4/27/2015. Cardiac Events #1 cause of postoperative complications/ mortality- CHF, complete heart block, MI,

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1 Not intended for medical clearance Identify, document, and evaluate health conditions Medication Management Stratify Risks Optimize conditions within context of surgical illness Recommend measures that may improve short- and long-term outomes Order testing only if it influences patient management. Cardiac Events #1 cause of postoperative complications/ mortality- CHF, complete heart block, MI, Respiratory Events close second Don t forget about hospital delirium, diabetic control, DVT prevention 1

2 76 year old male admitted with hip fracture Active at home, working part-time on farm, building fence, subsequently fell and broke hip HTN Stable Class One Angina No history or symptoms of heart failure What are his risks for postoperative cardiac event? Good Functional Status-(can climb two flights of stairs or walk four blocks without difficulty) (4 METs work) Absence of known cardiovascular disease Low score on the Revised Cardiac Risk Indices 6 Independent predictors RCRI score 1 to 2 defined as intermediate risk (10% chance of postoperative cardiac complication) RCRI score > 3 defined as high risk (20% chance of postoperative cardiac complication 6 Independent predictors, equal weighted High Risk Surgery Known CAD/PAD CHF Previous Stroke or TIA Insulin-Treated DMII Renal Insufficiency (serum creatinine >2) 2

3 64 year old woman, referred for medical clearance for total hip replacement Recent cardiac catheterization 3 months before, stable 2 vessel CAD Stable Class 1 angina Optimal Medical Regimen (asa, beta-blocker, statin, ace inhibitor) What do you recommend? Revascularization by cardologist, referral for Bypass, or to operating room Two Influential Studies (2004) (2006) Patients with CAD undergoing vascular surgery randomized normal or abnormal EF Prophylactic revascularization plus optimal medical regimen or Optimal Medical Regimen alone NO DIFFERENCE In longterm or postop event Order pre-operative stress test only if symptoms raise concern, or results of test might dissuade high risk patients from having surgery Medical Therapies work to prevent Cardiac Events Anti-platelet therapy Peri-operative Beta-Blocker Statin Therapy 3

4 73 year old male, referred for partial colectomy for colon cancer DM2 on insulin therapy, Mild COPD, Prior CVA, Creatinine >2, HTN, Hyperlipidemia? Strong Evidence suggests for the use of perioperative Beta-Blocker true or false? RCRI score 1 to 2 defined as intermediate risk (10% chance of postoperative cardiac complication) RCRI score > 3 defined as high risk (20% chance of postoperative cardiac complication 6 Independent predictors, equal weighted High Risk Surgery Known CAD/PAD CHF Previous Stroke or TIA Insulin-Treated DMII Renal Insufficiency (serum creatinine >2) Increase in postoperative platelet reactivity Volume shifts and blood loss Hypothetical Event-Physiologic stressful time Hyperadrenergic State- Causes relative tachycardia Increased Myocardial oxygen demand Increased shear across atherosclerotic placque Subsequent placque rupture, thrombus, and ultimately MI 4

5 Late 1990s Small trials showing reduced long-term cardiac ischemic complications associated with non-cardiac surgery (DECREASE TRIALS) 2006-two medium sized trials failed to duplicate these findings POISE TRIAL- (23 countries) 8300 patients, non-cardiac surgery, lower incidence of MI and fatal MI, but higher incidence of stroke and mortality! (But 100mg Toprol XL given Bid for 30 days, held with bradycardia or hypotension) In a large retrospective analysis, (VA medical centers) Perioperative Beta Blocker use associated with decreased mortality only in patients with >2 Cardiac Risk Index variables. No difference in undergoing vascular surgery. European Society of Cardiology 2009 CLASS IA indication in patients with established CAD or ischemia on a periaoperative stress test, or high-risk surgery patients ( titrated based on heart rate) Class IIA indication in intermediate-risk surgery American College of Cardiology/AHA CLASS IIA indication in patients undergoing vascular surgery Continue therapy, do not stop on patients taking them, start with high risk patients, best to start early and titrate to heart rate 65 if blood pressure tolerates. 74 year old male, history of continuing tobacco abuse at 1ppd, COPD with stable dyspnea on mild exertion. HTN, no history of CAD, CVA, DM. What are your recommendations? Stop smoking, or continue? 5

