pre-operative cardiovascular evaluation and related imaging€¦ · pre-operative cardiovascular...

Ivan Anderson, MDRIHVH Cardiology

Pre-Operative Cardiovascular Evaluation

and Related Imaging

Outline

• General algorithm• High risk conditions• Prior Cardiac stents• Specific testing• Medical management in the peri-operative

setting

Lee A. Fleisher et al. JACC 2014;64:e77-e137

General Algorithm

Step by Step

• Step 1: Is surgery Emergent?– If Yes, go to surgery– If No, go to Step 2

Step by Step

• Step 2: Is the patient having a heart attack (i.e. ACS, Acute Coronary Syndrome)?– If Yes, treat ACS (see slides

from my NSTEMI lecture)– If No, go to Step 3

• MACE = Major Adverse Cardiac event• GDMT = Guideline Directed Medical

Treatment

Step by Step

• Step 3: Divide patients based on risk of adverse cardiac event (MI, CVA)– Low risk is defined as <

1% – High risk > 1%

• MACE = Major Adverse Cardiac event

• GDMT = Guideline Directed Medical Treatment

High Risk Conditions

• Congestive heart failure• Severe Aortic Stenosis• Severe Mitral Stenosis• Pulmonary Hypertension• Left Main Disease or triple vessel coronary

artery disease• Ventricular tachycardia or defibrillator

Specifics of High Risk Conditions: CHF

• CHF: Guidelines cite retrospective study demonstrating risk of death with CHF and atrial fibrillation, 30-day risk of death was – 9.3% with non-ischemic CHF– 9.2% with ischemic CHF– 6.4% with atrial fibrillation– 2.9% with CAD and no clinical diagnosis of of CHF

• You can consider checking a BNP to refine risk (> 116 pg/mL is elevated by meta-analysis)

• CHF = congestive heart failure, BNP = brain natriuretic peptide

Circulation. 2011;124:289–96J Am Coll Cardiol. 2011;58:522–9.

Specifics of High Risk Conditions: Valvular Heart Disease

• In general, regurgitation is better hemodynamically tolerated than stenosis

• Guidelines: say check echo for suspected moderate or greater valve disease (stenosis or regurgitation)

J Am Coll Cardiol. 2014;64: e77-137

Specifics of High Risk Conditions: Valvular Heart Disease

• Severe Aortic Stenosis: – Traditionally considered high cardiac risk, new guidelines

say surgery is ok with cardiac anesthesia– Study cited quotes a 2.1% 30-day risk of death with

moderate aortic stenosis– My advice: fix the valve first

• Severe Mitral Stenosis– Replace valve or do balloon commissurotomy first if

possible– Can consider surgery if valve repair is not an option– My advice: fix the valve, proceed with extreme caution

Am J Med. 2013;126:529–35

More High Risk Conditions

• Severe Mitral Regurgitation – acceptable risk if asymptomatic

• Severe Aortic Regurgitation – acceptable risk if normal left ventricular ejection fraction

• Untreated sustained or symptomatic ventricular tachycardia – refer to cardiology and arrange for ICD implantation

• ICD or pacemaker present: have representative available or discuss with anesthesia


More High Risk Conditions

• Pulmonary hypertension– Risk of peri-operative death 4-26% by cited

studies in the guidelines

• Adult congenital heart disease (ACHD): highest risk is prior Fontan procedure, cyanotic ACHD, pulmonary hypertension, heart failure and significant dysrhythmia


Risk Calculators• Revised Cardiac Risk Index (RCRI)

– https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk

• American College of Surgeons NSQIP MICA – National Surgical Quality Improvement Program

Myocardial Infarction Cardiac Arrest– http://www.surgicalriskcalculator.com/miorcardiacarrest

• American College of Surgeons NSQIP Surgical Risk Calculator– NSQIP again is National Surgical Quality Improvement

Program– www.riskcalculator.facs.org

Surgeries by Risk (of Cardiovascular Event)

• Low Risk Surgeries– Ophthalmologic– Plastic Surgery

• Highest Risk– Open heart surgery– Vascular surgery

• Anorectal• Bariatric• Brain• Breast• ENT• Foregut/hepatopancreatobiliary• Gallbladder/adrenal/appendix/• spleen• Intestinal• Neck• Obstetric/gynecological• Orthopedic• Other abdomen• Peripheral vascular• Skin• Spine• Thoracic• Vein• Urologic

Step by Step

• Step 4: Low risk patients, pretty easy

Step by Step

• Step 5: Higher risk patients– Can the do 4 METs?

