cornia presentation.ppt

The The preoperative medical preoperative medical

evaluation: evaluation: Risk stratification and prevention of Risk stratification and prevention of

complicationscomplications

June 3, 2009June 3, 2009HuBio600, Capstone IIHuBio600, Capstone II

Paul B. Cornia, MDPaul B. Cornia, MDVA Puget Sound HCS and University of VA Puget Sound HCS and University of

WashingtonWashington

Purpose of the preoperative Purpose of the preoperative medical evaluationmedical evaluation

““The purpose of preoperative evaluation is not to The purpose of preoperative evaluation is not to give medical clearance but rather to perform an give medical clearance but rather to perform an evaluation of the patient’s current medical evaluation of the patient’s current medical status; make recommendations concerning the status; make recommendations concerning the evaluation, management, and risk of (cardiac) evaluation, management, and risk of (cardiac) problems over the entire perioperative period; problems over the entire perioperative period; and provide a clinical risk profile that the patient, and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, primary physician, and nonphysician caregivers, anesthesiologist, and surgeon can use in making anesthesiologist, and surgeon can use in making treatment decisions that may influence short- treatment decisions that may influence short- and long-term cardiac outcomes. No test should and long-term cardiac outcomes. No test should be performed unless it is likely to influence be performed unless it is likely to influence patient treatment.” patient treatment.”

Fleisher, L. A. et al. Circulation 2007;116:e418-e499

Purpose of the preoperative Purpose of the preoperative medical evaluationmedical evaluation

““A critical role of the consultant is to determine A critical role of the consultant is to determine the stability of the patient’s (cardiovascular) the stability of the patient’s (cardiovascular) status and whether the patient is in optimal status and whether the patient is in optimal medical condition, within the context of the medical condition, within the context of the surgical illness.”surgical illness.”

““The consultant must also bear in mind that the The consultant must also bear in mind that the perioperative evaluation may be the ideal perioperative evaluation may be the ideal opportunity to effect the long-term treatment of a opportunity to effect the long-term treatment of a patient with significant cardiac disease or risk of patient with significant cardiac disease or risk of such disease.” such disease.”


Goals of the preoperative medical Goals of the preoperative medical evaluationevaluation

Identify medical conditions that may Identify medical conditions that may increase the risk of perioperative increase the risk of perioperative complicationscomplicationsOptimize these conditions, as possibleOptimize these conditions, as possibleRecommend preoperative testing only if it Recommend preoperative testing only if it aids in risk stratification patients or aids in risk stratification patients or influences managementinfluences managementRecommend postoperative measures that Recommend postoperative measures that may reduce the risk of complications may reduce the risk of complications

The Art of Consultation The Art of Consultation (for non-specialists)(for non-specialists)

“ “Although medical house staff and practicing Although medical house staff and practicing internists spend much of their time performing internists spend much of their time performing consultations, few training programs offer formal consultations, few training programs offer formal instruction in the subtleties of this art. Most instruction in the subtleties of this art. Most physicians learn how to perform consultation physicians learn how to perform consultation through trial and error, resulting in considerable through trial and error, resulting in considerable variability in consultative skills. Thus, some variability in consultative skills. Thus, some consultants are much sought after by their consultants are much sought after by their colleagues, while others have trouble translating colleagues, while others have trouble translating their expertise into effective consultation.” their expertise into effective consultation.”

Goldman L, Lee T, Rudd P. Arch Intern Med 1983; 143: 1753-5.

Ten Commandments for Effective Ten Commandments for Effective ConsultationConsultation

I.I. Determine the questionDetermine the questionII.II. Establish urgencyEstablish urgencyIII.III. Look for yourselfLook for yourselfIV.IV. Be as brief as appropriateBe as brief as appropriateV.V. Be specificBe specificVI.VI. Provide contingency plansProvide contingency plansVII.VII. Honor thy turf (or thou shalt not covet thy neighbor’s Honor thy turf (or thou shalt not covet thy neighbor’s

patient)patient)VIII.VIII. Teach…with tactTeach…with tactIX.IX. Talk is cheap…and effectiveTalk is cheap…and effectiveX.X. Follow-upFollow-up

Goldman L, Lee T, Rudd P. Arch Intern Med 1983; 143: 1753-5.

Perioperative cardiac carePerioperative cardiac carePreoperative cardiac evaluationPreoperative cardiac evaluation– Revised cardiac risk index (RCRI)Revised cardiac risk index (RCRI)– Preoperative cardiac testing Preoperative cardiac testing

Strategies to reduce postoperative cardiac Strategies to reduce postoperative cardiac complicationscomplications– Beta blockersBeta blockers– StatinsStatins– Revascularization (CARP trial)Revascularization (CARP trial)– Anti-platelet agents (especially in patients with drug-Anti-platelet agents (especially in patients with drug-

eluting coronary stents)eluting coronary stents)– OtherOther

Perioperative cardiac care: BackgroundPerioperative cardiac care: Background

Worldwide, ~100 million adults undergo noncardiac Worldwide, ~100 million adults undergo noncardiac surgery annually; ~30 million annually in the US. surgery annually; ~30 million annually in the US. Up to 1/2 have coronary artery disease (CAD) or risk Up to 1/2 have coronary artery disease (CAD) or risk factors for it.factors for it.Therapies for CAD allow persons to live longer…and Therapies for CAD allow persons to live longer…and develop conditions for which surgery may be develop conditions for which surgery may be considered to treat/cure disease (e.g., cancer considered to treat/cure disease (e.g., cancer resection) or improve quality of life (e.g., joint resection) or improve quality of life (e.g., joint replacement)replacement)

Perioperative cardiac care: BackgroundPerioperative cardiac care: Background

50,000 perioperative myocardial infarctions and 1 50,000 perioperative myocardial infarctions and 1 million cardiac complications occur annually in the million cardiac complications occur annually in the US. US. More than half of postoperative deaths are caused by More than half of postoperative deaths are caused by cardiac events.cardiac events.Perioperative cardiac complications prolong hospital Perioperative cardiac complications prolong hospital course by a mean of 11 days.course by a mean of 11 days.

