Non-cardiac surgery for the cardiac patient 2024.pptx

Non-cardiac surgery for the cardiac patient Summer 2024  Terminology MACE Major adverse cardiac events (including death and MI) Clinical history Co-morbidities present which increase risk of MACE Cardiovascular disease, diabetes mellitus, cerebrovascular disease...

Non-cardiac surgery for the cardiac patient Summer 2024  Terminology MACE Major adverse cardiac events (including death and MI) Clinical history Co-morbidities present which increase risk of MACE Cardiovascular disease, diabetes mellitus, cerebrovascular disease Advanced age is independently associated with MACE and ischemic stroke  Pre-operative Evaluation Focus of pre-op evaluation in a patient with known or suspected cardiovascular disease: Identification of clinical risk factors Pre-operative cardiac testing Goals of pre-op evaluation in a patient with known or suspected cardiovascular disease: Define risk Identify which patients will benefit from further testing Determine whether peri-operative  -blockade is beneficial or needed Determine if interventional therapy is beneficial or needed Determine if a cardiac surgical procedure is beneficial or needed (prior to planned procedure) Develop an appropriate anesthetic plan lassification 4:111. Physical Status Classification ASA PS class 1 Normal healthy patient. No organic, physiologic, biochemical, or psychiatric disturbance ASA PS class 2 Mild-to-moderate systemic disease that is well controlled and causes no organ dysfunction or functional limitation (e.g., treated hypertension) ASA PS class 3 Severe systemic disease of at least one organ system that does cause functional limitation (e.g., stable angina) ASA PS class 4 Severe systemic end-stage disease of at least one organ system that is life threatening with or without surgery (e.g., congestive heart failure or renal failure) ASA PS class 5 Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort; e.g., ruptured aortic aneurysm) ASA PS class 6 A declared brain-dead patient whose organs are being removed for donor purposes Emergency operation (E) Any patient in whom an emergency operation is required  Revised Cardiac Risk Index (RCRI) An update of the Goldman Risk Factors RCRI Risk Assessment Cardiac Risk Index Ischemic heart disease Low (0 factor) Validated method to assign Congestive heart Low (1 factor) perioperative risk using failure readily available clinical Cerebrovascular Intermediate (2 variables disease factors) Easier to use and more Diabetes mellitus High (3 or more treated with factors) accurate insulin Serum creatinine >2 mg/dL High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular) Six independent predictors of complications (RCRI) High-risk type of surgery History of ischemic heart disease History of congestive heart failure History of cerebrovascular disease Preoperative treatment with insulin Preoperative serum creatinine (> 2 mg/dL) CARDIAC COMPLICATIONS with an in # of comorbidities Laboratory Values Biomarkers BNP (brain natriuretic peptide) N-terminal brain natriuretic peptide C-reactive protein levels Elevated BNP levels in pre-op are significantly associated with MACE in vascular patients within 30 days of surgery Defining cardiovascular risk factors Symptomatic coronary disease Change in the frequency or pattern of anginal symptoms Elderly, women, diabetic patients The presence of unstable angina is associated with HIGH perioperative risk of MI Active congestive heart failure Major risk factor for increased perioperative morbidity Clinical features: dyspnea, limited exercise tolerance, orthopnea, jugular vein distention, crackles, third heart sound, peripheral edema CXR reveals pulmonary edema or vascular redistribution Defining cardiovascular risk factors Ejection fraction Significantly reduced LVEF (e.g., < 30%) appears to be an independent risk factor for adverse perioperative outcome and long-term mortality Systolic/Diastolic dysfunction Associated with an increased 30-day cardiovascular peri- operative risk Clarifying the CAUSE of heart failure is important! Non-ischemic cardiomyopathy, cardiac valvular insufficiency, stenosis Arrhythmias and conduction disorders Supraventricular and ventricular arrhythmias are independent risk factor for peri-operative cardiac events Presence of arrhythmia in pre-operative setting should prompt