preoperative cardiacpreoperative cardiac...
TRANSCRIPT
![Page 1: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/1.jpg)
Preoperative CardiacPreoperative Cardiac Evaluation 2012Evaluation 2012
John E. Ellis MDUniversity of Pennsylvania (USA)y y ( )
![Page 2: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/2.jpg)
![Page 3: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/3.jpg)
WHAT’S THE GOAL OF PREOPEVAL?
•Is patient in best possible shape?C th ti t b d b tt ?•Can the patient be made better?
•Risk assessment?Risk assessment?•Who should not have surgery?
![Page 4: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/4.jpg)
What will kill the patient?p
•T i l l CAD•Triple vessel CAD•L ft i CAD•Left main CAD•A ti t i•Aortic stenosis
![Page 5: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/5.jpg)
Anesthesiology 2010; 113:794 – 805
![Page 6: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/6.jpg)
PERIOP CV EVAL 2012•Falling periop event rates make aggressive workup less rewardingaggressive workup less rewarding•What’s it worth to reduce complications 50%50%…
•From 10% to 5%? (NNT = 20)From 2% to 1%? (NNT = 100)•From 2% to 1%? (NNT = 100)
![Page 7: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/7.jpg)
Who is at risk for perioperativemyocardial infarction?
![Page 8: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/8.jpg)
![Page 9: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/9.jpg)
![Page 10: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/10.jpg)
What tools to use?What tools to use?• American Society of• American Society of
Anesthesiologists?• Charlson comorbidity?• Lee (Goldman) cardiac risk index?Lee (Goldman) cardiac risk index?• Eagle• F ilt ?• Frailty?
![Page 11: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/11.jpg)
Pathophysiologic differences?Pathophysiologic differences?
•Different risk factors•Different risk factorsoSmokinggoObesity
Di b toDiabetesoSleep apneaoSleep apnea
![Page 12: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/12.jpg)
“BEDSIDE” RISK FACTORS
Lee TH et al Circulation 1999
![Page 13: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/13.jpg)
“BEDSIDE” RISKFACTORS
•High risk surgeryh/o ischemic heart disease•h/o ischemic heart disease
•h/o CHF•h/o CVAInsulin Rx•Insulin Rx
•Creatinine > 2.0 mg/dL
Lee TH et al Circulation 1999
![Page 14: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/14.jpg)
By definition, patients undergoing AAA, thoracic, and abdominal procedures were excluded from class I.
Risk class predicts cardiovascular morbidity
Class 1: 0 riskClass 2: 1 risksClass 3: 2 risksClass 3: 2 risksClass 4: >3 risks
![Page 15: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/15.jpg)
But that’s not allBut that s not all…Changing nature of cardiovascular
disease
![Page 16: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/16.jpg)
Circulation 2011, 124:289-296: originally published online June 27, 2011
![Page 17: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/17.jpg)
Circulation 2011, 124:289-296: originally published online June 27, 2011
![Page 18: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/18.jpg)
![Page 19: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/19.jpg)
Wh t b t h t i ?What about hypertension?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 6 (December), 2010: pp 927-930
![Page 20: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/20.jpg)
Limitations of "traditional" evaluationevaluation
T d t f 1Tend to focus on 1 organ systemsystemOften the heartOften the heart
Yet surgical morbidityYet, surgical morbidity and mortality have ychanged
![Page 21: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/21.jpg)
The Elderly PatientThe Elderly Patient
![Page 22: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/22.jpg)
Aging DemographicsAging DemographicsLife RankLife expectancy
Rank
Australia 81.81 9thust a a 8 8 9t
Hong Kong 82.04 8th
New Zealand 80.59 23rd
https://www.cia.gov/library/publications/the‐world‐factbook/rankorder/2102rank.html
![Page 23: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/23.jpg)
Functional status in elderlyFunctional status in elderly
http://www.nytimes.com/2012/08/25/sports/25iht-athlete25.html?_r=0
![Page 24: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/24.jpg)
• Unintentional weight loss ≥10 pounds in lastyear.yea
• Decreased grip strength (weakness).• ExhaustionExhaustion.• Low physical activity.• Slowed walking speed (walk 15 feet)Slowed walking speed (walk 15 feet).
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
![Page 25: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/25.jpg)
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
Journal of the American College of SurgeonsVolume 210, Issue 6, June 2010, Pages 901–908
![Page 26: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/26.jpg)
Who “needs” a stress test?Cardiology consultation?