– Fleischmann KE. Am J Med. 2003;115:515-20.Fleischmann KE. Am J Med. 2003;115:515-20.

Estimated cost perioperative cardiac complications Estimated cost perioperative cardiac complications (US) = $20 billion/year(US) = $20 billion/year

– Mangano DT. Anesthesiology. 1990;72:153-84.Mangano DT. Anesthesiology. 1990;72:153-84.

Case 1Case 1A 72 year old male is admitted to the hospital with a left hip A 72 year old male is admitted to the hospital with a left hip fracture. A preoperative medical evaluation is requested by the fracture. A preoperative medical evaluation is requested by the orthopedic surgeon. The injury was suffered after he tripped on a orthopedic surgeon. The injury was suffered after he tripped on a rug in his home. He is fairly active and walks approximately one rug in his home. He is fairly active and walks approximately one mile daily with rare angina and can climb 2 flights of stairs in his mile daily with rare angina and can climb 2 flights of stairs in his home without difficulty. home without difficulty.

His past medical history is notable for CAD with prior MI and His past medical history is notable for CAD with prior MI and subsequent CABG x3; hypertension; prior TIA; and recently subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus. diagnosed type 2 diabetes mellitus.

Current medications: aspirin 325 mg qd, simvastatin 20 mg qd, Current medications: aspirin 325 mg qd, simvastatin 20 mg qd, glyburide 5 mg bid, atenolol 25 mg qd, and lisinopril 10 mg qd. glyburide 5 mg bid, atenolol 25 mg qd, and lisinopril 10 mg qd.

Vital signs on admission are pulse 84 and blood pressure 162/90. Vital signs on admission are pulse 84 and blood pressure 162/90. Cardiopulmonary examination is unremarkable. ECG is notable Cardiopulmonary examination is unremarkable. ECG is notable for pathologic q waves in leads 1 and avL. for pathologic q waves in leads 1 and avL.

Preoperative medical evaluationPreoperative medical evaluation

When should I consider cancelling/delaying When should I consider cancelling/delaying surgery?surgery?– Decompensated/uncontrolled disease (e.g., Decompensated/uncontrolled disease (e.g.,

decompensated heart failure, asthma/COPD decompensated heart failure, asthma/COPD exacerbation, uncontrolled arrhythmia)exacerbation, uncontrolled arrhythmia)

– Uninvestigated symptoms or signs that may Uninvestigated symptoms or signs that may increase the risk of perioperative complications increase the risk of perioperative complications (e.g., uninvestigated angina) (e.g., uninvestigated angina)

Preoperative cardiovascular questions Preoperative cardiovascular questions for the medical consultantfor the medical consultant

1)1) Does the patient require additional cardiac Does the patient require additional cardiac testing (e.g., myocardial perfusion study, testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to coronary angiography) before proceeding to surgery?surgery?

2)2) What is the estimated cardiac risk?What is the estimated cardiac risk?

3)3) What can be done to decrease cardiac risk for What can be done to decrease cardiac risk for those at high (or intermediate) risk? those at high (or intermediate) risk?

Cardiac RiskCardiac Risk* * Stratification for Noncardiac Surgical Stratification for Noncardiac Surgical ProceduresProcedures

Risk Stratification Risk Stratification Procedure Examples Procedure Examples

Vascular Vascular

(reported cardiac risk often more than 5%) (reported cardiac risk often more than 5%)

Aortic and other major vascular surgeryAortic and other major vascular surgery

Peripheral vascular surgeryPeripheral vascular surgery

Intermediate Intermediate

(reported cardiac risk generally 1% to 5%) (reported cardiac risk generally 1% to 5%)

Intraperitoneal and intrathoracic surgeryIntraperitoneal and intrathoracic surgery

Carotid endarterectomyCarotid endarterectomy

Head and neck surgeryHead and neck surgery

Orthopedic surgeryOrthopedic surgery

Prostate surgeryProstate surgery

Low Low

(reported cardiac risk generally less than (reported cardiac risk generally less than 1%) 1%)

Endoscopic proceduresEndoscopic procedures

Superficial procedureSuperficial procedure

Cataract surgeryCataract surgery

Breast surgeryBreast surgery

Ambulatory surgeryAmbulatory surgery

*Combined incidence of cardiac death and nonfatal myocardial infarction.

Eagle, K. A. et al. Circulation 2002;105:1257-1267

Copyright ©2007 American Heart Association


Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known

cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater

Case 1Case 1

1)1) Does the patient require additional cardiac Does the patient require additional cardiac testing (e.g., myocardial perfusion study, testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to coronary angiography) before proceeding to surgery?surgery?

