Clinical Controversies in Perioperative Medicine

Transcription

1 Clinical Controversies in Perioperative Medicine Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco

2 Predicting & Managing Cardiac Risk A 70-y.o. man with progressive weakness due to cervical myelopathy will have spinal decompression & fusion. He had a drug-eluting stent placed 8 months ago for stable angina. He also has insulin-requiring diabetes and a remote CVA. He uses a walker, needs help with some ADLs. 1. How do you assess his risk for cardiac complications? 2. What about his drug-eluting stent? 3. Should you start a beta-blocker?

3 70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. How would you estimate this patient s cardiac risk? 1. I use the Revised Cardiac Risk Index (RCRI), so ~ 10% 2. I use the RCRI, so ~ 5% 3. I use the NSQIP prediction tool, so ~ 1% 4. I don t need a prediction tool; my gut says he s high risk

4 Revised Cardiac Risk Index Predictors: Ischemic heart disease Congestive heart failure Diabetes requiring insulin Creatinine > 2 mg/dl Stroke or TIA High Risk operation (intraperitoneal, intrathoracic, or suprainguinal vascular) # of RCRI Complications Predictors All Serious 0 0.5% 1 1.3% 2 4% 3 9% 0.4% 1% 2.4% 5.4% All: MI, cardiac arrest, complete heart block, pulmonary edema Serious: MI & cardiac arrest Devereaux PJ et al. CMAJ 2005; 173:627.

5 2007 ACC/AHA Guideline Good Functional Capacity? no or? yes Go to OR no predictors* 1 or 2 predictors 3 predictors Go to OR * CAD, CHF, DM, CKD, CVA/TIA Control HR & go to OR (IIa) no or (IIb) Vascular surgery? yes Consider stress test if results will change management (IIa)

6 New Cardiac Risk Prediction Tool Derived from National Surgical Quality Improvement Program (NSQIP) database: > 400 K patients in derivation & validation cohorts Wide range of operations Complication = 30-day incidence of MI & cardiac arrest Independent Predictors 1. Type of surgery 2. Age 3. Serum creatinine > 1.5 mg/dl 4. Functional status (dependency for ADLs) 5. American Society of Anesth (ASA) class Gupta PK et al. Circulation 2011; 124:681

7 ASA Class (a brief digression) American Society of Anesthesiologists Physical Classification 1. Healthy, normal 2. Mild systemic disease 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. Moribund patient not expected to survive without surgery Subjective assessment Moderate inter-observer variability

8 NSQIP Cardiac Risk Calculator

9 70-y.o. with h/o remote MI, stroke, IDDM undergoing cervical spine surgery. Needs help with some ADLs. Age 70 Cr < 1.5 ASA Class 3 Partially dependent Spine surgery

10 70-y.o. with h/o remote MI, stroke, IDDM undergoing cervical spine surgery for progressive weakness. 0.72% Other findings: Excellent performance (AUC = 0.88) MI/Cardiac arrest strongly predicts mortality (61% vs. 1%) Caveats: Didn t look at all possible variables (e.g., TTE, stress test)

11 Which Prediction Tool is Better? RCRI NSQIP Sample size ~4000 ~400,000 # of hospitals 1 > 200 Currency of data Screen for MI? CK-MB, ECG No Changes to Practice & Guideline? Suspect new ACC/AHA guideline will still use RCRI Personal practice: use NSQIP when quantifying risk

12 70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. What about that stent? 1. Operate now, he can t wait 2. Operate now only if he can continue antiplatelet therapy 3. Wait until 12 months after stent placement

13 ACC/AHA Guidelines for PCI Avoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapy Delay elective surgery in patients with recent PCI Bare metal stent: 1 month Drug eluting stent: 1 year

14 Surgical Outcomes After Stenting Question: How do stent type and time until surgery affect risk of cardiac complications? Study Design: Retrospective cohort analysis Over 25,000 pts who had noncardiac surgery between 6 weeks & 2 years after BMS or DES placement Identify risk factors for cardiac complications (all-cause mortality, MI, revascularization) Hawn MT et al. JAMA. doi: /jama

15 Time Since Stent Placement Time of surgery after PCI didn t matter after first 6 months Complications 20% 15% 10% 5% 6 months BMS DES Time between PCI & Surgery Hawn MT et al. JAMA. doi: /jama

16 Surgical Outcomes After Stenting Question: Does holding or continuing antiplatelet drugs affect risk of cardiac complications in patients with stents? Study Design: Case-control study 284 patients with stents who had antiplatelet drugs held for noncardiac surgery matched with patients who had drugs continued Results: Holding antiplatelet drugs did not increase risk of cardiac complications (O.R. for 0.86; 95%CI, ). Hawn MT et al. JAMA. doi: /jama

17 Guidelines for DES Guideline ACC / AHA ACCP ESC Recommendation Wait 12 months before elective surgery if it requires stopping dual therapy Wait 6 months before surgery (strong) If < 6 months, continue dual therapy (weak) 6-12 months of dual therapy Continue ASA in favor of clopidogrel

18 70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. Would you start a beta-blocker? 1. Yes, I follow the guidelines 2. Maybe, I do this less often now 3. No, I ve stopped doing this 4. No, I ve never done this because I don t trust the Dutch

19 2009 ACC / AHA Guideline for β-blockers Definite indications (Class 1): Already using β-blocker to treat angina, HTN, arrhythmia Probable indications (Class 2a): Vascular or intermediate-to-high risk surgery patients with coronary disease, or more than 1 other risk predictor * Uncertainty (Class 2b): Patients undergoing vascular or intermediate risk surgery without coronary disease but with 1 other predictor * * CAD, CHF, DM, CKD, CVA/TIA

