preoperative assessment for non-cardiac surgery assessment for non-cardiac surgery kim a. eagle, md...

Preoperative Assessment forPreoperative Assessment forNonNon--Cardiac SurgeryCardiac Surgery

Kim A. Eagle, MDAlbion Walter Hewlett Professor

Director

Kim A. Eagle, MDKim A. Eagle, MDAlbion Walter Hewlett ProfessorAlbion Walter Hewlett Professor

DirectorDirector

University of MichiganUniversity of MichiganCardiovascular CenterCardiovascular Center

Kim A. Eagle, MD, FACCKim A. Eagle, MD, FACCDirectorDirector

University of MichiganUniversity of MichiganCardiovascular CenterCardiovascular Center

Grants: NIH, Hewlett Foundation, Grants: NIH, Hewlett Foundation, Mardigian Foundation, Varbedian Fund, Mardigian Foundation, Varbedian Fund,

GOREGORE

Consultant: NIH NHLBIConsultant: NIH NHLBI

Lecture OutlineLecture Outline

• Estimating Patient Risk

• Causes of Perioperative Cardiac Events

• Role of Non Invasive Testing

• Medical Therapy

• Role of Revascularization

• Approach to Preoperative Screening

• Perioperative Management

• Final Comments

Estimation of the PatientEstimation of the Patient’’s Risks Risk

Functional Status

Surgery - Specific Risk

Proceed with Surgery

Clinical Markers

Eagle KA, et al. JACC Guidelines 2002;39:542-53.

Further Evaluation/Mgmt.

Independent Clinical Markers of Elevated Perioperative Risk

Independent Clinical Markers of Independent Clinical Markers of Elevated Perioperative RiskElevated Perioperative Risk

Marker Relative Risk Confidence Limit

Known CAD 2.4 1.3 - 4.2

Prior Heart Failure 1.9 1.1 - 3.5

Diabetes 3.0 1.3 - 7.1

Renal Insufficiency 3.0 1.4 - 6.8

Lee, et al. Arch Int Med 1999;159:2185-92.

Clinical Risk Status andVascular Surgery

Clinical Risk Status andClinical Risk Status andVascular SurgeryVascular Surgery

Clinical Risk Status

0%

5%

10%

Low Risk(0 markers)

Per

iop.

MI o

r Dea

th(n=1476)

0.3%Intermediate Risk

(1-2 markers)High Risk

(≥ 3 markers)

2.2%

8.5%

Poldermans et al. JACC 2006;48:964-969.

Higher

Functional StatusFunctional StatusFunctional Status

Lower

Risk

• Difficulty with ADL• Can’t walk four blocks or

up two flight of stairs• Inactive but no limitation• Active: Easily does

vigorous tasks• Performs regular

vigorous exercise


Surgery - Specific RiskSurgery Surgery -- Specific RiskSpecific Risk

• Aortic• Non-Carotid Peripheral

Vascular• Major Thoracic• Major Abdominal• Carotid• Head/Neck• Orthopedic• Eye, Skin


Higher

Lower

Risk

Operative MortalityOperative Mortality

Birkmeyer et al. N Engl J Med 2002;346:1128-37.

0

4

8

12

Carotid Endarterectomy

Lower-extremity bypass

Elective repair of abdominalaortic aneurysm

<40

40-69

70-10

911

0-164

>164 <22

22-39

40-60

61-94 >9

4

<17

17-30

31-49

50-79 >7

9

Adj

uste

d M

orta

lity

(%)

1.7 1.51.51.61.6

5.1

4.14.84.64.8

6.5

5.24.6 4.7

3.9

Independent Predictors of RiskIndependent Predictors of RiskIndependent Predictors of Risk

Surgery - High Risk

Poor Functional Status

Clinical Markers

(RR 2.8)

(RR 1.8)

Renal Insuf. (RR 3.0)

DM (RR 3.0)

HF (RR 1.9)

CAD (RR 2.4)

Who Needs FurtherNonInvasive Testing?Who Needs FurtherWho Needs Further

NonInvasive Testing?NonInvasive Testing?

Questions:

1. Will test results lead to change in care?

2. Has the patient been tested recently?

3. Is the concern related to CAD or is LV

Dysfunction a concern?

