Perioperative Cardiac Risk Assessment & Management for Noncardiac Surgery

Transcription

1 Perioperative Cardiac Risk Assessment & Management for Noncardiac Surgery STEVEN L. COHN, MD, FACP, SFHM PROFESSOR EMERITUS DIRECTOR-MEDICAL CONSULTATION SERVICE JACKSON MEMORIAL HOSPITAL UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE

2 Disclosures Nothing relevant (except royalties from): UpToDate (multiple topics) McGraw Hill (Perioperative Medicine-Just the Facts) Springer (Perioperative Medicine)

3 Objectives Review the American College of Cardiology (ACC) guidelines and algorithm for preoperative risk assessment Discuss various risk calculators and cardiac tests Evaluate risk reduction strategies (coronary revascularization & medical therapy)

4 Purpose of Preop Medical Consultation Identify risk factors and assess severity & stability Provide a clinical risk profile for informed and shared decision-making Make recommendations for any management changes, need for further testing, or specialty consultation NOT to CLEAR FOR SURGERY! Pt is in his/her OPTIMAL MEDICAL CONDITION for surgery.

5 Definitions of Urgency & Risk Urgency Emergency: <6 hours Urgent: 6-24 hours Time sensitive: can delay 1-6 weeks Elective: can delay up to 1 year Risk (combined surg & pt characteristics) Low risk: <1% MACE Elevated: >1% MACE Use RCRI, MICA, or ACS-SRC to calculate risk

6 Revised Cardiac Risk Index (RCRI) (Lee et al, Circulation 1999;100: ) 4315 pts, >50 y/o, LOS >2 days 6 independent predictors: high-risk surgery, hx ischemic heart disease, CHF, CVA, DM Rx with insulin, preop creat >2.0 # of risk factors % major cardiac complications % (in-hospital) % 2-4-7% >3-9-11% LOW ELEVATED Separates low vs high risk Underestimates risk-aaa/vasc surg

7 Cardiac Risk Calculator (MICA) ( Used NSQIP database - multivariate logistic regression Developed from 2007 data - 211,410 pts; Validated with 2008 data - 257,385 pts 5 predictors of MI/card arrest (30-day outcomes) 1) Type of surgery 2) Dependent functional status 3) Abnormal creatinine (>1.5 mg/dl) 4) ASA class 5) Increasing age Risk calculator had better discriminative or predictive ability for MI/CA than RCRI or VSGNE-CRI Database RCRI VSG Risk calculator Vasc surg Gupta, Circulation 2011

8 ACS NSQIP Surgical Risk Calculator (30-day outcomes) Bilimoria et al. J Am Coll Surg 2013

9

10 BNP/NT-proBNP Elevated BNP/NT-proBNP preop, postop, or both, is associated with increased postop death/mi Adding preop BNP to RCRI improves risk prediction. BNP pg/ml NT-proBNP pg/ml 30-d death/mi <92 < % >92 > % Recommended by Canadian Cardiovascular Society Guidelines for patients: >65 yrs old, yrs old with CV disease, RCRI>1 Can J Cardiol 2017; 33:17-32 Anesthesiology 2015; 123:264-71

11 Clinical Risk Factors CAD Isch Sx/NYHA, prior MI/timing, CABG/PCI, elevated biomarkers HF Decompensated + depressed LV funct worst; Sx > asympt; syst (EF<30-40%) > diastolic Valvular disease Type (stenotic>regurg), severity, symptoms Arrhythmias Hemodynamic effects, underlying structural heart disease

12 2014 ACC/AHA ALGORITHM

13 ACC/AHA 2014: Periop Cardiac Assessment for CAD Step 1 Step 2 Step 3 Need for emergency noncardiac surgery? No No ACS? Estimate risk of MACE (combined clin/surg risk RCRI or ACS-NSQIP) Moderate or greater (>4METS) functional capacity No or unknown Yes Yes Step 5 Yes Clinical risk stratification & proceed to surgery Evaluate & treat according to GDMT Low risk (<1%) Elevated risk Yes Step 4 Proceed to surgery (no further testing) Fleisher et al. JACC 2014 Valve dis HF Arrhythmias as per GDMT Proceed to surgery (no further testing) Step 6 (<4METS) Will further testing impact decision making or periop care? Yes Pharmacologic stress testing Step 7 No Proceed to surgery (GDMT) or alternative strategies Abnormal Coronary revascularization (as per clinical practice guidelines)

14

15 Which Test? (if indicated) (Exercise if possible) Aerobic but need to achieve target heart rate Pharmacologic (if unable to exercise) DSE: fewer false positives, incr HR/BP, more physiologic Dipyridamole/adenosine nuclear: with LBBB; -COPD/bronchospasm PPV 15-20%; NPV 95-99% Cardiac CTA? Cardiac catheterization Abn NIT, Class III/IV unstable angina, high pretest probability Resting 2D Echo Only for valvular disease or heart failure