No – proceed to surgery without additional cardiac No – proceed to surgery without additional cardiac testing.testing.When to consider:When to consider:– Angina that has not been investigatedAngina that has not been investigated– High risk patients undergoing moderate or high risk surgery High risk patients undergoing moderate or high risk surgery

with poor functional status, if it will alter managementwith poor functional status, if it will alter management

Revised Cardiac Risk IndexRevised Cardiac Risk Index

1)1) High risk surgery (major vascular, intra-High risk surgery (major vascular, intra-abdominal, or intrathoracic)abdominal, or intrathoracic)

2)2) Ischemic heart disease (h/o MI, Q waves, Ischemic heart disease (h/o MI, Q waves, angina, use of nitrates, or positive stress test)angina, use of nitrates, or positive stress test)

3)3) Congestive heart failureCongestive heart failure4)4) Cerebrovascular disease (prior stroke or TIA)Cerebrovascular disease (prior stroke or TIA)5)5) Insulin-treated diabetes mellitusInsulin-treated diabetes mellitus6)6) Renal insufficiency (serum creatinine >2.0 Renal insufficiency (serum creatinine >2.0

mg/dL)mg/dL)

Lee TH et al. Circulation. 1999; 100: 1043-1049.

Preoperative cardiac risk stratification:Preoperative cardiac risk stratification:Revised Cardiac Risk IndexRevised Cardiac Risk Index

•*Major cardiac events = cardiac arrest, MI (fatal or non-fatal)•**All cardiac events = cardiac arrest, MI (fatal or non-fatal), pulmonary edema, or complete heart block.

ClassClass Number Number

of predictorsof predictors

Major cardiac Major cardiac

events, % *events, % *

All cardiac All cardiac

events, % **events, % **

II 00 0.4 0.4

(0.1-0.8)(0.1-0.8)

0.5 0.5

(0.05-1.5)(0.05-1.5)

IIII 11 1.0 1.0

(0.5-1.4)(0.5-1.4)

0.9 0.9

(0.3-2.1)(0.3-2.1)

IIIIII 22 2.4 2.4

(1.3-3.5)(1.3-3.5)

6.6 6.6

(3.9-10.3)(3.9-10.3)

IVIV ≥≥33 5.4 5.4

(2.8-7.9)(2.8-7.9)

11.0 11.0

(5.8-18.4)(5.8-18.4)

Lee TH. Circulation. 1999;100:1043-9.

Case 1Case 1

1)1) What is the estimated cardiac risk?What is the estimated cardiac risk?

““His past medical history is notable for CAD with prior M His past medical history is notable for CAD with prior M and subsequent CABG x3; hypertension; prior TIA; and and subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus.” recently diagnosed type 2 diabetes mellitus.”

– RCRI score = 2RCRI score = 2

– ~5-10% risk of perioperative cardiac ~5-10% risk of perioperative cardiac complicationscomplications

Perioperative cardiac events:Perioperative cardiac events:PathophysiologyPathophysiology

Cardiac deathCardiac death– Myocardial infarction (MI), fatal arrhythmia, or heart Myocardial infarction (MI), fatal arrhythmia, or heart

failurefailure

MIMI– Majority of Majority of non-operativenon-operative MIs are due to atherosclerotic MIs are due to atherosclerotic

plaque rupture plaque rupture thrombosis thrombosis– Perioperative MIPerioperative MI

Limited available data is conflictingLimited available data is conflicting– Datwood MM. Int J Cardiol. 1996;57-37-44.Datwood MM. Int J Cardiol. 1996;57-37-44.– Cohen MC. Cardiovasc Pathol. 1999;8:133-9.Cohen MC. Cardiovasc Pathol. 1999;8:133-9.– Landesberg G. J Cardiothorac Vasc Anesth. 2003;17:90-100.Landesberg G. J Cardiothorac Vasc Anesth. 2003;17:90-100.

Plaque rupture Plaque rupture oror prolonged myocardial oxygen supply-demand prolonged myocardial oxygen supply-demand mismatch (in setting of CAD)mismatch (in setting of CAD)

Perioperative cardiac care: Perioperative cardiac care: PathophysiologyPathophysiology

Postoperative period is a hyperadrenergic state – an extreme stress test.Postoperative period is a hyperadrenergic state – an extreme stress test.Also, inflammation and hypercoagulabilityAlso, inflammation and hypercoagulabilitySeveral studies have linked postoperative myocardial ischemia (assessed Several studies have linked postoperative myocardial ischemia (assessed by continuous ECG monitoring) to postoperative cardiac events, as well as by continuous ECG monitoring) to postoperative cardiac events, as well as long-term cardiac morbidity and mortality.long-term cardiac morbidity and mortality.Hypothesis:Hypothesis:– (Relative) tachycardia (Relative) tachycardia myocardial O2 supply/demand mismatch myocardial O2 supply/demand mismatch

shear stress across atherosclerotic plaque shear stress across atherosclerotic plaque plaque rupture plaque rupture thrombus thrombus MI MI

Postoperative myocardial ischemia is:Postoperative myocardial ischemia is:– commoncommon– almost always clinically silentalmost always clinically silent– associated with relative tachycardiaassociated with relative tachycardia

Copyright ©2005 Canadian Medical Association or its licensors

Devereaux, P.J. et al. CMAJ 2005;173:779-788

Case 2Case 2 A 72 year-old male is referred for preoperative medical evaluation A 72 year-old male is referred for preoperative medical evaluation

prior to partial colectomy for colon cancer. prior to partial colectomy for colon cancer.

PMHx: DM2; hypertension; stage 3 CKD (SCr 2.2); h/o CVA (mild PMHx: DM2; hypertension; stage 3 CKD (SCr 2.2); h/o CVA (mild residual right arm weakness); hyperlipidemia; mild COPD; GERDresidual right arm weakness); hyperlipidemia; mild COPD; GERD

Medications: Insulin (basal NPH, prandial regular), HCTZ 25 mg qd, Medications: Insulin (basal NPH, prandial regular), HCTZ 25 mg qd, lisinopril 20 mg qd, simvastatin 20 mg qd, omeprazole 20 mg qd, lisinopril 20 mg qd, simvastatin 20 mg qd, omeprazole 20 mg qd, albuterol MDI prnalbuterol MDI prn

Functional status is excellent. He has no angina or heart failure sx’s. Functional status is excellent. He has no angina or heart failure sx’s. Cardiopulmonary examination and ECG are normal.Cardiopulmonary examination and ECG are normal.