4. Can the patient do an exercise test?

Radionuclideventriculography 8 532 54 50 (32-69) 91 (87-96)Ambulatoryelectrocardiography 8 893 52 52 (21-84) 70 (57-83)Exerciseelectrocardiography 7 685 25 74 (60-88) 69 (60-78)Myocardial perfusionscintigraphy 23 3119 207 83 (77-89) 49 (41-57)Dobutamine stressechocardiography 8 1877 82 85 (74-97) 70 (62-79)Dipyridamole stressechocardiography 4 850 33 74 (53-94) 86 (80-93)

NonCardiac Testing Prior to Vascular NonCardiac Testing Prior to Vascular Surgery Meta Analysis Surgery Meta Analysis

Devereaux, P.J. et al. CMAJ 2005;173:627-634.

No. of No. of No. of Sensitivity, Specificity,Test studies patients events % (95% CI) % (95% CI)

Preoperative Thallium Study PerformancePreoperative Thallium Study Performance N PPV NPV

Boucher ‘85 48 19% 100% Cutler ‘87 116 20% 100% Fletcher ‘88 67 20% 100% Sachs ‘88 46 14% 100% Eagle ‘89 200 16% 98% McEnroe ‘90 95 9% 96% Younis ‘90 111 15% 100% Mangano ‘91 60 5% 95% Strawn ‘91 68 6% 100% Watters ‘91 26 20% 100% Hendel ‘92 327 14 99% Lette ‘92 355 17% 99% Madsen ‘92 65 11% 100% Brown ‘93 231 13% 99% Kresowik ‘93 170 4% 98% Baron ‘94 457 4% 96% Bry ‘94 237 11% 100% Koutelou ‘95 106 6% 100% Marshall ‘95 117 16% 97% Van Damme ‘97 142 N/A N/A Huang ‘98 106 13% 100% Cohen ‘03 153 4% 100% TOTAL 3303 12% 99%

Preoperative Dobutamine Preoperative Dobutamine Echocardiogram PerformanceEchocardiogram Performance

N PPV NPV Lane ‘91 38 16% 100% Lalka ‘92 60 23% 93% Eichelberger ‘93 75 7% 100% Langan ‘93 74 17% 100% Poldermans ‘93 131 14% 100% Davila-Roman ‘93 Poldermans ‘95 Shafritz ‘97 Plotkin ‘98 Ballal ‘99 Bossone ‘99 Das ’00

88 302 42 80 233 46 530

10% 24% NA

33% 0% 25% 15%

100% 100% 97% 100% 96% 100% 100%

Boersma ’01 1097 14% 98% Morgan ’02 78 0% 100% Torres ’02 105 18% 98% Labib ’04 429 9% 98% TOTAL 466 20% 99%

No Yes Test

Can the patient exercise? ETT

Am I concerned about valve disease? Echo

Am I quantifying muscle at risk? Nuclear

Am I concerned about false positive? Echo

Am I concerned about LV? Echo/Nuke

Which Stress Test?Which Stress Test?Which Stress Test?

x

x

x

x

x

Role of CT and MR not yet clear

Clinical Assessment Only

1081 patients

Moderate8%(42/550)

(6-10%) (p<0.0001)

DypridomoleThallium

550 patients

Moderate9%(7/76)(4-18%)

(p<0.0001)

Low3%(11/345)

(2-6%)

High19%(24/129)

(13-26%)

Low3%(10/344)

(1-7%)

High18%(33/187)

(12-24%)Dypridomole

Thallium344 patients

DypridomoleThallium

187 patients

Moderate3%(1/33)(0-16%) (p=.610)

Low3%(9/281)

(2-6%)

High0%(0/30)(0-12%)

Moderate7%(2/31)(0-21%) (p=.107)

Low12%(3/25)(3-31%)

High24%(28/131)

(15-30%)

L’Italien G, et al. JACC 1996;27:779-786.

BayesTheorem

What Causes Perioperative Cardiovascular Events?

What Causes Perioperative What Causes Perioperative Cardiovascular Events?Cardiovascular Events?

