Patients with Cardiovascular Diseases-What s the Update?

Transcription

1 Patients with ardiovascular Diseases-What s the Update? Praveen Maheshwari, MD Assistant Professor Department of Anesthesiology Disclosures: I have no relevant financial relationships or affiliations with commercial interests to disclose. 45 year old 220 lb, 5 feet 6 inches male presents to same day surgery for resection of intraabdominal mass (?cancer) 1

2 PMH: Hypertension x10 years, IDDM * x15 years AD* long standing, MI * s/p DES * x2 (proximal LAD * and mid ircumflex oronary Art) 7 Months ago *(IDDM- Insulin Dependent DM, AD- oronary Artery Disease, MI- Myocardial Infarction, DES- Drug Eluting Stent, LAD- Left Anterior Descending Artery) PSX: Gastric banding 3 years ago, Left renal cyst excision 1 year ago No problems with anesthesia Social Hx: urrent Smoker with 30 pack year s history social drinker infrequent Marijuana use (last use 1 week ago). Family Hx: Father died from MI at age 40. 2

3 Medications: Losartan 50 mg twice daily Insulin Lantus 20 units at bed time daily, Regular insulin before meal per sliding scale, Aspirin 325 mg daily, lopidogrel 75 mg daily Nitroglycerin sublingual prn OT multi vitamins and fish oil. Allergies: Sufla drugs, Penicillins, seasonal allergies Review of Systems: General: malaise Neuro: normal V: denies current chest discomfort/pain, c/o occasional leg cramps Pulmonary: denies dyspnea, orthopnea/ PND *, c/o dry cough for last few days Abdomen: abdominal mass, decreased appetite (* Paroxysmal Nocturnal Dyspnea) Physical Exam: Airway- MP * class-1, TMD * >3FB *, good ROM * of neck Normal S1 and S2 lear lungs Abdomen consistent with intra-abdominal mass No dependent edema Vitals: HR 92, BP 144/88, RR 18, Temp. 98.6F, SpO2 98% on RA *(MP- Mallampati, Thyro-mental Distance, FB- Finger Breadth, ROM- Range of Motion, RA- Room AIr) 3

4 EKG: SR with 2 nd degree Mobitz 1 block, nonspecific ST/T changes. Labs: T Abdomen: 8x10x12 cm mass left upper abdomen (* SR- Sinus Rhythm) Would you proceed with surgery? Patient had DES 7 months ago, Would you consider delaying surgery? What would you do with antiplatelets? Urgency of the procedure: (GW* developed the following definitions by onsensus) Emergency- life or limb is threatened if not in the operating room within <6 hours. Urgent- life or limb is threatened if not in the operating room between 6 and 24 hours. Time-sensitive- delay of >1 to 6 weeks will negatively affect outcome. e.g. oncologic procedures. Elective- could be delayed for up to 1 year. (* GW- Guideline Writing ommittee) 4

5 If this patient presents for hernia repair? Would you consider delaying surgery? How would you manage antiplatelets? 5

6 Urgency of the procedure: (GW* developed the following definitions by onsensus) Emergent- life or limb is threatened if not in OR within <6 hours. Urgent- life or limb is threatened if not in OR between 6 and 24 hours. Time-sensitive- delay of >1 to 6 weeks will negatively affect outcome. e.g. oncologic procedures. Elective- could be delayed up to 1 year. (* GW- Guideline Writing ommittee) ELETIVE sx after PI Delay 14 d after PI I B/ Delay 30 d after BMS and 365 d after DES I B A consensus decision as to the relative risks of discontinuation or continuation of antiplatelet therapy can be useful IIa May be considered after 180 d of DES IIb B NOT within 30 d after BMS or within 365 d after DES, if DAPT will need to be discontinued III B NOT within 14 d of balloon angioplasty, if aspirin will need to be discontinued III 6

7 Let s say that you proceeded with surgery!!! How would you determine risk for perioperative cardiac event/ MAE (Major Adverse ardiac Event- MI/ Death)? Estimation of peri-op risk of MAE: Three prediction tools Revised ardiac Risk Index 4 American ollege of Surgeons National Surgical Quality Improvement Program (NSQIP) Myocardial Infarction and ardiac Arrest (MIA) 5,* American ollege of Surgeons NSQIP Surgical Risk alculator 6, * * New in recent guideline 4. irculation. 1999;100: J Am oll Surg. 2013;217: irculation. 2011;124: riteria RRI American ollege of Surgeons NSQIP MIA reatinine 2 Increasing age mg/dl reatinine >1.5 mg/dl HF Partially or completely dependent Insulin-dependent functional status diabetes mellitus Intrathoracic, intraabdominal, or suprainguinal vascular surgery History of cerebrovascular accident or TIA Ischemic heart disease American ollege of Surgeons NSQIP Surgical Risk alculator Age Acute renal failure HF Functional status Diabetes mellitus Procedure (PT ode) ASA Physical Status lass Wound class Ascites Systemic sepsis Surgery type: Ventilator dependent Anorectal Aortic Bariatric Brain B Disseminated cancer reast ardiac ENT Foregut/hepatop Steroid use ancreatobiliary Gallbladder/adrenal/ Hypertension appendix/spleen Intestinal Neck O Previous cardiac event bstetric/gynecological Orthopedic O Sex ther abdomen Peripheral Dyspnea vascular Skin Spine Thoracic Vein Urologic Smoker OPD Dialysis Acute kidney injury BMI Emergency case 7

