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Slide 2 Perioperative care: beta blockers and a little beyond Deepti Rao Slide 3 Objectives Recognize ACC/AHA guidelines for cardiac risk assessment Understand the controversy surrounding the use of perioperative beta blockers Understand the complexities and tools used to make decisions regarding perioperative management of antithrombotic therapy Slide 4 Cardiac evaluation and care algorithm for noncardiac surgery Slide 5 Major predictors that require intensive management and may lead to delay in or cancellation of the operative procedure-- per ACC/AHA guideline summary Unstable coronary syndromes including unstable or severe angina or recent MI Decompensated heart failure including NYHA functional class IV or worsening or new-onset HF Significant arrhythmias including high grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with ventricular rate > 100 bpm at rest, symptomatic bradycardia, and newly recognized ventricular tachycardia Severe heart valve disease including severe aortic stenosis or symptomatic mitral stenosis Slide 6 Cardiac evaluation and care algorithm for noncardiac surgery Slide 7 ACC/AHA guideline summary: Cardiac risk stratification for noncardiac surgical procedures High risk (reported risk of cardiac death or nonfatal myocardial infarction [MI] often) Aortic and other major vascular surgery Peripheral arterial surgery Intermediate risk (reported risk of cardiac death or nonfatal MI generally 1 to 5 percent) Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery Low risk* (reported risk of cardiac death or nonfatal MI generally less than 1 percent) Ambulatory surgery Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Slide 8 Cardiac evaluation and care algorithm for noncardiac surgery Slide 9 Estimated energy requirements for various activites Take care of self Eat, dress, use toilet Walk indoors around the house Walk a block or 2 on level ground Do light work around the house like dusting or washing the dishes Climb a flight of stairs or walk up a hill Walk on level ground at 4 mph Run a short distance Do heavy work around the house like scrubbing floors Participate in moderate activities like golf or dancing Participate in strenuous activities like swimming or skiing Slide 10 Cardiac evaluation and care algorithm for noncardiac surgery Slide 11 Revised Goldman cardiac risk index (RCRI) Six independent predictors of major cardiac complications High-risk type of surgery (includes any intraperitoneal, intrathoracic, or suprainguinal vascular procedures) History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present) History of compensated or prior HF History of cerebrovascular disease Diabetes mellitus requiring treatment with insulin Preoperative serum creatinine >2.0 mg/dL (177 mol/L) Slide 12 Cardiac evaluation and care algorithm for noncardiac surgery Slide 13 Perioperative beta blockers Perioperative cardiac ischemia 1-10% of patients older than 50 Causes Increased inflammatory mediators increased sympathetic tone, catecholamine surge oxygen supply/demand mismatch in heart Hypercoagulability and decreased fibrinolytic activity Acute plaque rupture, thrombosis and occlusion How do we prevent this? Slide 14 Perioperative beta blockers How do they work? Decrease cardiac oxygen demand Antiarrhythmic Limit sympathetic and neuroendocrine responses to stress May limit free radical production/inflammation Slide 15 Perioperative Beta blockers 1970s, 1980s,1990s Small trials showing bb reduced risk of periop cardiac events in selected patients with known or suspected cardiac events Use endorsed by Leapfrog group, AHRQ and National Quality Forum Slide 16 The effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular SurgeryDECREASE Poldermans, et al 1999 Randomized 112 high risk patients to either standard care or standard care plus bisoprolol High risk: Risk factors and positive dobutamine echo Not blinded except to adverse events committee/no placebo Undergoing major vascular surgery Slide 17 The effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular SurgeryDECREASE Started bisoprolol at doses of 5mg, increased to 10mg if heart rate >60 bpm 1 week later. Started bisoprolol average of 37 days prior to surgery (!!!!!!), at least 1 week prior In hospital If symptoms or signs of perioperative mi with tachycardia developed, patients received beta-bl (4) If unable to take bisoprolol postop, heart rate monitored q1hr and given metoprolol iv if hr>80 bpm Medication withheld if hr 75 yr CHADS 2 score of 3 or 4 VTE within the past 3 to 12 mo Nonsevere thrombophilic conditions (eg, heterozygous factor V Leiden mutation, heterozygous factor II mutation) Recurrent VTE Active cancer (treated within 6 mo or palliative) Slide 46 Suggested Patient Risk Stratification for Perioperative Arterial or Venous Thromboembolism Risk StratumMechanical Heart Valve Atrial FibrillationVTE LowBileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke CHADS 2 score of 0 to 2 (and no prior stroke or transient ischemic attack) Single VTE occurred > 12 mo ago and no other risk factors Slide 47 Managing the patient on warfarin undergoing an elective surgery--- from Jaffer, talk Patient risk factors 1.Indication 2.RF for Thromboembolism Surgical risk factors 1.Type of surgery 2.Risk of Bleeding 3.Risk of thromboembolism 4.Time off anticoag Weigh the consequences of TE and Bleeding Determine the need for bridging therapy Slide 48 What is the procedural risk of bleeding? High Bleeding Risk: CABG or valve replacement surgery Intracranial or spinal surgery AAA repair, peripheral artery bypass, and other major vascular surgery Major orthopedic surgery such as hip or knee replacement Reconstructive plastic surgery Major cancer surgery Prostate and bladder surgery Slide 49 What is the procedural risk of bleeding? Perioperative anticoagulation should be undertaken with caution: Resection of colonic polyps esp sessile polyps>2 cm in diameter Biopsy of prostate or kidney Cardiac pacemaker or defibrillator implantation Slide 50 Managing the patient on warfarin undergoing an elective surgery--- from Jaffer, talk Patient risk factors 1.Indication 2.RF for Thromboembolism Surgical risk factors 1.Type of surgery 2.Risk of Bleeding 3.Risk of thromboembolism 4.Time off anticoag Weigh the consequences of TE and Bleeding Determine the need for bridging therapy Slide 51 Perioperative risk of TE Rate of TE approx 1.6% Risk of VTE 100 fold greater during the perioperative period relative to the nonoperative period Surgical milieu induces a hypercoagulable state However major bleeding is also an issue approx 3% Full dose bridging leads to 4-6 fold increase in major bleedingwait couple of days prior to starting full dose and just use prophylactic dose? Slide 52 How do I balance the risk of thromboembolism with the risk of bleeding? Art of medicine On coumadin for afib undergoing CABG vs on coumadin for mitral valve replacement undergoing lap chole Slide 53 Managing the patient on warfarin undergoing an elective surgery--- from Jaffer, talk Patient risk factors 1.Indication 2.RF for Thromboembolism Surgical risk factors 1.Type of surgery 2.Risk of Bleeding 3.Risk of thromboembolism 4.Time off anticoag Weigh the consequences of TE and Bleeding Determine the need for bridging therapy Slide 54 . If I do have to interrupt my patients antithrombotic therapy, should I recommend bridging therapy? Based on risk of embolism from table above suggeted regimens for bridging: High Therapeutic SC LMWH IV UFH Moderate Therapeutic SC LMWH IV UFH Low dose SC LMWH Low Low dose SC LMWH none Slide 55 Other bridging issues Many bridging protocols Jaffer, et al. CCM 2003;70:973 If want to eliminate any residual antithrombotic effect stop vka 5 days prior to procedure, LMWH 24 hours prior asa 7-10 days (could make argument 2-3 days) nsaids 24 hours (no increased risk bleeding with cox-2) clopidogrel 5-7 days prior In resuming antithrombotic therapy with LMWH wait until hemostasis is obtained Slide 56 Other bridging issues Time to activity of antithrombotic therapy: Warfarin 2-3 days LMWH 3-5 hours for peak effect ASA minutes Clopidogrel 3-7 days