• Catecholamine surges

• Prothrombotic milieau

• Blood Loss

• Volume Shifts

• Coronary Plaque destabilization

• Fixed Coronary Disease+

+Stress testing predicts only one of the six!

Coronary Stenosis Pathology(<50% X-section narrowing) Fatal Periop (MI)Left main 8 (19%)3-vessel disease 25 (59%)2-vessel disease w/LAD 11 (26%)2-vessel disease w/o LAD 1 (2.3%)1-vessel disease 1 (24%)No severe CAD 2 (4.7%)Plaque disturbed – 55%; more than half the time not the most severe stenosis

Fatal Perioperative MICoronary Pathology (n=42)

Fatal Perioperative MIFatal Perioperative MICoronary Pathology (n=42)Coronary Pathology (n=42)

Dawood MM et al. Intl J Cardiol 1996;57:37-44.

Medical Therapy to Reduce Perioperative Events

Medical Therapy to Reduce Medical Therapy to Reduce Perioperative EventsPerioperative Events

• Beta Adrenergic Blockers

• Statins

• Aspirin

Decrease Study DesignDecrease Study DesignDecrease Study Design

Elective Aortic SurgeryElective Aortic Surgery

Clinical Markers of RiskClinical Markers of Risk

Demonstrable IschemiaDemonstrable Ischemiaonon

Dobutamine EchoDobutamine Echo

BB--BlockerBlocker++ PlaceboPlacebo

NEJM 1994; 341:1749.

+Titrated over days/weeks

High risk vasc surgeryHigh risk vasc surgeryBisoprolol 7Bisoprolol 7--89 days pre89 days pre--op (mean 37)op (mean 37)

BetaBeta--blocker Rx (Bisoprolol)blocker Rx (Bisoprolol)11

PeriPeri--operative Managementoperative Management

1Poldermans D et al. NEJM 1999;341:1789

D(%) MI(%) p

CONT 17 17 0.02BIS 3.4 0 <0.001P<0.001

0 7 14 21 28Days after Surgery

Perc

enta

ge o

f Pat

ient

s

0

10

20

30

40Standard care

Bisoprolol

“I always like to use a

new drug before its

effectiveness wears off”- William Osler

Effect of Perioperative BEffect of Perioperative B--BlockadeBlockadein Nonin Non--cardiac surgery among Medicare beneficiariescardiac surgery among Medicare beneficiaries

Lindenaeur PK, Pekow P, Wang K, et al., Perioperative Beta Blocker Therapy and Mortality following major Non-cardiac Surgery. NEJM 2005;353:349-61.

AmongIdeal

MedicarePatients

Treatedwith

Beta Blockers(n=75,190)

Not treatedwith

Beta Blockers(n=260,238)

Mortality 2.73% 2.91%

Revised Cardiac Risk Death Rate Odds Ratio #Needed: Treat #Needed: HarmClinical SubgroupScore - 0 1.4% 1.36 - 208Score - 1

All 2.2% 1.09 - 504Diabetes 1.7% 1.28 - 209Isch. Hrt. Disease 2.0% 1.12 - 408Cerebro. Vasc. Dis. 9.0% 1.03 - 410Renal Insuff. 7.2% 1.01 - 1505High Risk Surgery 2.0% 0.94 864

Score - 2 3.9% 0.88 227Score - 3 5.8% 0.71 62Score - 4 7.4% 0.58 33

Targeting PerioperativeB-Blockers to the “Right” Patients

Targeting PerioperativeTargeting PerioperativeBB--Blockers to the Blockers to the ““RightRight”” PatientsPatients

Lindenaur PK, et al. NEJM 2005; 353:349-61.

Perioperative Ischemic EvaluationPOISE Trial

PPerieriooperative perative IsIschemic chemic EEvaluationvaluationPOISE TrialPOISE Trial

8351 Patients8351 Patients++

Toprol XLToprol XL100mg 2100mg 2--44

Hrs PreopHrs Preop→→30 Days30 Days

Randomized

PlaceboPlacebo

+ >45yrs of age+ >45yrs of ageHad or at risk forHad or at risk for

AtherosclerosisAtherosclerosis--82%82%Had CAD or PVDHad CAD or PVD

Toprol3.6%5.8%1.0%6.6%

Placebo5.1%6.9%0.5%2.4%

P-value<0.001

0.040.005

<0.001

30 Day EventNon Fatal MICV Death, MI, ♥ ArrestStrokeBradycardia

Devereaux PJ, et al. Lancet 2008: 371:1839-47.