16 Supplemental Preoperative Evaluation Assessment of LV Function Recommendations COR LOE It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. IIa C It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative IIa C evaluation of LV function. Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if IIb C there has been no assessment within a year.? Routine preoperative evaluation of LV function is not III: No recommended. Benefit B

17 Supplemental Preoperative Evaluation Noninvasive Pharmacological Stress Testing Before Noncardiac Surgery Recommendations COR LOE It is reasonable for patients who are at an elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo noninvasive pharmacological stress testing (DSE or pharmacological stress MPI) IF it will change management. IIa B Routine screening with noninvasive stress testing is not useful for patients undergoing low-risk noncardiac surgery. III: No Benefit B Preoperative Coronary Angiography Recommendation COR LOE Routine preoperative coronary angiography is not recommended. III: No Benefit C

18 Perioperative Cardiac Risk Reduction Strategies

19 Prophylactic Coronary Intervention CABG and PCI no evidence of better outcome vs medical therapy alone (need to consider risk of revascularization) RCTs: CARP (McFalls et al. N Engl J Med 2004;351: ) Stable cardiac disease, elective vascular surgery (510 pts) Medical Rx +/- revascularization No difference in 30-day MI/death or long-term mortality (22 vs 23%) CABG better than PCI DECREASE V (Poldermans et al. J Am Coll Cardiol : ) Abnormal DSE (5 segments or more) 101 pts Medical Rx +/- revascularization No difference in 30-day MI/death or long-term mortality If previously revascularized (survived, asymptomatic), potentially beneficial (CASS)

20 Perioperative Therapy Coronary Revascularization Prior to Noncardiac Surgery Recommendations COR LOE Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs. I C It is not recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events. III: No Benefit B

21 Circulation, 2016 Timing of Noncardiac Surgery after PCI Risk of stent thrombosis if DAPT is interrupted Timeframe 6 months irrespective of stent type Lower with 2 nd generation DES Higher if placed in setting of MI Consequences of delaying surgery Increased periop bleeding risk if DAPT is continued

22 Urgency of surgery Type of surgery Individualize Patient clinical risk factors Risk factors for stent thrombosis Patient (ACS, low EF, DM, age) Procedure (LAD/LM, multiple stents/vessels) Lesion (bifurcation, length, diameter, multiple) Management of antiplatelet therapy Continue both, stop one, stop both

23 Timing of Elective Noncardiac Surgery in Pts With Previous PCI (Levine et al, Circulation 2016) Possibly after 1 month as per ESC

24 Perioperative Therapy Antiplatelet Agents (cont d) Recommendations COR LOE In patients undergoing nonemergency/nonurgent noncardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased IIb B bleeding. Initiation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting, unless the risk of ischemic events outweighs the risk of surgical bleeding. III: No Benefit B C

25 Outcome 25 Results Aspirin (4998) Placebo (5012) HR (95% CI) 1 O outcome: death or MI 351 (7.0) 355 (7.1) 0.99 ( ) O outcome: death, MI, or stroke death, MI, revasc, or VTE 362 (7.2) 402 (8.0) 370 (7.4) 407 (8.1) 0.98 ( ) 0.99 ( ) P O outcomes: MI 309 (6.2) 315 (6.3) 0.98 ( ) 0.85 Safety outcome Major bleeding 230 (4.6) 188 (3.8) 1.23 ( ) 0.04

26 Antiplatelet Therapy Secondary prophylaxis continue ASA Recent stent continue DAPT Any PCI after completing DAPT continue ASA (POISE-2 subgroup) If surgery mandates discontinuation, stop: ASA 3-7 days before surgery Clopidogrel 5-7 days before Prasugrel 7 days before Ticagrelor 5 days before Irreversible Reversible

27 BETA-BLOCKERS CONTROVERSY: - Poldermans question about scientific integrity of DECREASE trials - POISE question regarding dosing of metoprolol