8 Revised ardiac Risk Index (RRI) History of cerebrovascular accident or TIA* Ischemic heart disease Heart Failure Insulin-dependent diabetes mellitus reatinine 2 mg/dl Intra-thoracic, intra-abdominal, or suprainguinal vascular surgery * TIA- Transient Ischemic Attack irculation. 1999;100: Revised ardiac Risk Index: 6 risk predictors Patients with 0 or 1 predictor of risk- low risk (<1%) of MAE. Patients with 2 predictors of risk- elevated* risk ( 1%) of MAE. Only 1 predictor is based on surgery type. (* New in recent guideline) riteria RRI American ollege of Surgeons NSQIP MIA reatinine 2 Increasing age mg/dl reatinine >1.5 mg/dl HF Partially or completely dependent Insulin-dependent functional status diabetes mellitus Intrathoracic, intraabdominal, or suprainguinal vascular surgery History of cerebrovascular accident or TIA Ischemic heart disease American ollege of Surgeons NSQIP Surgical Risk alculator Age Acute renal failure HF Functional status Diabetes mellitus Procedure (PT ode) ASA Physical Status lass Wound class Ascites Systemic sepsis Surgery type: Ventilator dependent Anorectal Aortic Bariatric Brain B Disseminated cancer reast ardiac ENT Foregut/hepatop Steroid use ancreatobiliary Gallbladder/adrenal/ Hypertension appendix/spleen Intestinal Neck O Previous cardiac event bstetric/gynecological Orthopedic O Sex ther abdomen Peripheral Dyspnea vascular Skin Spine Thoracic Vein Urologic Smoker OPD Dialysis Acute kidney injury BMI Emergency case 8

9 AS NSQIP MIA: Increasing age Dependent functional status reatinine >1.5 mg/dl Surgery type: Anorectal, Aortic, Bariatric, Brain, Breast, ardiac, ENT, Foregut/ hepato-pancreatobiliary, Gallbladder/adrenal/appendix/spleen, Intestinal, Neck, Obstetric/gynecological, Orthopedic, Other abdomen, Peripheral vascular, Skin, Spine, Thoracic, Vein, Urologic NSQIP MIA: Single study, large multicenter trial ( rdiacarrest). alculated risks (MI or cardiac arrest) for different surgical sites, with inguinal hernia as the reference group. SUPERIOR to RRI particularly in VASULAR sx. riteria RRI American ollege of Surgeons NSQIP MIA reatinine 2 Increasing age mg/dl reatinine >1.5 mg/dl HF Partially or completely dependent Insulin-dependent functional status diabetes mellitus Intrathoracic, intraabdominal, or suprainguinal vascular surgery History of cerebrovascular accident or TIA Ischemic heart disease American ollege of Surgeons NSQIP Surgical Risk alculator Age Acute renal failure HF Functional status Diabetes mellitus Procedure (PT ode) ASA Physical Status lass Wound class Ascites Systemic sepsis Surgery type: Ventilator dependent Anorectal Aortic Bariatric Brain B Disseminated cancer reast ardiac ENT Foregut/hepatop Steroid use ancreatobiliary Gallbladder/adrenal/ Hypertension appendix/spleen Intestinal Neck O Previous cardiac event bstetric/gynecological Orthopedic O Sex ther abdomen Peripheral Dyspnea vascular Skin Spine Thoracic Vein Urologic Smoker OPD Dialysis Acute kidney injury BMI Emergency case 9