POISE Trial: Metoprolol vs. Placebo in Patients Undergoing Noncardiac Surgery

POISE Trial: Metoprolol vs. Placebo in POISE Trial: Metoprolol vs. Placebo in Patients Undergoing Noncardiac SurgeryPatients Undergoing Noncardiac Surgery

5.8

6.9

3.12.3

0

2

4

6

8

CV Death, MI, or CardiacArrest HR 0.83

Total Mortality HR 1.33

MetoprololPlacebo

Devereaux PJ, et al. Lancet 2008;371:1839-47.

Perc

ent

P=0.04 P=0.03

Independent Postoperative Independent Postoperative Predictors of DeathPredictors of Death

Predictor HR 95% CI

Stroke 12.74 7.77-20.88

Hypotension 4.32 3.22-5.80

Symptomatic MI 3.51 2.02-6.11

Asymptomatic MI 2.80 1.87-4.19

Bradycardia 1.99 1.35-2.92

Bleeding 1.54 1.09-2.16

Negative Consequences ofSudden Discontinuation of Beta-

Blockers after Hip Surgery

Negative Consequences ofSudden Discontinuation of Beta-

Blockers after Hip Surgery

Van Klei et al. Anesthesiology 2009;111:717-24.

Fleisher L, et al. J Am Coll Cardiol 2007:50:1707-1732.

Recommendations for Beta-Blocker Medical Therapy

Class I1. Beta blockers should be continued in patients

undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications. (Level of Evidence: C)

2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level of Evidence: B)

Durazzo et al. J Vasc Surg 2004;39:967.

Days after Surgery

RCT of StatinsRCT of Statins• 100 vascular

surgery patients

• 20mg atorvastatin or placebo for 45 days

• Vascular surgery an average of 30 days after randomization

0 30 60 90 120 150 180

50 44 43 41 40 40 40

50 38 36 35 34 33 33

0

20

40

60

80

100

Even

t-fre

e Su

rviv

al (%

)

Atorvastatin

Placebo

AtorvastatinPlacebo

P = 0.018

0%

2%

4%

In-hospital Mortality after Non-Cardiac Surgery: Lipid lowering therapy

In-hospital Mortality after Non-Cardiac Surgery: Lipid lowering therapy

2.13%

3.05%

Lipid Rx No Lipid Rx

(OR 0.71; 95% CI0.67-0.75)

Lindenauer PK, et al. JAMA 2004;291:2092-99.

Assessed for Eligibility(n=1669)

Assessed for EligibilityAssessed for Eligibility(n=1669)(n=1669)

N = 250N = 250 N = 247N = 247

AllocationAllocation

AnalysisAnalysis

FollowFollow--upup

Excluded (n=1172)Excluded (n=1172)Not meeting inclusion criteria Not meeting inclusion criteria (n=356)(n=356)Statin users (n=798)Statin users (n=798)Other reasons (n=18)Other reasons (n=18)

Dutch Echographic Cardiac Risk Evaluation Applying Stress Echo III

EnrollmentEnrollment

Lost to followLost to follow--up at 30 days (n= 0)up at 30 days (n= 0)Temporarily discontinued (n=54)Temporarily discontinued (n=54)Permanently discontinued (n=18)Permanently discontinued (n=18)

Lost to followLost to follow--up at 30 days (n=0)up at 30 days (n=0)Temporarily discontinued (n=61)Temporarily discontinued (n=61)Permanently discontinued (n=16)Permanently discontinued (n=16)

RandomizationRandomization

Allocated to Fluvastatin (n= 250)Allocated to Fluvastatin (n= 250)Received allocated interventionReceived allocated intervention

(n= 247)(n= 247)

Allocated to Placebo (n= 247)Allocated to Placebo (n= 247)Received allocated interventionReceived allocated intervention

(n= 246)(n= 246)

DECREASE IIIDECREASE III

Days after surgery

Placebo

Fluvastatin

0

3

6

9

12

15

0 5 10 15 20 25 30

Car

diac

dea

th o

r non

fata

l MI

(%)

P = 0.039

N Engl J Med. 2009;361:984.

