Agenda. Disclosures. Surgical Mortality: What is High Risk?

Transcription

1 Pre-Operative Cardiac Evaluation of the Vascular Patient: Updated AHA/ACC Guidelines Choosing Wisely UCSF Vascular Symposium 2015 Joshua A. Beckman, M.D., M.S. Brigham and Women s Hospital Consulting Merck Novartis Astra Zeneca Bristol Myers Squibb Stock Janacare EMX Research Grant Bristol Myers Squibb Boards VIVA Phyiscian s Group Disclosures Agenda Surgical Mortality: What is High Risk? Risk of noncardiac surgery Risk stratification Patient-based Procedure-based Modifiers Follow up Operation N Age (years) Emergent Status (%) 30-Day Mortality (%) AAA Repair ± Infrainguinal Vascular Bypass ± CEA ± Lobectomy / Pneumonectomy Laparoscopic Cholecystectomy ± ± Colectomy ± Total Hip Arthroplasty ± Khuri, SF. Ann Surg 1999;230(3):414

2 Risk-Adjusted Mortality In Cardiovascular Operations in Medicare Patients, Methods for Assessing Risk Pre-Operatively Patient Based High risk conditions Functional Capacity Surgery Based Vascular Surgery Emergency surgery Intervention Based Medications Revascularization Finks JF et al. N Engl J Med 2011;364: High Risk (Unstable) Conditions: Fix These Pre-Op! Unstable coronary syndromes Unstable or severe angina* (CCS class III or IV) Recent MI (>7, <30 days) Decompensated HF NYHA functional class IV Worsening or new-onset HF Significant arrhythmias High-grade atrioventricular block (Mobitz II, Third-degree AV block) Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including AF) with HR > 100 Symptomatic bradycardia Newly recognized ventricular tachycardia Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic) Symptomatic mitral stenosis ACC/AHA Periop Guidelines 2007 The Trump Card: Functional Capacity Perioperative cardiac risk is increased in patients unable to exercise 4 METs Functional capacity can be estimated in the office Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs Swimming and singles tennis exceeds 10 METs

3 A Rapid Functional Screen: Exercise Role of Noninvasive Testing Events Prior to D/C (%) 600 consecutive pts w/consultation for preoperative evaluation before major noncardiac procedures stratified by exercise tolerance 10 0 Cardiovascular Complications Exercise Tolerance 2 flights/4blocks < 2 flights/4blocks Reilly, D. Arch Int Med 1999;159(18): 2185 What is the amount of myocardium in jeopardy? Is there multivessel disease? What is the ischemic threshold, i.e. amount of stress required to produce ischemia? What is the ventricular function? Predictive Value of Preoperative Exercise Testing before Surgery Predictive Value Author n % Abn Positive Negative McCabe % 91% Cutler % 99% Arous % NR Gardine % 90% von Knorring % 99% Kopecky % 100% Leppo % 92% Hanson % 100% McPhail % 93% Urbinati % 100% Predictive Value of Preoperative Vasodilator- Nuclear Testing before Surgery MI or Predictive Value Author n Death Positive Negative Eagle % 98% Cutler % 100% Younis % 100% Hendel % 99% Lette % 99% Brown % 99% Vanzetto % 98% Baron % 96% Bry % 100% Roghi % 98% Graybum, PA. Ann Intern Med 2003; 138:506 Graybum, PA. Ann Intern Med 2003; 138:506

4 Surgery-Specific Risk: High Risk* Major emergency surgery Vascular surgery including: aortic surgery, infra-inguinal bypass Prolonged surgery with large fluid shifts or blood loss * Reported risk of cardiac death or nonfatal MI >5% Assessment of Possible Risk- Reduction Interventions Medications Beta Adrenergic Blockers Statins Coronary Artery Revascularization CABG PCI Invasive Pressure Monitoring Audience Question Which of the following therapies increase the risk of death perioperatively? A. Aspirin B. Beta blockers C. Clonidine D. Statins 25% 25% 25% 25% β-blockade and Perioperative Risk 112 patients undergoing vascular surgery with positive DBA stress test, randomized to bisoprolol or usual care Patients (%) Standard Care P < Bisoprolol A s p i r i n B e t a b l o c k e r s C l o n i d i n e S t a t i n s : Days after surgery Poldermans, NEJM 1999: 1789