Case 2Case 2

For this patient, strong evidence exists to For this patient, strong evidence exists to support the use of a prophylactic perioperative support the use of a prophylactic perioperative beta-blocker in this patient to reduce the risk beta-blocker in this patient to reduce the risk of cardiac complications (i.e., class I of cardiac complications (i.e., class I recommendation, level A evidence).recommendation, level A evidence).

1. True1. True2. False2. False

Perioperative cardiac care: Perioperative cardiac care: Beta-blockade – landmark trialsBeta-blockade – landmark trials

200 patients scheduled for noncardiac surgery who had or 200 patients scheduled for noncardiac surgery who had or were at risk for CAD were randomized to receive either were at risk for CAD were randomized to receive either perioperative atenolol or placebo. perioperative atenolol or placebo.

Atenolol was started on the day of surgery and continued for Atenolol was started on the day of surgery and continued for the length of the hospitalization to a maximum of 7 days. the length of the hospitalization to a maximum of 7 days.

No difference in in-hospital cardiac morbidity/mortality (as No difference in in-hospital cardiac morbidity/mortality (as expected). expected).

Prospective follow-up (for 2 years) showed a decrease in both Prospective follow-up (for 2 years) showed a decrease in both overall mortality and event free survival with perioperative overall mortality and event free survival with perioperative beta-blockade.beta-blockade.

Mangano DT et al. N Engl J Med 1996; 335: 1713-20.



2- year survival =90%

2- year survival =79%



2- year event free survival =68%

2- year event free survival =83%


112 patients scheduled for elective major vascular 112 patients scheduled for elective major vascular surgery (AAA repair or lower extremity surgery (AAA repair or lower extremity revascularization) with a positive dobutamine revascularization) with a positive dobutamine echocardiogram randomized to bisoprolol or placebo.echocardiogram randomized to bisoprolol or placebo.

Bisoprolol was started at least 1 week preoperatively, Bisoprolol was started at least 1 week preoperatively, uptitrated if heart rate >60 bpm, and continued for 30 uptitrated if heart rate >60 bpm, and continued for 30 days postoperatively. days postoperatively.

Dramatic reduction in 30-day postoperative cardiac Dramatic reduction in 30-day postoperative cardiac death and non-fatal MI. death and non-fatal MI.

Poldermans D et al. N Engl J Med 1999; 341: 1789-94.


Poldermans D et al. N Engl J Med 1999; 341: 1789-94.

Cardiacdeath ornon-fatalMI

Perioperative beta-blockade…what’s Perioperative beta-blockade…what’s newnew

Recent trials showing no benefit Recent trials showing no benefit – POBBLE trial POBBLE trial ((J Vasc Surg 2005; 41: 602-9.)

103 patients without known CAD undergoing elective vascular surgery. 103 patients without known CAD undergoing elective vascular surgery. Randomized to metoprolol (Randomized to metoprolol (fixed dosefixed dose) or placebo () or placebo (started on admissionstarted on admission, continued for up to 7 , continued for up to 7 days).days).

– MaVS study (Am Heart J. 2006;152:983-90.)496 patients undergoing elective vascular surgery. undergoing elective vascular surgery. Randomized to metoprolol (Randomized to metoprolol (fixed dosefixed dose) or placebo () or placebo (started on admissionstarted on admission, continued for up to 5 , continued for up to 5 days).days).

– DIPOM trial (BMJ. 2006;332:1482-8.)921 patients with diabetes undergoing major, non-cardiac surgery.Randomized to metoprolol (Randomized to metoprolol (fixed dosefixed dose) or placebo () or placebo (started 1 day before surgerystarted 1 day before surgery, continued for , continued for up to 8 days).up to 8 days).

– Large (>300 hospitals, >700k patients), retrospective database study confirmed Large (>300 hospitals, >700k patients), retrospective database study confirmed reduced mortality in high and (probably) intermediate risk, but trend towards reduced mortality in high and (probably) intermediate risk, but trend towards harm in low risk. harm in low risk. ((Lindenauer PK et al. N Engl J Med 2005; 353: 348-61.)

Perioperative beta-blockade: PeriOperative Perioperative beta-blockade: PeriOperative ISchemic Evaluation (POISE) trialISchemic Evaluation (POISE) trial

190 hospitals, 23 countries, 8351 patients enrolled190 hospitals, 23 countries, 8351 patients enrolledInclusion:Inclusion:– >45 yrs old, expected hospitalization >24 hours, and: CAD; PVD; prior >45 yrs old, expected hospitalization >24 hours, and: CAD; PVD; prior

stroke; hospitalization for CHF within 3 years; major vascular surgery; stroke; hospitalization for CHF within 3 years; major vascular surgery; or any 3 of the following: intrathoracic or intraperitoneal surgery, h/o or any 3 of the following: intrathoracic or intraperitoneal surgery, h/o CHF, h/o TIA, DM, Cr >2.0, >70 yrs old, or emergent/urgent surgery)CHF, h/o TIA, DM, Cr >2.0, >70 yrs old, or emergent/urgent surgery)

Exclusion:Exclusion:– HR <50 bpm, 2HR <50 bpm, 2ndnd or 3 or 3rdrd degree AVB, asthma, on beta-blocker or degree AVB, asthma, on beta-blocker or

planned periop beta-blockade, prior ADR with beta-blocker, CABG planned periop beta-blockade, prior ADR with beta-blocker, CABG within 5 yrs and no recurrent angina; low risk surgery; on verapamil. within 5 yrs and no recurrent angina; low risk surgery; on verapamil.