45,00045,000

6,4606,460

1,4211,421

1,066(2.4%)

Eligible Eligible Excluded

38,540(86%)

5,039(78%)

355(25%)

Low or High Risk

Beta-Blocker and/or Statin Therapy

Informed Consent, Previous Participation

IncludedIncludedIncluded

DECREASE IVDECREASE IV

Outcome: Primary End PointOutcome: Primary End Point

Bisoprolol vs. Bisoprolol-Control

Days after surgery

Combination vs. Double Control

Fluvatatin vs. Fluvastatin-Control

Log-rank p-value 0.003 Log-rank p-value 0.17 Log-rank p-value 0.003

0%

2%

4%

6%

8%

0%

2%

4%

6%

8%

0 15 300%

2%

4%

6%

8%

15 300 15 30 0

Dunkelgrum M, et al. Ann Surg 2009;249:921-926.


Recommendations for Statin Therapy

Class I

1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B)

Class IIa

1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B)

What About Immediate

Coronary Revascularization

To Lower Risk?

What About Immediate

Coronary Revascularization

To Lower Risk?

Surgery After (bare metal) Stent Implantation –Methodist Hospital Houston

Kaluza et al, JACC 2000

0.0 0.0

28.0

32.0

0

20

40

1-14 days >14 days

MIMIDeath

P=0.015Surgery 1-14d

(n=25)Surgery 15-39d

(n=15)

Stent

• 8 deaths•6 due to MI•2 due to bleeding

• 11 bleeds• 3/5 pts operated on

ticlid died (1 bleed – 2 MI+ bleed)

Results Pt(%)

6 of 7 pts died (86%)

Death/MI after Non Cardiac SurgeryDeath/MI after Non Cardiac Surgeryin Patients with Recent Bare Metal Stentin Patients with Recent Bare Metal Stent

0%

1%

2%

3%

4%

5%

J Am Coll Cardiol 2003;42:234-40.

PCI ≤ 6 weeksBefore Surgery

PCI ≥ 7 weeksBefore Surgery

0%0%(0/39)(0/39)

4.8%4.8%(8/168)(8/168)

Stent Thrombosis AfterNonCardiac Surgery

Stent Thrombosis AfterNonCardiac Surgery

Anwaruddin S, et al. JACC Intv 2009;2:542-9.

Time from PCI with DES (yrs)

10

8

6

4

2

0

30 D

ay S

tent

Thr

ombo

sis

(%)

p = 0.014

0.00 0.25 0.50 0.75 1.00 1.25 1.50 1.75 2.00 2.25 2.50 2.75

CARP: Coronary Revascularization Prophylaxis before Major Vascular Surgery

CARP: Coronary Revascularization CARP: Coronary Revascularization Prophylaxis before Major Vascular SurgeryProphylaxis before Major Vascular Surgery

McFalls EO, et al. N Engl J Med 2004;351:2785-804.

Study PatientsStudy Patients(n=510; 8.7%)(n=510; 8.7%)

CoronaryCoronaryAngiographyAngiography

ScreeningScreeningProcessProcess

VascularVascularPatientsPatients

Anatomical Exclusions from the TrialAnatomical Exclusions from the Trial• Non-obstructive coronary arteries (n=363)• Not amenable to revascularization (n=215)• Left Main Stenosis > 50% (n=54)• LV Ejection Fraction < 20% (n=11)• Refusal (n=29)

Clinical Exclusions from the TrialClinical Exclusions from the Trial• Insufficient cardiac risk (n=1654)• Urgent/Emergent surgery (n=1025)• Prior CABG/PCI and no ischemia (n=626)• Co-morbid condition (n=731)• Refusal or non-eligible (n=633)

Surgical Indications for the TrialSurgical Indications for the Trial• Abdominal Aortic Aneurysm (n=1935)• Claudication (n=1528)• Rest Pain (n=981)• Tissue Loss (n=1415)