10 AS NSQIP Surgical Risk alculator Age Sex BMI Functional status ASA-Physical Status lass Emergency case Procedure (PT ode) Wound class Smoker Dyspnea OPD Ventilator dependent Hypertension Heart Failure Previous cardiac event Diabetes mellitus Ascites Systemic sepsis Disseminated cancer Steroid use Acute kidney injury Acute renal failure Dialysis NSQIP Surgical Risk alculator: PT codes to determine procedure specific risk. ASA classification as one of the predictor. 21 patient specific variables. BEST estimation of surgery specific risk of MAE. Limitations: Definition of MI includes only STEMI or a large troponin bump (>3 times N). Risk stratification of the procedure Low risk- ombined surgical and patient characteristics predict a risk of MAE of <1%. Elevated risk - ombined surgical and patient characteristics predict a risk of MAE of 1%. change from previous guideline 10

11 How would you approach to Perioperative ardiac Testing?? Exercise tolerance: Patient is able to do following activities: walk 3 mph with no symptoms slow ballroom dancing golfing with a cart 11

12 <4 METs*: slow ballroom dancing golfing with a cart playing a musical instrument walking at approximately 2 mph to 3 mph *Arch Intern Med. 1999;159: >4 METs * : climbing a flight of stairs walking up a hill walking on level ground at 4 mph performing heavy work around the house *Arch Intern Med. 1999;159: Another functional status scale: DASI (Duke Activity Status Index) Activity Weight an you. 1. walk indoors (such as around your house)? take care of yourself (eating, dressing, bathing, or using the toilet)? do light work around house (dusting or washing dishes)? walk a block or 2 on level ground? do moderate work around the house (vacuuming, sweeping floors, or carrying in groceries)? do yardwork (raking leaves, weeding, or pushing a power mower)? have sexual relations? climb a flight of stairs or walk up a hill? moderate recreational activities (golf, bowling, dancing, doubles tennis, or throwing a baseball or football)? strenuous sports (swimming, singles tennis, football, basketball, or skiing)? run a short distance? do heavy work around the house (scrubbing floors or lifting or moving heavy furniture)? 8.00 Am J ardiol. 1989;64:

13 Do you need any other tests? Echo Stress test ardiology note Transthoracic Echo: Mild Left Ventricular systolic dysfunction, LV EF 50-55%, grade 1 diastolic dysfunction Normal RV size and systolic function Mild MR and Mild AS 13

14 Stress test: Patient had moderate fixed scar at apex of left ventricle. Small reversible perfusion defect in anteroseptal wall of left ventricle. LVEF 50-55%. ardiology note: Patient is at intermediate risk for surgery May proceed to surgery with heart rate control and avoid major fluid shifts. Recommendations? 14

15 EG? PREOP EG Reasonable in AD or structural heart disease, except for low-risk sx IIa B May be considered for asymptomatic patients, except for low-risk sx IIb B ROUTINE is NOT useful for asymptomatic patients for LOW RISK sx III B Echo? 15

16 Preop Assessment of LV function Reasonable if dyspnea of unknown origin IIa Reasonable if HF with worsening dyspnea or other change in clinical status May be considered for reassessment in clinically stable patients IIa IIb ROUTINE is NOT recommended III B Stress test? 16

17 Stress testing Reasonable to FORGO testing if excellent or moderate to good functional capacity IIa/IIb B Reasonable to perform if elevated risk and unknown or poor functional capacity (IF IT WILL HANGE MANAGEMENT) IIa/IIb B/ ROUTINE is NOT useful for low risk sx III B Perioperative Therapy oronary revascularization: Who should undergo preoperative revascularization? 17

18 oronary revascularization before NS Recommended when indicated by existing PGs I NOT recommended EXLUSIVELY TO REDUE PERIOPERATIVE ARDIA EVENT III B Beta blockers: Would you start beta blockers? When would you start? Perioperative BB therapy ontinue BB if on BB chronically I B Guide management of BB after surgery by clinical circumstances IIa B Reasonable to BEGIN if intermediate- or high-risk preop tests IIb Reasonable to BEGIN if 3 RRI IIb B Reasonable to BEGIN in advance to assess safety and tolerability, preferably >1 d before sx IIb B NOT be STARTED ON DAY of sx III B 18

19 AEI/ ARBs: Would you stop Losarton? What s the recommendation? AE inhibitors/arbs Reasonable to ONTINUE peri-op* IIa B Reasonable to restart as soon as clinically feasible postop if held preop. IIa Statins: Would you start him on statins? Would you start if patient presenting for AAA repair? 19

20 Perioperative statin therapy ontinue if currently taking I B Reasonable to BEGIN for VASULAR sx IIa B May be considered in patients with LINIAL RISK FATORS for elevated-risk sx IIb Antiplatelet therapy: Would you stop antiplatelet therapy? When is it safe to stop DAPT? Would you at least continue aspirin? Ask 4 questions to yourself: Time since stents Time before surgery Risk of surgery ompare risk of bleeding vs stent thrombosis 20

