LOE B).

procedures (LOE B).

Class III

Preoperative and postoperative resting 12Preoperative and postoperative resting

12--lead ECGs are not indicated in asymptomatic lead ECGs are not indicated in asymptomatic persons undergoing low

persons undergoing low--risk surgical risk surgical procedures

procedures (LOE B).(LOE B).

Controversy: Another View

2009 retrospective study reviewed EKG’s,

5 predictors of “significantly abnormal

EKG”:

Sensitivity 87.6%, specificity 59.5%.

Risk Factor OR CHF 12.18 Angina 7.49 MI 6.16 Severe valvular dz 4.80 Age > 65 4.08 High cholesterol 2.26 Anesthesiology 2009;110:1217 Anesthesiology 2009;110:1217--2222

(13)

What’s Wrong With This Data?

20% 20% 20% 20%

20% _1._1.

It’s Disease

It’s Disease--Oriented Evidence

Oriented Evidence

2.

Retrospective Study

3.

Not Pt

Not Pt--Oriented Evidence that Matters

Oriented Evidence that Matters

4.

Predict EKG findings, not pt outcomes

5.

All the above

Noninvasive Stress Testing

Class I

Pts w/Pts w/active cardiac conditions active cardiac conditions in whom in whom

noncardiac

noncardiac surgery is plannedsurgery is planned——evaleval & & TxTxper per ACC/AHA guidelines (LOE B).

ACC/AHA guidelines (LOE B).

Class

Class IIa

IIa

Pts w/Pts w/3 or more clinical risk factors (RCRI) 3 or more clinical risk factors (RCRI)

and poor functional capacity

and poor functional capacity (less than 4 (less than 4 METs) who require

METs) who require vascularvascularsurgerysurgery—— reasonable

reasonable if it will change management if it will change management (LOE (LOE B).

B).

Noninvasive Stress Testing

Noninvasive Stress Testing –

– 2

2

Class

Class IIb

IIb

Noninvasive stress testing may be Noninvasive stress testing may be consideredconsidered

for patients with

for patients with at least 1 to 2 clinical risk at least 1 to 2 clinical risk factors

factorsand and poor functional capacity poor functional capacity (less than (less than 4 METs) who require

4 METs) who require intermediate risk or intermediate risk or vascular

vascular surgery surgery if it will change if it will change management

management. (Level of Evidence: B). (Level of Evidence: B)

Circulation 2009;120:e169--e276; NEJM 1995;333:1750e276; NEJM 1995;333:1750--6; Circulation 6; Circulation 2006;113:1361

2006;113:1361--7676

Noninvasive Stress Testing

Noninvasive Stress Testing –

– 3

3

NOTE: stress testing has

NOTE: stress testing has high NPV

high NPV

(90+%), low PPV

(6

(6 –

– 67%, 18% in one

67%, 18% in one

review).

Useful in predicting low risk if neg.Useful in predicting low risk if neg.

Not as useful identifying high risk if +.Not as useful identifying high risk if +.

Echocardiography

Reasonable (Class

Reasonable (Class IIa

IIa, LOE C):

, LOE C):

DyspneaDyspneaof unknown etiology.of unknown etiology.

Current or prior Current or prior CHFCHFw/worsening dyspnea or w/worsening dyspnea or

other

other change in clinical statuschange in clinical status——if LV function if LV function has not been assessed within last 12 months. has not been assessed within last 12 months.

Summary

Higher risk

more

more preop

preop testing and

testing and

more treatment (

β

--blockers).

blockers).

Pt risk factorsPt risk factors

Risk of surgeryRisk of surgery

Cards consult:Cards consult:

••Acute cardiac condition.Acute cardiac condition.

••High risk High risk surgsurg + + intermedintermed risk pt, or vice versa.risk pt, or vice versa.

(14)

Perioperative

Perioperative Statins

Statins

ACC says:

Class IClass I

••ContinueContinuestatins in pts currently on statin and statins in pts currently on statin and scheduled for

scheduled for noncardiacnoncardiac surgery (LOE B).surgery (LOE B).

Class Class IIaIIa

••For pts undergoing For pts undergoing vascularvascularsurgery with or surgery with or without clinical risk factors, statin use is

without clinical risk factors, statin use is reasonablereasonable

(LOE B). (LOE B).

Class Class IIbIIb

••For pts w/For pts w/at least 1 clinical risk factor at least 1 clinical risk factor who are who are undergoing

undergoing intermediateintermediate--risk risk procedures, statins procedures, statins may be

may be considered considered (LOE C).(LOE C).

Perioperative

Perioperative Statins

Statins

Evidence says:

Statins may prevent Statins may prevent A Fib A Fib in pts undergoing in pts undergoing

cardiovascular & non

cardiovascular & non--cardiac surgery.cardiac surgery.

40% reduction in A Fib, even in pts already on 40% reduction in A Fib, even in pts already on β

β--blockers.blockers.

Statins reduce Statins reduce periopperiopmortalitymortality, MI, ischemia., MI, ischemia.

Some Some conflictingconflictingevidence.evidence.