an investigation into underlying cardiopulmonary disease, ongoing myocardial ischemia or MI, drug toxicity, or metabolic derangements Valvular Heart Disease Can be effectively managed in the peri-operative period to limit morbidity 2014 AHA/ACC Guidelines: Pre-operative ECHO in patients with moderate to severe valvular stenosis or regurgitation with no ECHO studies within 1 year or worsening clinical status Valvular interventions (repair or replacement) may be warranted BEFORE elective non-cardiac surgery depending in symptoms of severity of the disease Valvular Heart Disease Recommendations Aortic Stenosis Elevated-risk elective non-cardiac surgery with appropriate intra-operative and post-operative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis. Avoid hypotension and tachycardia → decreased coronary perfusion pressure, development of arrhythmias or ischemia, myocardial injury, cardiac failure and death Moderate aortic stenosis: valve area 1.0 cm2 to 1.5 cm2 Severe aortic stenosis: valve area 24 hours, major arrhythmia Predictors of death with moderate to severe MR and severe AR undergoing non-cardiac surgery: Depressed LVEF < 55%, renal dysfunction (creatinine >2 mg/dL), high surgical risk, lack of pre-operative cardiac medications Adults with prior myocardial infarction (MI) Almost ALWAYS have coronary artery disease (CAD) Historically based risk on time for re-infarct-6 months Patients should be individually evaluated from the perspective of their risk for ongoing ischemia Percutaneous transluminal coronary angioplasty Thrombolysis Coronary artery bypass grafting (CABG)  Atherosclerotic Cardiac Disease Risk factors: Peripheral artery disease Diabetes mellitus Accelerates the progression of atherosclerosis DM patients have higher incidence of CAD and silent MI and myocardial ischemia DM requiring insulin treatment is an independent risk factor (RCRI) Duration and associated end-organ dysfunction Autonomic neuropathy – best predictor of silent ischemia Pre-operative ECG should be obtained to examine for the presence of Q waves  Atherosclerotic Cardiac Disease Hypertension Increased incidence of silent MI and infarction Patient with HTN and LVH undergoing non-cardiac surgery are at higher risk Strain pattern on ECG suggests chronic ischemic state Well recognized marker for LVH ST depression and T wave inversion Aggressive treatment of BP long-term MI risk Treat elevated SBP 150 mmHg or higher or DBP above 90 mmHg in patients 60 years or older Treat elevated SBP 140 mmHg or higher or DBP above 90 mmHg in patients 60 years or younger Literature suggests delaying elective surgery if DBP is greater than 110 mmHg Risk vs. benefit in the absence of end-organ changes Atherosclerotic Cardiac Disease Metabolic Syndrome Criteria: High blood pressure Atherogenic dyslipidemia (high triglycerides and low HDL concentrations) High fasting glucose Central obesity Risk: Higher rates of cardiovascular, pulmonary, and renal peri-operative events and wound infections Tobacco Increased risk of developing CAD Not shown to independently increase cardiac risk Pulmonary Vascular Disease Therapy should be continued unless contraindicated or not tolerated in patients with pulmonary hypertension who are undergoing non-cardiac surgery Unless the risks of delay outweigh the potential benefits, pre-operative evaluation by a pulmonary hypertension specialist before non-cardiac surgery can be beneficial for patients with pulmonary hypertension, particularly for those with features of increased peri- operative risk. Surgical Procedure Influences scope of pre-operative evaluation (physiologic changes) Low-risk Peripheral procedures High-risk Major open vascular procedures - **highest incidence of complications** Abdominal procedures Thoracic procedures Orthopedic surgery  Exercise Tolerance One of the MOST IMPORTANT predictors of peri-operative risk for non- cardiac surgery Helps define the need for further testing and invasive monitoring: Patient-reported poor exercise tolerance (i.e., inability to walk four blocks or two flights of stairs) seems to be an independent predictor of serious peri-operative complications Serious adverse event(s) are inversely related to the # of blocks that can be walked Minimal additional testing is necessary if the patient describes good exercise tolerance  Table 23-9 Estimated Energy Requirement for Various Activities Exercise Tolerance 1 MET Daily self-care: Eat, dress, or use the toilet. Walk indoors around the house. Walk a block or two on level ground at 2–3 mph or 3.2–4.8 km/h. Do light work around the house, like dusting or washing dishes. 