21 Antiplatelet agents ontinue DAPT if URGENT sx in first 4 to 6 wk after stents (unless risk of bleeding outweighs benefit of stent thrombosis prevention) I If discontinuation of P2Y12 inhibitor is required, continue aspirin and restart P2Y12 inhibitor ASAP after sx Management of periop APT should be determined by consensus of treating clinicians and patient Reasonable to continue aspirin if nonemergency/non-urgent sx without prior coronary stent, (when the risk of increased cardiac events outweighs the risk of increased bleeding) NOT beneficial to continue aspirin if elective sx without prior coronary stent I I IIb III B B : If risk of ischemic events outweigh s risk of surgical bleeding What would you do if patient has ardiac Implantable Electronic Device (IED)? 21

22 IEDs ONTINUOUS cardiac monitoring during entire period of inactivation External defibrillation equipment available Must be reprogrammed to active therapy I Valvular Heart Disease: Recommendations Who should have pre-op Echo? If clinically suspected moderate stenosis or regurgitation and either no prior echo within 1 year or significant change in clinical status I 22

23 Who should undergo intervention? If standard indications for valvular intervention (replacement and repair) on the basis of s/s. Intervention before elective sx is effective in reducing peri-op risk. I Regurgitant lesions? Asymptomatic severe AR or MR- Reasonable to perform Elevated-risk elective sx with appropriate peri-op monitoring IIa Stenotic lesions? Asymptomatic severe AS- Reasonable to perform Elevated-risk elective sx with appropriate peri-op monitoring Asymptomatic severe MS- Reasonable to perform Elevated-risk elective sx with appropriate peri-op monitoring (if non favorable percutaneous mitral balloon commissurotomy). IIa IIb B 23

24 Pulmonary Hypertension? Pulmonary Hypertension hronic pulmonary vascular targeted therapy (i.e., PDE 5 inhibitors, endothelin receptor antagonists, and prostanoids) should be continued unless contraindicated or not tolerated I Preop evaluation by specialist can be beneficial particularly in those at increased perioperative risk* (unless the risks of delay > potential benefit) IIa High Risk Pulmonary Hypertension Pulmonary arterial hypertension PA systolic pressures >70 mm Hg and/or moderate RV dilatation and/or dysfunction and/or PVR >3 Wood units WHO/NYHA class III or IV symptoms (d/t pulm htn) 24

25 Anesthetic considerations Volatiles vs TIVA Either volatile anesthetic agent or total intravenous anesthesia is reasonable IIa A Neuraxial for peri-op pain management an be effective to reduce cardiac events in ABDOMINAL AORTI sx IIa B May be considered to reduce cardiac events in HIP sx IIb B 25

26 Thermoregulation May be reasonable maintain normothermia to reduce perioperative cardiac events IIb B Prophylactic intra-op nitroglycerin No Benefit III B Peri-op use of PAs May be considered when underlying medical conditions that significantly affect hemodynamics cannot be corrected before surgery IIb Routine- NOT recommended III A 26

27 Intra-op TEE Emergency use is reasonable if hemodynamic instability and expertise is available IIa Routine- NOT recommended III Hemodynamic assist devices May be considered for urgent or emergent non-cardiac sx in acute severe cardiac dysfunction IIb Anemia Management* Restricted transfusion strategy (hb <7 g/dl to 8 g/dl) Asymptomatic, hemodynamically stable without AD. Hospitalized patients with cardiovascular disease (consider transfusion if symptoms (e.g., chest pain, orthostasis, congestive HF) or hb <8 g/dl). Liberal transfusion strategy (hb 8 g/dl) Postoperative patients (unless symptomatic). No specific recommendations for hemodynamically stable patients with AS. Expert consensus recommended a symptom-guided approach to transfusion. *American Association of Blood Banks PG Ann Intern Med. 2012;157:

28 Management for Peri-op MI EKG & troponin measurements if s/s of myocardial ischemia or MI. Postop EKG and/or troponin of uncertain benefit if high risk for peri-op MI but without s/s of myocardial ischemia or MI, and without established risks and benefits of management strategy I IIb A/B B Routine postop troponins NOT useful for guiding peri-op management if asymptomatic III B The patient went for surgery, did well & lived happily ever after!!! References: 1. Fleisher et al. A/AHA Perioperative linical Practice Guideline V O L. 6 4, NO. 2 2, , e h t t p : / / d x. d o i. o r g / / j. 2. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999;159: Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J ardiol. 1989;64: Lee TH, Marcantonio ER, Mangione M, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. irculation. 1999;100: ohen ME, Ko Y, Bilimoria KY, et al. Optimizing AS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am oll Surg. 2013;217: Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. irculation. 2011;124:

29 Questions??? 29