Preoperative Evaluation: Patients with Cardiac Disease

Transcription

1 Advances in Internal Medicine 2012 Preoperative Evaluation: Patients with Cardiac Disease Mary O. Gray, MD Professor of Medicine UC San Francisco Circulation 2007:100:e418-e500 (1) Cardiac Risk Assessment (2) Medication Management (3) Cardiac Device Management Circulation 1999:100:

2 Derivation Cohort Validation Cohort Circulation 1999:100: Circulation 2011:124:

3 Risk Model Performance: Calibration of Predictions NSQIP RCRI -- MICA: myocardial infarction or cardiac arrest -- prospective database from > 250 hospitals -- training set: 2007 data (211,410 patients) -- validation set: 2008 data (257,385 patients) C statistic C statistic Forty-year-old woman, ASA class 2, independent, with normal creatinine, laparoscopic cholecystectomy: 0.08% Sixty-five-year-old man, ASA class 4, partially dependent, elevated creatinine, peripheral vascular surgery: 5.75% Ann Intern Med 2010:152:

4 Conditions Warranting Evaluation, Treatment, and Testing Before Noncardiac Surgery Unstable Coronary Syndromes -- Unstable angina (CCS class III or IV) -- Acute myocardial ischemia or infarction -- Recent myocardial infarction (< 1 month) Conditions Warranting Evaluation, Treatment, and Testing Before Noncardiac Surgery Decompensated Heart Failure -- NYHA functional class IV symptoms -- Newly detected heart failure -- Deteriorating heart failure Conditions Warranting Evaluation, Treatment, and Testing Before Noncardiac Surgery Significant Arrhythmias -- Symptomatic bradycardia -- High-grade atrioventricular block -- Mobitz type II block -- Third-degree atrioventricular block -- Supraventricular arrhythmias with rapid ventricular rate at rest (> 100 bpm) -- Atrial fibrillation with rapid ventricular rate 4

5 Conditions Warranting Evaluation, Treatment, and Testing Before Noncardiac Surgery Conditions Warranting Evaluation, Treatment, and Testing Before Noncardiac Surgery Ventricular Arrhythmias -- Newly detected ventricular tachycardia -- Ventricular fibrillation Severe Valvular Disease -- Severe aortic stenosis: AVA < 1 square cm or mean systolic gradient > 40 mmhg -- Symptomatic mitral stenosis: associated with either heart failure or presyncope Lancet 2008:371: recruitment between October 2002 and July patients undergoing non-cardiac surgery, age > 45 years -- expected length of hospital stay > 24 hours -- any one of the following clinical criteria: -- history of coronary artery disease -- history of peripheral vascular disease -- hospitalization for heart failure within past 3 years -- major vascular surgery -- any three of the following risk criteria: -- intrathoracic, intraperitoneal, or emergent surgery -- history of heart failure or transient ischaemic attack -- diabetes, creatinine > 175 µmol/l, age > 70 years Lancet 2008:371:

6 Metoprolol Group: Beneficial Effects -- first dose of study drug 2-4 hours before operation -- metoprolol succinate 100 mg or matching placebo -- first postoperative dose within 6 hours after surgery -- metoprolol succinate 100 mg or matching placebo -- maintenance: metoprolol succinate 200 mg or placebo Metoprolol Group: Adverse Effects 6

7 Perioperative Beta Blockers in Non-Cardiac Surgery SUGGESTIONS -- Given the risk of sudden cessation of beta blockers, therapy should be continued in patients already taking beta blocker. -- Beta-1 cardioselective agent should be used. Long-acting beta-1 cardioselective agents may be more effective than short-acting. -- Blood pressure and heart rate should be monitored closely, with pre-specified targets for each patient. Dosing should not be fixed but titrated to target. Heart rate of 60 beats per minute suggested. -- Start beta blocker days to weeks in advance. Duration is unknown. N Engl J Med 2009;361: DECREASE III Non-cardiac Vascular Surgery at Erasmus Medical Center (2004 to 2008) Cardiovascular Implantable Electronic Devices (CIED) and Medical Electromagnetic Interference (EMI) Fluvastatin (n = 250) Placebo (n = 247) NEJM 2009;361:

8 CIED and Medical EMI CIED and Medical EMI Bipolar Electrosurgery -- Active and return electrode functions are performed at the surgical site. -- Two tines of the forceps perform active and return electrode functions. -- Only the tissue grasped between tines is included in the electrical circuit. Monopolar Electrosurgery -- Commonly used electrosurgery modality. Versatile and clinically effective. -- Active electrode is in the wound. Return electrode is elsewhere on body. -- Current passes through patient in circuit from active to return electrode. -- Complete Circuit: generator, active electrode, patient, return electrode Perioperative Management of Patients with Devices Table 2 Problems that can occur during medical procedures HeartRhythm 2011:8: Bipolar electrosurgery does not cause EMI unless applied directly to CIED. -- Lead-tissue interference from external current is considered an unlikely risk. -- RF ablation can cause all interactions that monopolar electrosurgery causes. -- Therapeutic radiation is the most likely EMI source to result in CIED reset. -- Electroconvulsive therapy has been reported to cause EMI during stimulus. 8

9 Perioperative Management of Patients with Devices Table 2 Problems that can occur during medical procedures EMI from monopolar electrosurgery is most common problem. -- Pacemakers may oversense and be inhibited when exposed to EMI. -- Anti-tachycardia functions may be inhibited or falsely detect arrhythmias. -- Impedance based rate responsive systems may go to upper rate behavior. Keep current path away from CIED and minimize length of monopolar bursts. Pacemaker Dependent? Yes: Pacemaker (not ICD) -- Use short electrosurgical bursts whenever possible. -- Place magnet over device for procedures above umbilicus. -- Magnet immediately available for procedures below umbilicus. -- Monitor patient with plethysmography and an arterial line. -- Transcutaneous pacing and defibrillation pads (anterior/posterior). -- Evaluate pacemaker before leaving cardiac-monitored environment. 9

10 Pacemaker Dependent? Yes: ICD or CRT-D -- Use short electrosurgical bursts whenever possible. -- Magnet over device to suspend tachyarrhythmia detection. -- Monitor patient with plethysmography and an arterial line. -- Transcutaneous pacing and defibrillation pads (anterior/posterior). -- Evaluate ICD before leaving a cardiac-monitored environment. Pacemaker Dependent? No: Pacemaker (not ICD) -- Have magnet immediately available. -- Monitor patient with plethysmography and an arterial line. -- Transcutaneous pacing and defibrillation pads (anterior/posterior). -- Evaluate pacemaker before leaving cardiac-monitored environment. Pacemaker Dependent? No: ICD or CRT-D -- Use short electrosurgical bursts whenever possible. -- Magnet over device to suspend tachyarrhythmia detection. -- Transcutaneous pacing and defibrillation pads (anterior/posterior). -- Evaluate ICD before leaving a cardiac-monitored environment. Cardiovascular Implantable Electronic Devices (CIED) and Magnetic Resonance Imaging (MRI) 10

11 Ann Intern Med 2011:155: Patients: 555 MRI Studies [1.5-T Siemens Avanto] 40% Brain, 22% Spine,16% Heart, 13% Abdomen-Pelvis, 9% Extremity Back-up programming mode [ power-on-reset ] noted in 3 patients No defibrillation threshold testing after magnetic resonance imaging 11

12 (1) Cardiac Risk Assessment (2) Medication Management (3) Cardiac Device Management 12