Primary outcome = cardiac death, non-fatal cardiac arrest or Primary outcome = cardiac death, non-fatal cardiac arrest or non-fatal MInon-fatal MI

POISE study group. Lancet 2008;371:1839-47.

Perioperative beta-blockade: POISE Perioperative beta-blockade: POISE trialtrial

Randomized to metoprolol XL vs. placeboRandomized to metoprolol XL vs. placebo– 11stst dose metoprolol XL = 100mg, given 2-4 hours preop dose metoprolol XL = 100mg, given 2-4 hours preop

– If HR > 80 bpm or SBP >100 mmHg at any time 1If HR > 80 bpm or SBP >100 mmHg at any time 1stst 6 hours 6 hours after surgery, another dose of metoprolol 100mg after surgery, another dose of metoprolol 100mg administered.administered.

– Daily dosage metoprolol 200mg thereafter x30 daysDaily dosage metoprolol 200mg thereafter x30 days

– If HR < 45 bpm or SBP <100 mmHg consistently, decrease If HR < 45 bpm or SBP <100 mmHg consistently, decrease metoprolol to 100mg qdmetoprolol to 100mg qd



Metoprolol Metoprolol PlaceboPlacebo HRHR p valuep value

Primary Primary

outcomeoutcome

244 244

(5.8%)(5.8%)

290290

(6.9%)(6.9%)

0.840.84

(0.70-0.99)(0.70-0.99)

0.03990.0399

Non-fatalNon-fatal

MIMI

152152

(3.6%)(3.6%)

215215

(5.1%)(5.1%)

0.700.70

(0.57-0.86)(0.57-0.86)

0.00080.0008

StrokeStroke 4141

(1.0%)(1.0%)

1919

(0.5%)(0.5%)

2.172.17

(1.26-3.74)(1.26-3.74)

0.00530.0053

TotalTotal

mortalitymortality

129129

(3.1%)(3.1%)

9797

(2.3%)(2.3%)

1.331.33

(1.03-1.74)(1.03-1.74)

0.03170.0317



Meta-analysis of β-blocker trials in patients undergoing non-cardiac surgery


Perioperative cardiac care: Perioperative cardiac care: Beta-blockade…bottom lineBeta-blockade…bottom line

For patients chronically receiving beta-For patients chronically receiving beta-blockers blockers continue perioperatively continue perioperatively

Which patients may benefit from Which patients may benefit from prophylacticprophylactic beta-blockade, if any, is uncertain. beta-blockade, if any, is uncertain. – My opinion:My opinion:

High risk patients (RCRI High risk patients (RCRI ≥3) are likely to benefit≥3) are likely to benefit

Must be started days to weeks before surgery with dose Must be started days to weeks before surgery with dose titration to achieve resting heart rate < ~70 bpmtitration to achieve resting heart rate < ~70 bpm

Perioperative cardiac care:Perioperative cardiac care:What about the other cardiac meds?What about the other cardiac meds?

In general:In general:– Continue uninterrupted including the morning of surgery:Continue uninterrupted including the morning of surgery:

Beta-blockersBeta-blockers

Calcium channel blockersCalcium channel blockers

Centrally acting alpha agonists (e.g., clonidine)Centrally acting alpha agonists (e.g., clonidine)

NitratesNitrates

DigoxinDigoxin

– Hold morning of surgery, resume postop:Hold morning of surgery, resume postop:ACE-I, ARB (if using for CHF or baseline BP is low – risk of ACE-I, ARB (if using for CHF or baseline BP is low – risk of intraop hypotension)intraop hypotension)

DiureticsDiuretics

Pathophysiology of perioperative MI is believed to be Pathophysiology of perioperative MI is believed to be similar to non-perioperative MI (i.e., plaque rupture similar to non-perioperative MI (i.e., plaque rupture in many cases)in many cases)

Pleiotropic effects of statins are well knownPleiotropic effects of statins are well known– Anti-inflammatory, stabilize vulnerable atherosclerotic Anti-inflammatory, stabilize vulnerable atherosclerotic

plaques, reduce platelet aggregation, improve endothelial plaques, reduce platelet aggregation, improve endothelial vasodilationvasodilation

Perioperative cardiac care: Perioperative cardiac care: StatinsStatins

Perioperative cardiac care: Perioperative cardiac care: StatinsStatins

Retrospective studiesRetrospective studies– Case control study of patients undergoing major vascular surgeryCase control study of patients undergoing major vascular surgery

4 fold reduction in perioperative morality in patients that received 4 fold reduction in perioperative morality in patients that received perioperative statins. perioperative statins.

– Poldermans D et al. Circulation 2003; 107: 1848-51.Poldermans D et al. Circulation 2003; 107: 1848-51.– Large cohort study of patients undergoing major noncardiac surgeryLarge cohort study of patients undergoing major noncardiac surgery

Reduced crude mortality rates in patients that received perioperative Reduced crude mortality rates in patients that received perioperative statins. statins. Benefit was greatest in patients at highest risk (RCRI Benefit was greatest in patients at highest risk (RCRI ≥≥4). 4).

– Lindenauer PK. JAMA 2004; 291: 2092-99.Lindenauer PK. JAMA 2004; 291: 2092-99.Single, small, RCT comparing 45 days of perioperative atorvastatin (irrespective of Single, small, RCT comparing 45 days of perioperative atorvastatin (irrespective of serum cholesterol) to placebo.serum cholesterol) to placebo.– 69% relative risk reduction in composite endpoint (death, nonfatal MI, stroke, 69% relative risk reduction in composite endpoint (death, nonfatal MI, stroke,

unstable angina) with atorvastatin.unstable angina) with atorvastatin.Durazzo AE et al. J Vasc Surg 2004; 39: 967-75.