4 METs Climb a flight of stairs or walk up a hill. Walk on level ground at 4 mph or 6.4 km/h. Run a short distance. Do heavy work around the house, like scrubbing floors or lifting or moving heavy furniture. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football >10 METs Participate in strenuous sports like swimming, singles Indications for further cardiac testing Extensive cardiac testing is not always necessary! ACC/AHA (2014) considers: Clinical history Surgery-specific risk Exercise tolerance Steps: 1. Urgency of surgery and appropriateness of formal pre-op assessment 2. Recent revascularization procedure or coronary evaluation 3. Decide on further testing depending on clinical risk factors, surgery-specific risk, and functional capacity.  Surgical procedure risk High risk (reported cardiac risk often > 5%) Vascular surgery Aortic and other major vascular surgery Peripheral vascular surgery Intermediate risk (reported cardiac risk generally 1% - 5%) Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low risk (reported cardiac risk generally < 1%) Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Ambulatory surgery Indications for further cardiac testing Patient with: Unstable coronary syndromes – should be identified and appropriate treatment instituted High risk patients – consider exercise tolerance and extent of planned surgery Take home message: NO PRE-OPERATIVE CARDIOVASCULAR TESTING SHOULD BE PERFORMED IF THE RESULTS WILL NOT CHANGE PERI- OPERATIVE MANAGEMENT  Cardiac testing: ECG 12-lead ECG Provides information about heart rhythm and evidence of LVH, prior MI Abnormal Q waves in high-risk patients highly suggestive of past MI 30% of MIs occur without symptoms (silent MI) and can only be detected on screening ECGs Highest incidence: Hypertensive and/or diabetic patients Long-term prognosis after MI not improved by absence of symptoms Absence of Q waves on the ECG does not exclude Q-wave MI If ECG reverts to normal after MI, prognosis improves (with or without Q waves) THE PRESENCE OF ABNORMAL Q-WAVES ON PRE-OPERATIVE ECG IN A HIGH-RISK PATIENT (regardless of symptoms) IS INDICATIVE OF INCREASED PERI-OPERATIVE RISK AND POTENTIAL FOR ACTIVE ISCHEMIA Cardiac testing: ECG 2014 ACC/AHA Guidelines: Pre-operative resting 12-lead ECG only for patients with known CAD or other structural heart disease (except for low-risk surgical procedures) significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease Consideration in asymptomatic patients with clinical risk factors (except for low-risk surgical procedures) At least 1 clinical risk factor who are undergoing vascular surgical procedures Routine pre-operative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures Non-invasive Cardiovascular Testing Exercise ECG stress test Traditional method for evaluating suspected CAD Most cost-effective, least invasive for detecting ischemia Sensitivity 70-80%, specificity 60-75% for identifying CAD Positive exercise stress test alerts anesthetist that patient is AT RISK of developing ischemia associated with increased heart rate Infrequently indicated (Why??)  Non-invasive Cardiovascular Testing Non-invasive pharmacologic stress test Used in high-risk patients who either are unable to exercise or have contraindications to exercise (e.g., claudication) Assess risk in patients who have poor or indeterminate functional capacity (< 4 METs) Should only be performed if results will change management Options: Dobutamine stress echocardiogram (DSE) - myocardial O2 demand ( BP and heart rate) Dipyridamole/adenosine/regadenoson myocardial perfusion imaging (MPI) with thallium-201 and/or technetium-99m and rubidium-82 Cardiac testing: Holter monitor Ambulatory ECG providing a means of continuous monitoring for significant ST changes  Non-invasive Cardiovascular Testing 2014 ACC/AHA Guidelines: Should undergo non-invasive stress testing BEFORE non-cardiac surgery: ACTIVE cardiac conditions (unstable angina, congestive heart failure, significant dysrhythmias, and severe valvular disease): Reasonable to undergo non-invasive stress testing