20 POISE: Treatment Protocol Patients: 8351 pts with s/f major noncardiac surgery CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery Not already taking β-blocker 2-4 h OR 0-6 h 12 h 1st dose Metoprolol XL 100 mg 2nd dose Metoprolol XL 100 mg 3rd & daily dose Metoprolol XL 200 mg Outcome: 30-day cardiac mortality, nonfatal arrest or MI Devereaux PJ. Lancet. 2008; 371:

21 POISE: Results Metoprolol XL: Reduced cardiac events (mostly nonfatal MI) but Increased risk of stroke & total mortality Devereaux PJ. Lancet. 2008; 371:

22 DECREASE-IV Patients: 1066 pts with estimated 1-6% risk of postoperative cardiac complications, undergoing elective non-cv surgery Treatment: 1. Bisoprolol 2.5 mg daily started at randomization; -- dose titrated in hospital by mg daily; -- maximum 10 mg daily; -- target heart rate = with SBP > Fluvastatin XL 80 mg daily 3. Bisoprolol + Fluvastatin 4. Double placebo Drugs started median 34 days prior to surgery Outcome: 30-day cardiovascular mortality or nonfatal MI Dunkelgrun, M et al. Ann Surgery, 2009; 249:

23 DECREASE-IV Results Cardiac Death or Nonfatal MI * P =.002 * * Bisoprolol-treated patients had fewer complications Trend towards benefit with statins No safety issues Dunkelgrun, M et al. Ann Surgery, 2009; 249:

24 Investigation of possible breaches of academic integrity Findings regarding DECREASE IV: Data poorly documented Inclusion criteria violated Outcomes not assessed per protocol Conclusions: Cannot vouch for reliability of findings or validity of conclusions from this trial

25 β-blockers: So Now What? Meta-analysis of secure β-blocker trials Reduces perioperative MI (mostly asymptomatic) Increase in mortality & strokes Practice & Guideline Changes? Uncertain benefit vs. risk, even in high risk patients Avoid fixed dose (non-titrated) perioperative β-blockade No good reason to start β-blocker without other indication Bouri, S et al. Heart 2013;0:1 9. doi: /heartjnl

26 Managing Perioperative Anticoagulation Your orthopedic colleague asks your advice on how to manage anticoagulation in two patients who had hip fractures. One has atrial fibrillation due to HTN. The other has a mechanical AVR. Neither has any other relevant comorbidity 1. Heparin bridge for AVR only 2. Heparin bridge for AF only 3. Heparin bridge for both 4. Heparin bridge for neither

27 Thromboembolic Risks with Atrial Fibrillation Annual Stroke Risk CHADS-2 Score: 1 point for CHF, HTN, Age>75, DM 2 points for Stroke/TIA Score 0-2: < 5% stroke risk / yr Score 3-4: 5-10% Score 5-6: > 10% Ansell J. Chest. 2004;126:204S-233S.

28 Thromboembolic Risks with Mechanical Valves Annual Incidence Cannegieter, et al. Circulation, 1994

29 Effect of Mechanical Valve Location & Design on Thromboembolic Risk Valve Location: Aortic RR = 1.0 Mitral RR = 1.8 Valve Design: Caged Ball RR = 1.0 Tilting Disk RR = 0.7 Bi-leaflet RR = 0.6 Cannegieter, et al. Circulation, 1994

30 Benefits & Harm of Bridging Perioperative Anticoagulation Death or disability from thromboembolism averted by bridging Death or disability from perioperative bleeding caused by bridging

31 Benefits & Risks Randomized trial in progress Review of cohort studies: Thrombosis Total Bleeding Serious Bleeding Bridged 1.1% 11% 3.7% Not Bridged 0.9% 2% 0.9% Odds Ratio (95% CI) 0.8 ( ) 5.4 ( ) 3.6 ( ) Seigal, D et al. Circulation, 2013; 126:1630

32 Perioperative Anticoagulation: 2012 ACCP Guidelines (9 th Edition) Atrial Fib. Mechanical Valve Recommendation CHADS2 = 5-6; recent CVA; rheumatic AF CHADS2 = 3-4 CHADS2 = 0-2 Any MVR; older (cagedball or tilting disc) AVR; recent CVA Bileaflet AVR plus other stroke risk factor(s) Bileaflet AVR without AF or other stroke risk factor Bridge with heparin??? No heparin bridge All recommendations are weak, based on low quality evidence

33 Are Curbside Consults Safe? You re about to leave the hospital when an orthopedic surgeon calls you with a quick, curbside question about diabetes management for a stable patient. 1. I never do curbside consults 2. Ask questions to determine whether curbside is appropriate 3. No problem! She s stable.

34 Curbside Consults Studied 47 requests for curbside advice to hospitalist Curbside consultant could ask questions ad lib Made recommendations without seeing patient or chart Different hospitalist performed formal, in-person evaluation Questions: Did curbside consultant obtain accurate information? Did advice and management differ? Burden, M et al. J Hosp Med, 2013; 8:31 3

35 Curbside vs. Formal Medicine Consult Compared to formal consultation, how often did curbside evaluation lead to: Incomplete clinical information 34% Inaccurate clinical information 28% Different recommendations 55% Any difference in management 60% Major difference in management 36% Burden, M et al. J Hosp Med, 2013; 8:31 3

36 Thank You