6 Almost as common as cardiac complications Early activity MDI inhalers Positioning Believed to be due to reduced lung volumes Incentive spirometry Preoperative smoking cessation-aids with healing and reduction of postop complications Age >50 years COPD Asthma Smoking General Health Status Obesity OSA Serum Albumen <3.5 Pulmonary Hyertension Heart Failure URI Metabolic Factors Type of surgery-abdominal, head and neck,chest Surgery time >3 hours General Anesthesia-vs- Spinal or epidural (pancuronium) Careful history and physical Unexplained cough, exercise intolerance, unexplained dyspnea PFTs, Chest Xray, exercise testing not routinely recommended Chest Radiograph only if >50 with high-risk surgery or history of COPD, Heart Disease within the last 6 months. PFTs and exercise testing only as indicated. Smoking cessation even 48 hours prior shows benefit. Ensure proper use medications, inhalers, oxygen, activity, and Incentiv spirometry 6

7 Observational data support the use of statins perioperatively Two small randomized controlled trials of vascular surgery patients showed reductions in postoperative cardiac events without adverse effects In patients on long-term statin therapy, continue medication In patients undergoing vascular surgery not on statin, start it 82 year old female, referred post-operative for elective knee replacement Due to Advanced OA Manage general medical conditions- DM2-medication only, HTN, history of CVA Seen after surgery, awake, alert, hungry Perioperative Beta-blocker given, statin continued, Glipizide held due to AIC 6.2, Incentive spirometry recommended, FSBS, sliding scale insulin for highs Post-op morning found lethargic, confused No studies regarding stopping or not, 2014 Study Currently underway that should give better evidence basedguidelines 7

8 Considerations -no randomized trials Aspirin therapy increases risk of bleeding complication by factor of 1.5 Meta-analysis 1-10% patients with acute coronary events had stopped aspirin recent days before event (8 to 10 days) Meta-analysis 2- if on aspirin for secondary prevention, withdrawal resulted in 3fold greater risk for major CV event. Primary prevention- no difference. Type of surgery-abdominal, lung, Bypass, Vascular, prostate Site of surgery-closed spaces, (brain, spinal cord, posterior chamber of eye, some prostate surgeries) Minor dermatologic surgery-no major bleeds associated with continuing aspirin 2008 ACCP guidelines Cataract Surgery-some increase in bleeding but no life threatening or sight threatening bleeding complications 2008 ACCP guidelines support continuation of Aspirin for secondary prevention Brain Sugery-postoperative intracerebral hematoma high in patients taking aspirin, recommend discontinuation 7 to 10 days prior Cancer Surgery-consider CV risk when deciding. Sites at risk for major bleeds include major abdominal procedures for cancer, lung resections, CABG, PAD, prostate surgeries 8

9 High Risk--Mechanical heart valve, Atrial fibrillation, or VTE, High CHADS 2Vasc score >10% risk per month for venous event Stop Warfarin 7 to 10 days before and bridge therapy with lovenox at 1.5mg/kg daily or heparin Moderate Risk- Bi-leaflet aortic valve w/ CV risk, medium risk CHADS 2 score, active cancer Stop bridge with low dose lovenox 40mg daily or higher dose lovenox or heparin Low Risk- stop 5 days prior, use low dose lovenox to bridge Restart Warfarin within 12 to 24 hours!!! Bare Metal Stents- Plavix can be stopped after 6 weeks Drug Eluting Stent- Plavix, etc and aspirin must be continued for 12 months- will have to risk bleed Surgeons have multiple interventions for bleedingpressure, suture, clamps, packing, electrocautery, Gelfoam, thrombin, topical agents, reoperation, argon beam coagulation, etc PRADAXA- XARELTO- BRILLINTA- ELIQUIS- 9

10 Every patient to be considered individually, good history, identify their unique risk factors Do not stop statins, beta-blockers, or aspirin prior to surgery (unless closed space surgery) in patients using for secondary prevention Start these meds in patients at higher risk and try to delay elective surgeries to allow for better control of current medical conditions Stop Warfarin 7 to 10 days before surgery in high risk patients and bridge with high dose lovenox, in lower risk can stop 5 days before and use low dose lovenox Good nursing and followup to prevent other complications! Journal Watch, Cardiology Up To Date JAMA 2013, April 24 Cleveland Clinic 10