5 POISE Trial 8351 patients 45 years or older undergoing noncardiac surgery with a history of CAD, PAD, stroke, or CHF within 3 years undergoing major vascular surgery; or have 3 of 7 risk factors undergoing high-risk surgery. Patients randomized to receive either metoprolol CR or placebo started 2-4 hrs preop and continued for 30 days at 100 mg preop, 100 mg in the six-hour post-op, 200 mg 12 hours later, and 200 mg daily thereafter. Outcome Metoprolol (n=4174), n (%) Placebo (n=4177), n (%) Hazard ratio Primary composite 243 (5.8) 290 (6.9) Nonfatal MI 151 (3.6) 215 (5.1) Total mortality 129 (3.1) 97 (2.3) Stroke 41 (1.0) 19 (0.5) p Outcome POISE Trial Metoprolol (n=4174), n (%) Placebo (n=4177), n (%) Hazard ratio Revascularization 11 (0.3) 27 (0.6) Atrial fibrillation 91 (2.2) 120 (2.9) Significant hypotension Significant bradycardia 626 (15.0) 404 (9.7) 1.55 < (6.6) 101 (2.4) 2.71 < p Devereaux, PJ. Lancet 2008; 371(9627)1829 Devereaux, PJ. Lancet 2008; 371(9627)1829 The Net Impact of Beta Blockade Per ~10,500 Patients Treated Effect of Clonidine on Perioperative Death/NFMI: POISE2 2-by-2 factorial evaluation of low-dose clonidine and low-dose aspirin versus placebo in 10,010 patients undergoing noncardiac surgery. Wijeysundera, D. JACC 2014;64(22): Devereaux P et al. N Engl J Med 2014;370:

6 Effect of Aspirin on Perioperative Death/NFMI: POISE2 2-by-2 factorial evaluation of low-dose clonidine and low-dose aspirin versus placebo in 10,010 patients undergoing noncardiac surgery. Effect of Aspirin on Perioperative Death/NFMI: POISE2 Devereaux P et al. N Engl J Med 2014;370: Devereaux P et al. N Engl J Med 2014;370: Statins Improve Survival After Vascular Surgery 100 pts randomized 20 mg atorvastatin or placebo for 45 days. Vascular surgery ~ 30 days after randomization. F/U 6 months Event-free survival (%) Primary Endpoint CV death + NFMI+ Ischemic stroke+ Unstable Angina Atorvastatin Placebo Days after Surgery Durazzo, AES. JVS 2004:39(5):975 Age Pre-Operative Stenting May Cause Catastrophic Outcomes Ticlid withheld ASA withheld Surgery 82 Yes Yes Femoral embolectomy Major Bleeding No No No CEA Yes 7 72 No Yes MVR Yes 3 68 Yes Yes CEA Yes 8 67 Yes Yes TAA repair No No 67 No Yes TAA repair Yes 8 72 Yes Yes Colectomy No 2 62 Yes Yes Lung TXP Yes Yes Yes TAA repair Yes 9 Death Kaluza, G. JACC 2000;35:1288

7 Coronary Revascularization Does Not Improve Immediate or Long-Term Outcomes 510 VA pts, aged 66 years, with stable CAD, scheduled for elective AAA repair (33%) or infrainguinal bypass (67%), randomized to Revasc (PCI 59%, CABG 41%) or conservative management Post-Op MI 30 Day Mortality Revascularization McFalls, E. CARP Trial;AHA Year Mortality Conservative Mgmt Surveillance for Perioperative Myocardial Infarction ECGs All intermediate and high-risk patients should get a post-op ECG. As neede for signs or symptoms of ischemia Troponin / CK In patients with signs or symptoms of ischemia Do not do screening biomarkers Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery A prospective, international cohort study that enrolled patients (aged 45 Years or older) from 2007 to January 11, Subjects required at least an overnight hospital admission after having noncardiac surgery. TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3. Postoperative TNT Levels and 30-Day Mortality In Noncardiac Surgery A prospective, international cohort study that enrolled noncardiac patients (aged 45 Years or older) from 2007 to January 11, TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3. Peak TNT (ng/ml) Vascular Mortality (n = 127) Number died/ Number group Adjusted HR Nonvascular Mortality (n = 155) Number died/ Number group < / / / / / / / / Adjusted HR Vascular death was defined as deaths following MI, cardiac arrest, stroke, PCI or CABG, pulmonary embolus, hemorrhage, or deaths due to an unknown cause. JAMA. 2012;307(21): doi: /jama Devereaux, PJ. JAMA. 2012;307(21):

8 Post-Operative Troponin Measurement In Asymptomatic Patients May Be Harmful Troponin outcomes in POISE Only 2 of the 8633 asymptomatic patients had a positive troponin and went to coronary revascularization (0.02%). Only 0.3% of asymptomatic patients with positive troponin levels went to cath. The test is misdirecting care providers 99% of the time. Devereaux, PJ. Ann Intern Med 2011;154: Take Home Messages Unstable syndromes require management prior to surgery. Look for Unstable angina Signs of heart failure Stenotic valve lesions Ventricular arrhythmias Functional tolerance is the best single predictor of outcome Be very specific in your history (one step at at time, regular or slow pace, etc) Every patient should get beta blockers & statins, unless contraindicated PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.