![Page 27: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/27.jpg)
LAURA C•55 yo F•s/p CVA MI CHF IDDM•s/p CVA, MI, CHF, IDDM•Gangrenous toesF di t l b d•Fem-distal bypass proposed
Does she need a stress test?
![Page 28: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/28.jpg)
JOHN B•75 yo WM for iliac angioplasty•Cath, stented RCA s/p MI 2 years agoCat , ste ted C s/p yea s ago
•No symptoms since•Medical Rx
•ACE-I•Beta blocker•Statin•Aspirin
Does he need a stress test?
![Page 29: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/29.jpg)
I will argueLaura C maybe needs a stress
test (or maybe straight to cardiac th)cath)
J h B d tJohn B does not
![Page 30: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/30.jpg)
WHAT DOES STRESS TEST ADD?
•L’Italien et alROC (P ti•ROC curve areas (Prognostic accuracy)
•74% by clinical criteria•81% by clinical criteria + stress81% by clinical criteria stress tests
J Am Coll Cardiol. 1996 Mar 15;27(4):779-86.
![Page 31: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/31.jpg)
It’s the history!It s the history!
Once again, history and physical more important than “specialized” testing
![Page 32: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/32.jpg)
![Page 33: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/33.jpg)
S SStep 1: Emergency Surgery
Proceed to surgery with medical risk reduction and perioperativerisk reduction and perioperativesurveillance
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
![Page 34: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/34.jpg)
St 2 A ti C di C ditiStep 2: Active Cardiac Conditions• Unstable angina, recent MI• Decompensated CHF• Decompensated CHF• Significant arrhythmias• Severe valvular disease• Severe valvular disease
Postpone surgery until stabilized or corrected
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
or corrected
![Page 35: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/35.jpg)
St 3 L Ri k S ( i k <1%)Step 3: Low Risk Surgery (risk <1%)• Superficial or endoscopic• Cataract or breast• Cataract or breast• Ambulatory
Proceed to surgery
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
![Page 36: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/36.jpg)
St 4 F ti l C itStep 4: Functional Capacity• Good• > 4 METs• > 4 METs
o Can walk flight of stairs without symptomssymptoms
Proceed to surgery
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
![Page 37: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/37.jpg)
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
![Page 38: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/38.jpg)
Risk factors• DMCVA / TIA• CVA / TIA• CHF• CAD
• Cr > 2 0• Cr > 2.0
No risk factors: 1 2 risk factors AND >3 risk factors:No risk factors:
PROCEED TO
1-2 risk factors ANDvascular / intermed.
surgery:
>3 risk factors:
CONSIDER STRESS TESTINGPROCEED TO
SURGERY PROCEED TO SURGERY WITH
HR CONTROL
STRESS TESTINGIF IT WILL CHANGE
MANAGEMENT
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185699v1
![Page 39: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/39.jpg)
![Page 40: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/40.jpg)
Ann Surg. 2012 Sep 7. [Epub ahead of print]
![Page 41: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/41.jpg)
Ann Surg. 2012 Sep 7. [Epub ahead of print]
![Page 42: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/42.jpg)
TABLE 5. Predictors of Preoperative Cardiac Stress Testing (N = 74,117)
Female
Year of surgery
Charlson comorbidity indexCharlson comorbidity index
Size of MSA
US region
Hospital size
Least in Pacific NW
Hospital size
MSA indicates metropolitan statistical area.All P < 0 05
Ann Surg. 2012 Sep 7. [Epub ahead of print]
All P < 0.05
![Page 43: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/43.jpg)
J Clin Anesth. 2010 Sep;22(6):402-9
![Page 44: Preoperative CardiacPreoperative Cardiac …vascularanesthesia.howilost100lbs.com/wp-content/uploads/...Cardiology consultation? LAURA C •55 yo F •s/p CVA MI CHF IDDMs/p CVA, MI,](https://reader035.vdocuments.us/reader035/viewer/2022081614/5fcc082ffef9ce739655b82f/html5/thumbnails/44.jpg)
ConclusionsConclusions• Declining cardiac event rates change theDeclining cardiac event rates change the
value of preop testing• Preop evaluation should be guided by historyPreop evaluation should be guided by history• Other factors important besides CAD:
o Heart failureo Heart failureo Arrhythmiaso Valvular heart diseaseoo Fraility
• Stress tests are marginally useful to g yreclassify intermediate risk patients