Available data is encouraging and suggests benefit, Available data is encouraging and suggests benefit, risk is largely unknown – larger, prospective trials are risk is largely unknown – larger, prospective trials are ongoingongoing– DECREASE IV DECREASE IV large RCT of beta-blocker (titrated), large RCT of beta-blocker (titrated),

statin, beta-blocker + statin, or placebo.statin, beta-blocker + statin, or placebo.

Bottom line:Bottom line:– Insufficient data to recommend routine perioperative statin Insufficient data to recommend routine perioperative statin

use.use.

– Consider continuing statin therapy perioperatively, Consider continuing statin therapy perioperatively, particularly in high-risk patients. particularly in high-risk patients.

Perioperative cardiac risk reduction: Perioperative cardiac risk reduction: Statin therapyStatin therapy

Perioperative cardiac care: Perioperative cardiac care: Prophylactic revascularization - Prophylactic revascularization -

backgroundbackgroundExpert groups and practice guidelines recommend preoperative Expert groups and practice guidelines recommend preoperative revascularization only if indicated for reasons independent of revascularization only if indicated for reasons independent of the non-cardiac surgery, but substantial variability in practice the non-cardiac surgery, but substantial variability in practice patterns exists.patterns exists.Observational studies (CASS and BARI) have suggested that Observational studies (CASS and BARI) have suggested that recent (<5 years) coronary revascularization reduces the risk of recent (<5 years) coronary revascularization reduces the risk of cardiac complications for subsequent non-cardiac operationscardiac complications for subsequent non-cardiac operations

– Eagle KA. Circulation 1997; 96: 1882-7.Eagle KA. Circulation 1997; 96: 1882-7.– Hassan SA. Am J Med 2001; 110: 260-6.Hassan SA. Am J Med 2001; 110: 260-6.

Increased rates of in-stent thrombosis Increased rates of in-stent thrombosis perioperative MI and perioperative MI and cardiac death when non-cardiac surgery performed in the cardiac death when non-cardiac surgery performed in the immediate period following PCIimmediate period following PCI

– Kaluza GL. J Am Coll Cardiol 2000; 35: 1288-94.Kaluza GL. J Am Coll Cardiol 2000; 35: 1288-94.– Wilson SH. J Am Coll Cardiol 2003; 42: 234-40.Wilson SH. J Am Coll Cardiol 2003; 42: 234-40.

Perioperative cardiac care: Perioperative cardiac care: Prophylactic revascularization – CARP Prophylactic revascularization – CARP

trialtrialRandomized controlled trial conducted at 18 VA Randomized controlled trial conducted at 18 VA medical centers.medical centers.510 patients with stable CAD (510 patients with stable CAD (≥70% stenosis in at ≥70% stenosis in at least one major coronary artery) scheduled for least one major coronary artery) scheduled for vascular surgery (AAA repair [1/3] or lower vascular surgery (AAA repair [1/3] or lower extremity bypass surgery [2/3]) randomized to extremity bypass surgery [2/3]) randomized to prophylactic revascularization (CABG [~40%] or PCI prophylactic revascularization (CABG [~40%] or PCI [~60%]) or none.[~60%]) or none.Medical therapy (including beta-blockade and statins) Medical therapy (including beta-blockade and statins) was equivalent in the 2 groupswas equivalent in the 2 groups

McFalls EO et al. N Engl J Med 2004; 351: 2795-804.

Perioperative cardiac care: Perioperative cardiac care: Prophylactic revascularization – CARP Prophylactic revascularization – CARP

trialtrial

No difference in 30-day No difference in 30-day rates of MI, stroke, limb rates of MI, stroke, limb loss, or dialysis loss, or dialysis

No difference in long-No difference in long-term mortalityterm mortality

McFalls EO et al. N Engl J Med 2004; 351: 2795-804.

Case 3Case 3 70 year-old male referred for preoperative medical evaluation 70 year-old male referred for preoperative medical evaluation

prior to planned RRP for recently dx’ed prostate cancer (PSA prior to planned RRP for recently dx’ed prostate cancer (PSA 21, Gleason 8, confined to prostate). 21, Gleason 8, confined to prostate).

PMHx: CAD (h/o MI, s/p CABG 10 years ago, and PCI PMHx: CAD (h/o MI, s/p CABG 10 years ago, and PCI 2 months ago for class 3 angina), HTN, hyperlipidemia, 2 months ago for class 3 angina), HTN, hyperlipidemia,

tobaccotobacco

Medications: ASA 325 mg qd, clopidogrel 75 mg qd, Medications: ASA 325 mg qd, clopidogrel 75 mg qd, metoprolol 50 mg bid, lisinopril 10 mg qd, simvastatin 40 mg metoprolol 50 mg bid, lisinopril 10 mg qd, simvastatin 40 mg qdqd

Functional status is good and he has had no angina since the Functional status is good and he has had no angina since the recent PCI. recent PCI.