(n=5859)

(n=4669; 79.7%)

(n=380; 11.6%)

Baseline Clinical Variables: CARPBaseline Clinical Variables: CARPBaseline Clinical Variables: CARPClinical Variables Revascularization No Revascularization P-value

(N=258) (N=252)

HistoryAge (years) 65±11.1 67.2±10.4 0.099Angina (%) 39.9 37.7 0.606Prior MI (%) 43.0 40.9 0.623Prior CHF (%) 12.0 7.5 0.089Diabetes (%) 37.6 40.0 0.840

LaboratoryLDL (mg/dL) 105±37 107±42 0.596

Cardiac StatusLV Ejection Fraction 54±12 55±12 0.3633-vessel CAD (%) 35.4 31.4 0.685

Indications for SurgeryAbdominal aneurysm (%) 34.4 32.1 0.613Claudication (%) 38.8 35.3 0.613Rest pain (%) 11.6 13.9 0.613

CARP: Main ResultsCARP: Main ResultsCARP: Main ResultsRevasc. Revasc. No Revasc.No Revasc. PP--valuevalue(N=225)(N=225) (N=237)(N=237)

Surgical ManagementSurgical ManagementAbdominal Surgery (%)Abdominal Surgery (%) 39.939.9 42.142.1 0.8900.890Urgent or Emergent (%)Urgent or Emergent (%) 5.85.8 5.95.9 0.9000.900General anesthesia (%)General anesthesia (%) 81.181.1 84.384.3 0.4990.499

Perioperative MedicationsPerioperative MedicationsBetaBeta--adrenergic blockers (%)adrenergic blockers (%) 83.983.9 86.486.4 0.4480.448Aspirin (%)Aspirin (%) 76.176.1 70.070.0 0.1630.163Statins (%)Statins (%) 53.553.5 54.054.0 0.9250.925

Postoperative EventsPostoperative EventsDeath (%)Death (%) 3.13.1 3.43.4 0.8730.873MI (enzymes and ECG) (%)MI (enzymes and ECG) (%) 7.67.6 6.86.8 0.7370.737Loss of LimbLoss of Limb 0.50.5 0.90.9 0.1140.114

McFalls EO, et al. N Eng J Med 2004;351:2785-804.

CARP: Long-Term Survival in theTwo Randomized Groups

CARP:CARP: LongLong--Term Survival in theTerm Survival in theTwo Randomized GroupsTwo Randomized Groups

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

Assigned to No Coronary Artery Revasularization

Assigned to Coronary Artery Revasularization

Survival Time (Years)0 1 2 3 4 5 6

0.0

0.2

0.4

0.6

0.8

1.0

Prob

abili

ty o

f Sur

viva

l

Long Term Survival in CARP (2-5 Yrs)Long Term Survival in CARP (2Long Term Survival in CARP (2--5 Yrs)5 Yrs)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

2-Vessel (N=204)

3-Vessel (N=130)

Left Main (N=48)

Prior CABG(N=225)

MedicalTreatment

PreoperativeRevascularization

Garcia S, et al. Am J Cardiol 2008;102:809-15.

Surv

ival

Pos

t-Vas

cula

r Sur

gery

Perioperative GuidelinesPerioperative GuidelinesPerioperative Guidelines

Treatment for patients requiring percutaneous coronary intervention who need subsequent surgery. ACS indicates acute coronary syndrome; COR, class of recommendation; LOE, level of evidence; and MI, myocardial infarction.

Fleisher L, et al. JACC 2007;50:1707-32.

Acute MI, highAcute MI, high--risk ACS, or highrisk ACS, or high--risk cardiac anatomyrisk cardiac anatomy

Bleeding riskBleeding riskof surgeryof surgery

Stent and continuedStent and continueddualdual--antiplateletantiplatelet

therapytherapy

14 to 29 days 30 to 365 days

Low

Greater than 365 days

BareBare--metalmetalstentstent

TimingofSurgery

DrugDrug--elutingelutingstentstent

BalloonBalloonangioplastyangioplasty

(COR IIb/LOE C) (COR IIa/LOE C) (COR IIb/LOE C)

(COR IIb/LOE C)Not Low


Coronary Revascularization before Non-Cardiac Surgery

Class III

It is not recommended that routine

prophylactic coronary revascularization

Be performed in stable CAD before non-

cardiac surgery.