IF it will change management: Patients requiring vascular surgery with multiple clinical risk factors and poor functional capacity Patients with elevated risk and unknown functional capacity Patients with elevated risk and moderate to good (4- 10 METs) functional capacity Patients with elevated risk and poor (< 4 METs) functional capacity Routine screening with non-invasive stress testing is NOT USEFUL for Non-invasive Pharmacological Stress Testing It is reasonable for patients who are at an elevated risk for non-cardiac surgery and have poor functional capacity (< 4 METs) to undergo non-invasive pharmacological stress testing if it will change management Routine screening with non-invasive stress testing is not useful for patients undergoing low-risk non-cardiac surgery  Ventricular and Valvular Function Assessing cardiac ejection fraction at rest and under stress: Echocardiography Less invasive, can assess regional wall motion abnormalities, wall thickness, valvular function, and valve area Recommended for dyspnea of unknown origin and for those with prior heart failure with worsening dyspnea or other change in clinical status to evaluate LVH Valvular function: Aortic stenosis has been associated with poor prognosis in non-cardiac surgical patients Knowledge of valvular lesions may modify peri-operative hemodynamic goals and therapy Radionuclide ventriculography Ventricular and Valvular Function 2014 ACC/AHA Guidelines Pre-operative echocardiography testing for moderate or severe degrees of valvular stenosis or regurgitation with no echocardiography studies within one year or worsening clinical status Pre-operative evaluation of LV function: Patients with dyspnea of unknown origin Patients with heart failure with worsening dyspnea or other change in clinical status Reassessment of LV function: Clinically stable patients with previously documented LV dysfunction if no assessment within one year Routine pre-operative evaluation of LV function is not recommended Coronary Angiography Best method for defining coronary anatomy Assesses ventricular and valvular function Hemodynamic indices determined: Atrial and ventricular pressures Pressure gradients across valves Critical coronary stenosis Area of risk for developing myocardial ischemia, functional response of that ischemia cannot be determined May or may not be underlying cause for peri-operative MI that occurs Many infarcts are the result of acute thrombosis of a non-critical stenosis Coronary Angiography 2014 ACC/AHA Guidelines: DO NOT recommend pre-operative coronary angiography prior to non-cardiac surgery without specific clinical indications Patients with restricted physical activity in whom functional capacity is difficult to determine may benefit from sophisticated imaging techniques, such as cardiac CT. The role of coronary angiography with calcium scoring requires further validation as a pre-operative assessment for non-cardiac surgery. 2014 ACC/AHA Guidelines 1. Is there a clinical need for emergency non-cardiac surgery? 2. Are there active cardiac conditions? 3. Does the planned surgery have a low cardiac risk? 4. Does the patient have good functional capacity without symptoms? 5. Does the patient have clinical risk factors? Peri-operative coronary interventions Coronary artery bypass grafting For those who survive, risk of subsequent non-cardiac surgery is low Indication for CABG prior to non-cardiac surgery remains the same as in other settings Revascularization Recommended before non-cardiac surgery Patients scheduled for high-risk surgery, long-term survival may be enhanced by revascularization Not recommended that routine coronary revascularization be performed before non-cardiac surgery exclusively to reduce peri- operative cardiac events Peri-operative coronary interventions Percutaneous transluminal coronary angioplasty 2014 ACC/AHA Guidelines for non-cardiac surgery: High-risk coronary anatomy (e.g., left main disease), unstable angina pectoris, MI, or life-threatening arrhythmias Coronary Artery Stents Early surgery after coronary stent placement is associated with adverse cardiac events Significant incidence of peri-operative death and hemorrhage in patients after stent placement 2016 ACC/AHA Guidelines (focused update): Delay elective non-cardiac surgery for: 14 days after coronary balloon angioplasty 30 days