Regarding perioperative anti-platelet Regarding perioperative anti-platelet management, you recommend:management, you recommend:

1.1. Hold aspirin and clopidogrel for 7 days preop and resume as Hold aspirin and clopidogrel for 7 days preop and resume as soon as possible postopsoon as possible postop

2.2. Hold clopidogrel for 7 days preop and resume as soon as Hold clopidogrel for 7 days preop and resume as soon as possible postop; continue aspirin (uninterrupted) possible postop; continue aspirin (uninterrupted) perioperativelyperioperatively

3.3. Hold aspirin for 7 days preop and resume as soon as Hold aspirin for 7 days preop and resume as soon as possible postop; continue clopidogrel (uninterrupted) possible postop; continue clopidogrel (uninterrupted) perioperativelyperioperatively

4.4. Cancel surgery, interruption of anti-platelet agents is not Cancel surgery, interruption of anti-platelet agents is not safesafe

5.5. More information is neededMore information is needed

PCI: generalPCI: generalPTCA alonePTCA alone– Relatively high rates of acute (during or immediately after procedure) Relatively high rates of acute (during or immediately after procedure)

and subacute (within 30 days) thrombosis or restenosisand subacute (within 30 days) thrombosis or restenosis

– Uncommonly used because of these limitationsUncommonly used because of these limitations

PTCA vs. Coronary stents (Bare metal and drug-PTCA vs. Coronary stents (Bare metal and drug-eluting [DES]) eluting [DES])

Acute (hours) thrombosis: up to 10% Acute (hours) thrombosis: up to 10% <1% <1%

Subacute (days) thrombosis: 5% Subacute (days) thrombosis: 5% 0.5-1% 0.5-1%

Restenosis: 30-40% (PTCA) vs. 20-30% (bare-metal) vs. <10% Restenosis: 30-40% (PTCA) vs. 20-30% (bare-metal) vs. <10% (DES) (DES)

Late thrombosis: DESLate thrombosis: DES

Drug-eluting coronary stentsDrug-eluting coronary stents

Schuchman M. N Engl J Med 2007; 356: 325-8

Drug-eluting coronary stentsDrug-eluting coronary stents

Dual anti-platelet therapy reduces the risk cardiac Dual anti-platelet therapy reduces the risk cardiac events following DESevents following DESPremature discontinuation may lead to in-stent Premature discontinuation may lead to in-stent thrombosis thrombosis MI, cardiac death. MI, cardiac death.Increasing reports of late (>1 month thrombosis) led to Increasing reports of late (>1 month thrombosis) led to recent ACC/AHA recommendation of 12 months dual recent ACC/AHA recommendation of 12 months dual antiplatelet therapy following DESantiplatelet therapy following DES

– Casey DE. Circulation. 2007; 115: 1-6.Casey DE. Circulation. 2007; 115: 1-6.

Elective procedures should be deferred at least until 12-Elective procedures should be deferred at least until 12-month course of dual antiplatelet therapy complete (or month course of dual antiplatelet therapy complete (or procedure may performed without interruption of procedure may performed without interruption of antiplatelet therapy). antiplatelet therapy).

Case 4Case 4

An 62-year old clinic patient of your with severe COPD An 62-year old clinic patient of your with severe COPD presents for preoperative evaluation prior to elective presents for preoperative evaluation prior to elective cholecystectomy. He smokes 1 pack of cigarettes daily. cholecystectomy. He smokes 1 pack of cigarettes daily. He is functionally limited by dyspnea, but this is stable. He is functionally limited by dyspnea, but this is stable.

His medications include inhaled albuterol/ipratroprium His medications include inhaled albuterol/ipratroprium qid, inhaled albuterol prn, and prednisone 10 mg qd. qid, inhaled albuterol prn, and prednisone 10 mg qd.

What are your recommendations?What are your recommendations?

Preoperative pulmonary risk Preoperative pulmonary risk stratification: Backgroundstratification: Background

Decreased lung volumes and atelectasis are the Decreased lung volumes and atelectasis are the principal cause of postoperative pulmonary principal cause of postoperative pulmonary complicationscomplicationsPostoperative pulmonary complications: Postoperative pulmonary complications: atelectasis, pneumonia, prolonged mechanical atelectasis, pneumonia, prolonged mechanical ventilation, respiratory failure, and exacerbation of ventilation, respiratory failure, and exacerbation of chronic lung diseasechronic lung diseasePostoperative pulmonary complications are as Postoperative pulmonary complications are as common as cardiac complicationscommon as cardiac complicationsPostoperative pulmonary complications may Postoperative pulmonary complications may predict long-term mortalitypredict long-term mortality– Manku K, Bacchetti P, Leung JM. Anesth Analg 2003; 96: 583-9.Manku K, Bacchetti P, Leung JM. Anesth Analg 2003; 96: 583-9.

Preoperative pulmonary risk Preoperative pulmonary risk stratificationstratification

Patient-related factorsPatient-related factors– Age (70-79 y OR 3.9, >80 y OR 5.63)Age (70-79 y OR 3.9, >80 y OR 5.63)– ASA II or higher (OR 4.87)ASA II or higher (OR 4.87)– Congestive heart failure (OR 2.93)Congestive heart failure (OR 2.93)– Total functional dependence (OR 2.51) Total functional dependence (OR 2.51) – COPD (OR 2.36)COPD (OR 2.36)– Cigarette use (OR 1.40)Cigarette use (OR 1.40)– NO: obesity, diabetes, asthmaNO: obesity, diabetes, asthma– POSSIBLY: sleep apneaPOSSIBLY: sleep apnea

Smetana G, Lawrence VA, Cornell JE. Ann Intern Med 2006; 144: 581-95.