These are high risk pts These are high risk pts consistent w/ACC consistent w/ACC

rec. rec.

Tune in again next time….

NEJM 2009;361:980

NEJM 2009;361:980--9; 9; JVascSurgJVascSurg 2004;39:9672004;39:967--75; JAMA 2004;291:209275; JAMA 2004;291:2092--9; Circulation 2003;107:18489; Circulation 2003;107:1848--51; 51; JACC 2005;45:336

JACC 2005;45:336--42; 42; AmJCardiolAmJCardiol 2007;100:3162007;100:316--20; 20; JThorCardiovascJThorCardiovasc SurgSurg 2008;135:4052008;135:405--411; 411; AnnThorCardiovascSurg

AnnThorCardiovascSurg 2011;17:3762011;17:376--82; 82; ArchSurgArchSurg 2012;147:1812012;147:181--189189

CV Risk Assessment: Not Quite

Ready For Prime Time

NSQIP (Nat’l Surgical

NSQIP (Nat’l Surgical Qual

Qual Improvement

Improvement

Prog

Prog))

Large retrospective study, internally validated.Large retrospective study, internally validated.

••Type of surgeryType of surgery

••Dependent functional statusDependent functional status

••Abnormal creatinineAbnormal creatinine

••American Society of Anesthesiologists' classAmerican Society of Anesthesiologists' class

••AgeAge

Performed better than RCRI.Performed better than RCRI.

Online calculator: Online calculator:

http://www.surgicalriskcalculator.com/miorcar http://www.surgicalriskcalculator.com/miorcar diacarrest

diacarrest

Circulation.2011;124:381

Circulation.2011;124:381--7; http://www.surgicalriskcalculator.com/miorcardiacarrest7; http://www.surgicalriskcalculator.com/miorcardiacarrest

CV Risk Assessment: Not Quite

Ready For Prime Time

Ready For Prime Time –

– 2

2

Erasmus index

Same as RCRI, adds ageSame as RCRI, adds age

Retrospective, not yet validated.Retrospective, not yet validated.

Ankle

Ankle--Brachial Index (ABI)

Brachial Index (ABI)

High risk population (19% DM, 14% CAD).High risk population (19% DM, 14% CAD).

ABI performed similarly to RCRI.ABI performed similarly to RCRI.

Abnormal ABI Abnormal ABI OR of 10.16 for cardiac OR of 10.16 for cardiac

complication. complication.

AmJMed

AmJMed 2005;118:11342005;118:1134––1141; 1141; AnesthAnalgAnesthAnalg 2008;107:1492008;107:149--5454

Case 1

You are called at 0200 by a surgeon to

see a pt with abdominal pain. The

surgeon tells you the pt is an 86

surgeon tells you the pt is an 86 yo

yo white

white

male with

male with CHF with

CHF with RLQ abdominal pain,

RLQ abdominal pain,

tenderness at

tenderness at McBurney’s

McBurney’s point, and a

point, and a

fever to 100.2. CBC shows WBC of 15.1

fever to 100.2. CBC shows WBC of 15.1..

Surgeon: “Please clear this pt for surgery.

I think I should wait until the morning and

have cardiology do an echo.”

86

86 yo

yo M w/H/O CHF &

M w/H/O CHF & Appy

Appy

sx

sx//sx

sx –

– echo?

echo?

33% 33%

33% _1._1.

Yes

Yes—

—echo only

echo only

2.

Yes

Yes—

—echo + Cardio

echo + Cardio eval

eval

3. 3.

No

(15)

Let’s Make it Crystal Clear

CT shows inflamed CT shows inflamed appendix appendix

In Other Words…

5 steps:

1.

1. Is surgery an emergency?Is surgery an emergency? 2.

2. Does pt have active cardiac conditions?Does pt have active cardiac conditions? 3.

3. Is it a low risk surgery?Is it a low risk surgery? 4.

4. Does pt have good functional capacity?Does pt have good functional capacity? 5.

5. What clinical or surgeryWhat clinical or surgery--related risk factors related risk factors

does pt have by the RCRI? does pt have by the RCRI?

In Other Words…

5 steps:

1.

1. Is surgery an emergency?Is surgery an emergency?

YES

YES go to OR!go to OR!

What Have We Learned?

1.

Functional limitations (4 METs)

2.

Ageism

3.

Preop labs

4.

Preop CV risk assessment

1. RCRI

2. ACC guidelines (“EARLI”)

3. Active cardiac conditions

4. Risks of surgeries

5. Preop EKG’s

What Have We Learned? – 2

5.

Periop management

1. Β-blockers

2. Statins

3. Preop cardiac testing

What Should You Sometimes

Say, per Miles?

1 2 3

33% 33% 33%

1.

1. The question isn't The question isn't "what are we going to "what are we going to do," the question is do," the question is "what aren't we going "what aren't we going to do?“

to do?“

2.

2. College women can College women can smell ignorance smell ignorance

3.

3. Sometimes you Sometimes you gottagotta say, “What the say, “What the @$%&.” @$%&.”