after bare metal stent (BMS) placement Optimal: 12 months for drug eluting stents (DES) but elective non- cardiac surgery can be considered after 6 months based on comparative benefits of surgery compared with risk of stent thrombosis and myocardial ischemia  Coronary Artery Stents Peri-operative management with anti-platelet therapy: Dual anti-platelet therapy: aspirin and clopidogrel (common after stent placement) A thienopyridine (ticlopidine or clopidogrel) is generally continued with aspirin for 1 month after BMS placement and 12 months after DES placement Peri-operative management should weigh the risk of bleeding with the risk of stent thrombosis Decision MUST involve surgeon, anesthesia, cardiology, and intensivist Patients with high risk for stent thrombosis – may need to continue aspirin in the peri-operative period Anesthetist must weigh risk of regional vs. general anesthesia with anti- platelet therapy Surgery in patients with recent stent placement should only be considered in centers where interventional cardiologists are available Cardiovascular Implantable Electronic Devices Pre-operative evaluation MUST address the management of cardiovascular implantable electronic devices: Pacemakers Implantable defibrillators Function of these devices CAN be impaired by electromagnetic interference during surgery Need to know: Type of device Programming Underlying clinical need Cardiologist needs to be involved in programming the device BEFORE and AFTER surgery!!  Peri-operative Beta-Blocker Therapy: Uses Beta-blockers should be continued in patients undergoing surgery who have been on beta-blockers chronically It is reasonable for the management of beta-blockers after surgery to be guided by clinical circumstances, independent of when the agent was started In patients with intermediate or high-risk myocardial ischemia noted in pre-operative risk stratification tests, it may be reasonable to begin peri-operative beta-blockers In patients with 3 or more RCRI risk factors, it may be reasonable to begin beta- blockers before surgery In patients with a compelling long-term indication for beta-blockers therapy but no other RCRI risk factors, initiating beta-blockers in the peri-operative setting as an approach to reduce peri-operative risk is of uncertain benefit In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin peri-operative beta-blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery Beta-blocker therapy should NOT be started on the day of surgery. Peri-operative Statin Therapy Statins should be continued in patients currently taking statins and scheduled for non-cardiac surgery Peri-operative initiation of statin use is reasonable in patients undergoing vascular surgery Peri-operative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures  Other Peri-operative Cardiac Therapies Alpha-2 agonists: Alpha-2 agonists for prevention of cardiac events are NOT recommended in patients who are undergoing non-cardiac surgery Calcium channel blockers: Large-scale trial needed Calcium blockers with substantial negative ionotropic effects, such as diltiazem and verapamil, may precipitate or worsen HF in patients with depressed EF ACE inhibitors Continuation of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) peri-operatively is reasonable If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart as soon as clinically feasible post-operatively Anti-platelet Agents In patients undergoing non-cardiac surgery during the first 4-6 weeks after BMS or DES implantation, DAPT should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y platelet receptor-inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y platelet receptor-inhibitor be restarted as soon as possible after surgery. Management of the peri-operative anti-platelet therapy should be determined by a consensus of the surgeon, anesthetist, cardiologist, and patient, who should weight the relative risk of bleeding versus prevention of stent thrombosis. Anti-platelet Agents In patients undergoing non-emergency/non-urgent non- cardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased bleeding. Initiation or continuation of aspirin is not beneficial in patients undergoing elective non-cardiac, non-carotid surgery who have not had previous coronary stenting unless the risk of ischemic events outweighs the risk of surgical bleeding.