Preoperative pulmonary risk Preoperative pulmonary risk stratificationstratification

Procedure-related factorsProcedure-related factors– Surgical siteSurgical site

Especially aortic, thoracic and upper abdominalEspecially aortic, thoracic and upper abdominal

– Duration of surgery (OR 2.26)Duration of surgery (OR 2.26)– Anesthetic technique (OR 1.83)Anesthetic technique (OR 1.83)


Preoperative pulmonary risk Preoperative pulmonary risk stratification: Laboratory testingstratification: Laboratory testing

SpirometrySpirometry– May not be superior to clinical evaluationMay not be superior to clinical evaluation– Uncertain if it is useful to identify patients at Uncertain if it is useful to identify patients at

higher risk of pulmonary complicationshigher risk of pulmonary complications– No “threshold” below which risk is prohibitive No “threshold” below which risk is prohibitive

Chest radiographChest radiograph– Commonly performed, but rarely changes Commonly performed, but rarely changes

management management


Arozullah, A. M. et. al. Ann Intern Med 2001;135:847-857

Postoperative Pneumonia Risk Index

Postoperative Respiratory Failure Risk Index

Arozullah, A. M. et. al. Ann Surg 2000;232:242-53.

Strategies to reduce postoperative Strategies to reduce postoperative pulmonary complicationspulmonary complications

Lung expansion maneuvers Lung expansion maneuvers – e.g., incentive spirometry, deep breathing exercises, e.g., incentive spirometry, deep breathing exercises,

CPAPCPAP

Preoperative smoking cessationPreoperative smoking cessation– Health benefits of cessation are well recognized; must Health benefits of cessation are well recognized; must

quit >2 months before surgery.quit >2 months before surgery.– Reduces wound complications (esp. infection) and Reduces wound complications (esp. infection) and

UTI, but has not been shown to reduce postoperative UTI, but has not been shown to reduce postoperative pulmonary complications (may increase risk if <2 pulmonary complications (may increase risk if <2 months before surgery)months before surgery)

Moller AM, Villebro N, Pederson T, Tonneson H. Lancet 2002; 359: 114-7.Moller AM, Villebro N, Pederson T, Tonneson H. Lancet 2002; 359: 114-7.

Selective nasogastric decompressionSelective nasogastric decompression– i.e., for postoperative nausea/vomiting, symptomatic i.e., for postoperative nausea/vomiting, symptomatic

abdominal distensionabdominal distension

Case 5Case 5

A 92 year-old male presents for consideration of total A 92 year-old male presents for consideration of total hip arthroplasty. Prior to the development of hip pain hip arthroplasty. Prior to the development of hip pain due to OA, he was quite active – played Pickleball due to OA, he was quite active – played Pickleball regularly. Currently, he remains active by performing regularly. Currently, he remains active by performing yoga exercises and doing push-ups. His medical yoga exercises and doing push-ups. His medical history is notable for CAD (s/p PCI), prior stroke history is notable for CAD (s/p PCI), prior stroke (minimal residua), HTN, dyslipidemia, hearing loss (minimal residua), HTN, dyslipidemia, hearing loss and macular degeneration (legally blind). and macular degeneration (legally blind).

Surgery in the elderlySurgery in the elderly

Persons age 65 years and older are the fastest Persons age 65 years and older are the fastest growing segment of the US population. growing segment of the US population. Advances in medicine, particularly therapies for Advances in medicine, particularly therapies for cardiovascular disease, allow persons to live longer…cardiovascular disease, allow persons to live longer…and develop conditions for which surgery may be and develop conditions for which surgery may be considered to treat/cure disease (e.g., cancer considered to treat/cure disease (e.g., cancer resection) or improve quality of life (e.g., joint resection) or improve quality of life (e.g., joint replacement).replacement).Surgeons and anesthesiologists rely on medical Surgeons and anesthesiologists rely on medical consultants to assist with perioperative careconsultants to assist with perioperative careIn general, perioperative data on elderly populations In general, perioperative data on elderly populations is limited is limited

Age and overall perioperative complications, Age and overall perioperative complications, length of stay and nursing home placementlength of stay and nursing home placement

Largest, prospective cohort study of non-Largest, prospective cohort study of non-emergent, non-cardiac major surgery:emergent, non-cardiac major surgery:– Increased risk of overall postop complications with Increased risk of overall postop complications with

increased age (RRI 2.3 for 70-79yrs and 3.1 for increased age (RRI 2.3 for 70-79yrs and 3.1 for >80 yrs, compared to 50-59 yrs)>80 yrs, compared to 50-59 yrs)

– Mean length of stay ~2 days longer for Mean length of stay ~2 days longer for

>80 yrs compared to 50-59 yrs>80 yrs compared to 50-59 yrs– >80yrs more likely to be discharged to nursing >80yrs more likely to be discharged to nursing

facility (39% vs. 16%) facility (39% vs. 16%) Polanczyk CA. Ann Intern Med 2001;134:637-43.

Polanczyk, C. A. et. al. Ann Intern Med 2001;134:637-643

Major postoperative complications and in-hospital mortality in patients undergoing noncardiac surgery

Surgery in the elderly – Surgery in the elderly – Take home pointsTake home points

Advanced age is associated with increased Advanced age is associated with increased postoperative complications, longer recovery times, postoperative complications, longer recovery times, and some age-specific morbitidities (most notably, and some age-specific morbitidities (most notably, delirium). delirium). In general, chronic medical comorbidities, rather than In general, chronic medical comorbidities, rather than chronologic age, are more important determinants of chronologic age, are more important determinants of perioperative morbidity and mortality. perioperative morbidity and mortality. Reported perioperative morbidity and mortality rates Reported perioperative morbidity and mortality rates in elderly persons undergoing a variety of surgical in elderly persons undergoing a variety of surgical procedures (eg, abdominal, cardiac, vascular, procedures (eg, abdominal, cardiac, vascular, orthopedic, etc) are favorable.orthopedic, etc) are favorable.

Thank youThank you

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