Cardiac Perioperative Risk Assessment American Heart Association Guidelines
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1 Cardiac Perioperative Risk Assessment American Heart Association Guidelines Dr Gary Liew, MBBS, PhD, FRACP US Board Certified in Cardiovascular CT Executive Committee, Cardiac Institute, Epworth Healthcare Senior Fellow, University of Melbourne Clinical Senior Lecturer, University of Adelaide
2 Perioperative Cardiac Guidelines American - AHA/ACC 2014 European - ESC / ESA
3 U.S. Perioperative Guidelines Fleisher et al, JACC 2014
4 European Perioperative Guidelines Kristensen et al, Eur Heart J, (2014) 35,
5 ESC Perioperative Guidelines App
6 Topics Coronary Artery Disease Heart Failure Atrial Fibrillation & Arrhythmias Valvular Disease Pacemakers & ICDs Stepwise approach to Pre-Op testing Treatment options in Peri-Op period
7 Coronary Artery Disease Current ACS or unstable angina Timing surgery since previous AMI < 1 Month 1 2 Months 2 3 Months 3 6 Months AMI 32% 18% 8% 6% Death 14% 11% 10% 9%
8 Heart Failure Patients with active / clinical heart failure have higher post-op death (9%) than patients with stable CAD (3%). Patients with LVEF < 30% highest risk 30-Day MACE rate based on symptoms: Symptomatic Heart Failure Asymptomatic LV systolic Heart Failure Asymptomatic LV Diastolic Heart Failure MACE 49% 23% 18%
9 Valvular Heart Disease
10 Valve stenosis worse than valve regurgitation Severe symptomatic AS or MS should be fixed prior to elective surgery Severe asymptomatic AS may be go ahead with caution and HDU monitoring Severe AS = AVA < 1.0cm 2 or mean gradient > 40 mmhg (normal LVEF) Severe asymptomatic AR or MR with normal LVEF may go ahead with caution and HDU monitoring
11 Atrial Fibrillation Rate control is key continue pre-op beta-blocker or digoxin. Diltiazem can be useful in asthmatics. Consult with cardiologist about stopping anti-coagulants. No bridging with clexane / heparin unless previous stroke or high CHADs-Vasc score or valvular. NOACs only stop hours pre-op.
12 Other arrhythmias Isolated RBBB or LBBB are fine to proceed (ie. No new CCF or CAD) 2 nd degree 2:1 AV block or CHB may require temporary pacing or pacemaker Beware Trifascicular Block = RBBB + 1 st degree AV block + left or right axis deviation (LAFB or LPFB) No pacing if asymptomatic but CHB.
13 Trifascicular Block - one step away from CHB RBBB + 1 st degree AV block + left or right axis deviation (LAFB or LPFB) RBBB Left Axis Deviation 1 st Degree AV Block = PR > 1 Big Square
14 Cardiac Implantable Electronic Devices (CIEDs) INVOLVE CIED TECHNICIAN PRE / PERI-OP Electro-cautery can cause inhibition of pacing, oversensing in ICDs = inappropriate shocks Magnet application and/or reprogramming can avoid these problems Mono-polar cautery can reduce EMI (electromagnetic interference)
15 Stepwise Approach 1. Urgent Surgery 2. ACS or unstable cardiac conditions 3. What is the risk of the procedure? 4. What is the functional capacity of patient? Good (> 4 METS = proceed) 5. Poor functional capacity then consider risk of surgery 6. Clinical risk factors for High Risk Surgery 7. Functional testing
16 Step 1: Urgent Surgery Emergency / Urgent Surgery will proceed no time to order investigations Patient or surgical factors will dictate strategy Cardiac monitoring and surveillance for complications eg. MI, arrhythmias Continuation of medical therapy for chronic conditions eg. Aspirin, B-blocker
17 Step 2: Active / Unstable cardiac Unstable Angina Recent MI (< 60 days) or residual ischaemia Acute heart failure Significant cardiac arrhythmias Symptomatic valvular heart disease Delay procedure Consultation with relevant specialists Investigate and optimize treatment
18 Step 3: Risk of surgery 30-Day risk of MI and death No further testing needed; proceed to surgery
19 Step 4: Functional Capacity Good > 4 METs & Asymptomatic Proceed to surgery
20 Step 5: Poor function < 4 METS If Moderate or High Risk Surgery then consult and consider functional test Stress Echocardiogram Stress Nuclear Perfusion
21 Step 6: Clinical Risk Factors Revised Cardiac Risk Index (RCRI) Lee et al, Circulation 1999: 100, IHD angina or previous AMI Heart Failure Stroke or TIA CKD Cr > 170 or CrCl < 60 Diabetes requiring insulin 2 factors = rest echo +/- stress 3 factors = Stress testing
22 RCRI Calculator App
23 Step 7: Functional testing Stress Echo (treadmill vs. dobutamine) LBBB, obesity, severe COAD Stress Nuclear Perfusion Treadmill / bike vs Persantin or Adenosine, Dobutamine Cardiac MRI access issue & cost Coronary CTA not indicated for routine pre-op testing. Routine coronary angiogram not indicated
24 Routine ECG or Echo?
25 Medications Peri-Op Beta-blockers Statins ACEi / ARBs
26 Beta-blockers
27
28 Other therapies 28
29 Stents and Dual-Antiplatelets Bare metal stents min. 4 weeks DES min. 12 months but? 6 months If surgery urgent, keep Aspirin going. Risk of MI = <30 days 15%, <6 months 8%
30 Summary Consider surgical & patient risk Patient functional status Low risk procedures no need to test Mod High risk surgery = consider patient status / risk factors Continue aspirin, statins, ACEi, ß blockers for chronic, stable patients. Not start new aspirin or ß blockers routinely unless indicated 30
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