• Yes, go to surgery• No, go to step 6

Step by Step: Steps 6 and 7

Outline


setting

Outline• General algorithm• High risk conditions

– Severe Aortic Stenosis (avoid)– Severe Mitral Stenosis (avoid)– Pulmonary Hypertension (avoid or optimize)– Ventricular tachycardia or Defibrillator (optimize)– Congestive heart failure (optimize)– Left Main Disease or triple vessel coronary artery disease

(optimize or revascularize)• Prior Cardiac stents• Specific testing• Medical management in the peri-operative setting

Outline


setting

Lee A. Fleisher et al. JACC 2014;64:e77-e137

Stents Algorithm

• Step 1: Were the stents put in less than 6 weeks ago?– Is the surgery elective?

• If yes, then delay for 1 year after drug-eluting stents or 30 days after bare metal stents

• If no, then keep on dual antiplatelet therapy unless risk of bleeding is greater than risk of stent thrombosis

Stents Algorithm

• Step 2: Were the stents put in > 6 weeks ago, but < 1 year ago?– Is the risk of delaying surgery greater than the risk of

stent thrombosis?• If yes, then delay for 6 months• If no, then delay for 1 year

• Step 3: Are stents over 1 year old and the patient is still on dual antiplatelet therapy (DAPT)?– Guidelines say keep DAPT if possible – I say why are they on it? Probably can safely stop

Plavix/Brilinta/Effient

Outline


setting

Outline• General algorithm• High risk conditions• Prior Cardiac stents• Specific testing

– EKG– Echocardiogram (or other assessment of LV function e.g. MUGA)– Exercise stress test– Pharmacologic nuclear– Cardiopulmonary Exercise Testing– Cardiac catheterization

• Medical management in the peri-operative setting

Testing in Pre-Operative Cardiovascular Evaluation

• Specific testing– EKG

• Do for everyone going for any surgery that is not low risk– Echocardiogram (or other assessment of LV function

e.g. MUGA)• Do for dyspnea, known cardiac conditions (CHF, CAD,

arrhythmia, valvular disease)– Exercise stress test

• Cardiopulmonary Exercise testing may be considered in anyone undergoing high-risk surgery

• Exercise stress test (treadmill nuclear, exercise stress echocardiogram) may be considered in anyone undergoing intermediate or higher risk

Testing in Pre-Operative Cardiovascular Evaluation

• Specific testing– Pharmacologic nuclear

• Consider if elevated patient specific risk and poor functional capacity (can’t run)

– Cardiac catheterization• Do not do routinely, only if other tests are abnormal

– Coronary calcium score: I recommend as the initial screening test of choice

Outline


setting

Outline• General algorithm• High risk conditions• Prior Cardiac stents• Specific testing• Medical management in the peri-operative

– Beta Blockers– Statins– ACE-Inhibitors– Alpha-2 agonists– Anti-platelet therapy– Calcium Channel blockers

Medical Management in the Peri-Operative Setting

– Beta Blockers• If they are on them, don’t stop them• If surgery is intermediate- to high-risk consider starting them• If the patient has > 2 risk factors for adverse cardiovascular

outcome (by RCRI calculator) then consider starting• Start them more than 1 day before surgery if at all possible

– Statins• Continue them if they are on them• Consider if vascular surgery• Consider if 1 or more risk factor for adverse outcome


Medical Management in the Peri-Operative Setting

– ACE-Inhibitors• Try to keep them on it during the peri-operative setting• If they need to stop, restart as soon as safely possible

– Alpha-2 agonists• Not useful, don’t start to prevent an event

– Anti-platelet therapy• See section on stents• Don’t start aspirin before surgery to prevent events

– Calcium Channel blockers• Diltiazem seems to prevents events (reduces ischemia), but

may precipitate a CHF exacerbation• All others don’t help (e.g. verapamil, amlodipine, felodipine,

etc.)


CARP Trial• Randomized Control Trial of revascularization before

elective vascular surgery• Patient population: 5859 patients were recruited from 18

VA hospitals who were scheduled for surgical revascularization/repair of an abdominal aortic aneurysm or bypass of PAD from 1999 to 2003. They had to have at least 1 70% stenosis on cardiac catheterization.

• 80% of patients were excluded for a final study population of 1654

• About 30% of patients had 3-V CAD, 15% with prior CABG• Randomized to stents or no stents (about 10% cross-over)

N Engl J Med 2004;351:2795-804

McFalls EO et al. N Engl J Med 2004;351:2795-2804.

Outcomes, CARP Trial

Predictive Accuracy of Non-Invasive Imaging – EVINCI Study

Circ Cardiovasc Imaging.2015;8:e002179

Patients Were Evaluated with

• Coronary Calcium Scan• Nuclear Stress Test (PET or SPECT)• Exercise Stress Echocardiogram• Cardiac MRI• Cardiac Catheterization +/- Fractional Flow

Reserve (FFR)

• SPECT = Single Photon Emission Computed Tomography• PET = Positron Emission Tomography

EVINCI Study Results

Circ Cardiovasc Imaging.2015;8:e002179

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