Who Needs Coronary Angiography?Who Needs Coronary Angiography?

• Indicators are the same as for patients not being seen for preop evaluation

• Unstable or poorly controlled symptoms on medical Rx

• Stable patients with likelihood of advanced multivessel CAD +/- LV Dysfunction facing high stress surgery


Who Should I ScreenWho Should I Screen

BeforeBefore

Non Cardiac Surgery?Non Cardiac Surgery?

Potential ApproachPotential ApproachPotential Approach1. Stable Clinical

Markers and/or Not Revascularization candidate

• Angina, q-waves, prior MI

– Beta Blocker + Statin + ASA

• Systolic heart failure– Beta Blocker,

ACE inhibitor, Aldo inhibitor

• Stress Echo• Rarely Cath if severe

ischemia in large regions• Best medical Rx based

on history & stress echo

2. Multiple Markers, established CAD or HF, and high risk surgery

Potential ApproachPotential ApproachPotential Approach

3.Unstable CAD and/or HF

• Cath

• Revascularize those eligible

• B-Blocker if HTN

• Statin if ↑ lipids

4.Non-cardiac markers only…DM, Age, ↑creatinine

Recommendations forPost-operative Surveillance

Recommendations forRecommendations forPostPost--operative Surveillanceoperative Surveillance

• Patients without evidence of CAD– Surveillance restricted to those who develop

perioperative signs of cardiovascular dysfunction

• Patients with known or suspected CAD, and undergoing high or intermediate risk procedure:

– ECG’s at baseline, immediately after procedure, and daily x 2 days

– Cardiac troponin measurements 24 hours postoperatively and on day 4 or hospital discharge (whichever comes first)

2002 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

Resource Use and Outcomes After Implementation of ACC/AHA Preoperative

Risk Assessment Guidelines

Resource Use and Outcomes After Resource Use and Outcomes After Implementation of ACC/AHA PreoperativeImplementation of ACC/AHA Preoperative

Risk Assessment GuidelinesRisk Assessment Guidelines

J Vasc Surg 2002;36:758-63.

Resource I II III P-value P-valueUtilization “Post “Late Post

“Controls” Guideline” Guideline” I vs. II I vs. III(n=102) (n=94) (104)

Stress Test 90 (88%) 44 (47%) 43 (41%) <0.001 <0.001

Coronary Angio. 24 (24%) 10 (11%) 11 (11%) <0.05 0.01

PTCA or CABG 24 (24%) 2 (2%) 6 (6%) <0.001 <0.001

Length of Stay 20.7 13.2 <0.001

PREOP Cost $1087 $171 <0.001

Cost per Case $21,947 $15,188 0.02

Resource Use and Outcomes After Implementation of ACC/AHA Preoperative

Risk Assessment Guidelines

Resource Use and Outcomes After Resource Use and Outcomes After Implementation of ACC/AHA PreoperativeImplementation of ACC/AHA Preoperative

Risk Assessment GuidelinesRisk Assessment Guidelines

J Vasc Surg 2002;36:758-63.

Resource I II III P-value P-valueUtilization “Post “Late Post

“Controls” Guideline” Guideline” I vs. II I vs. III

(n=102) (n=94) (104)

Outcomes

Death 4 (4%) 3 (3%) 0 (0%) 0.77

MI 7 (7%) 3 (3%) 5 (5%) 0.24

Death or MI 11 (11%) 4 (4%) 5 (5%) 0.08

““Prediction Is Very Difficult, Prediction Is Very Difficult,

Especially About The FutureEspecially About The Future””

-- Niels Bohr, Danish PhysicistNiels Bohr, Danish Physicist

Former President Bush VisitFormer President Bush VisitFormer President Bush Visit

““Medicine is an Art Medicine is an Art

of Uncertainty, and a of Uncertainty, and a

Science of ProbabilityScience of Probability””-- Sir William OslerSir William Osler

preoperative assessment for non-cardiac surgery assessment for non-cardiac surgery kim a. eagle, md...

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