28 *all statistically significant Perioperative beta-blockers (RCTs) Author # pts Drug Duration Endpoint Outcome* Mangano (NEJM 1996) 200 (noncard) Atenolol (titrated) <7 days 2 yr death 10 vs 21% RR 0.5 Poldermans (NEJM 1999) DECREASE-I 112 (vasc;abn DSE) Bisoprolol (titrated) 30 days 30 d cardiac death/mi 3.4 vs 34% RR 0.1 Dunkelgrun (Ann Surg 2009) DECREASE-IV 1066 (noncard) Bisoprolol (titrated) 30 days 30 d cardiac death/mi 2.1 vs 6% HR.34 Juul (DIPOM) (BMJ 2006) 921DM (noncard) Metoprolol (not titrated) 7 days In-hosp CV events 21 vs 20% Brady(POBBLE) (J Vasc Surg 2005) 103 (vasc) Metoprolol (not titrated) 7 days 30 day CV events 32 vs 34% Yang (MaVS) (Am H J 2006) 497 (vasc) Metoprolol (not titrated) 5 days 30 day CV events 10.1 vs 12% Devereaux (POISE) (Lancet, 2008) 8351 (noncard) Metoprolol ER;High-dose 30 days 30 day CV events: 1 MI, CA, CV death; vs 6.9% CVA: 1 vs 0.5% Total mort: 3.1 vs 2.3% 2 CVA,death,AF,revasc

29 Periop Beta-Blocker Efficacy/Safety Mixed results depending on studies in meta-analyses. Outcome Ischemia MI Beta-blocker use Beneficial Beneficial CVA Harmful based primarily on POISE; neutral/possible harm without POISE Hypotension Harmful & bradycardia Total mortality Possibly beneficial without POISE; detrimental with POISE

30 Perioperative Therapy Perioperative Beta-Blocker Therapy Recommendations COR LOE Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically. I B SR It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent IIa B SR was started. In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable IIb C SR to begin perioperative beta blockers. In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery. IIb B SR These recommendations have been designated with a SR to emphasize the rigor of support from the ERC s systematic review. See the ERC systematic review report, Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery for the complete evidence review on perioperative beta-blocker therapy.

31 Perioperative Beta-Blocker Therapy (cont d) Recommendations COR LOE In patients with a compelling long-term indication for betablocker therapy but no other RCRI risk factors, initiating beta B IIb blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit. In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery. IIb B SR Beta-blocker therapy should not be started on the day of surgery. III: Harm B SR What they don t tell you: Perioperative Therapy - Bisoprolol and atenolol may be better than metoprolol - BB should probably be started at least 1 week before surgery - BB were beneficial in several large observational studies

32 Perioperative Statins: RCTs Study # pts Surgery Statin Started Outcome Durrazo 100 vasc Atorvastatin 20 mg 2 wks preop composite endpoint UA,CVA,MI,CV death (8 vs 26%) at 6 mos DECREASE III 497 vasc Fluvastatin XL 80 mg >30 days preop isch (11 vs 19%) MI/CV death (5 vs 10%) at 30 days DECREASE IV 1066 Interm risk Fluvastatin XL 80 mg >30 days preop Statistically insignificant MI/CV death (3 vs 5%) at 30 days

33 Perioperative Statins: Newer Observational Studies Study # pts Surgery Outcome London (2016) 180,478 pts Prop cohort statin control NCS All-cause 30d mortality: 0.82 [ ] NNT: 244 Mod-high intensity statin better; discontinuation worse Any complic: 0.82 [ ]; Card: 0.73; Resp: 0.75 High intensity statin incr renal injury: 1.18 [ ] Berwanger (2015) VISION 15,478 Matched 2845 statin 4492 control NCS Composite: all-cause mort,mins,cva@30d: 0.83 [ ] Mort:.58; CV mort:.42; MINS:.86; NS for MI, CVA

34 What they don t tell you: STATINS Recommendations COR LOE Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery. I B Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery. IIa B Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures. IIb C - Which statin? Longer-acting to prevent withdrawal, more potent statin - What dose? Moderate to high - When to start it? Unclear may have some benefit early on - Downside? No evidence of harmful effects (rhabdo/lfts)

35 OTHER MEDICAL THERAPY POSTOP TROPONIN MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY (MINS) MANAGE

36 PRACTICE POINTS RISK ASSESSMENT ACC algorithm Low vs elevated risk (RCRI, MICA, ACS) If elevated & <4METS, stress testing only if it changes mgmt INTERVENTIONS Prophylactic revascularization is rarely necessary just to get a patient through surgery MED MANAGEMENT NCS may be OK if >3 but<6 mos after newer DES - try to continue ASA or DAPT Beta-blocker data remains controversial Statins are potentially helpful COMMUNICATION/COLLABORATION Team approach - shared decision-making Patient, surgeon, anesthesiologist, consultant

37 REFERENCES Cohn SL. The cardiac consult for patients undergoing noncardiac surgery. Heart. 2016; 102(16): PMID: Cohn SL. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med. 2016; 165(11):ITC81-ITC96. PMID: Patel AY, Eagle KA, Vaishnava P. Cardiac risk of noncardiac surgery. J Am Coll Cardiol. 2015; 66(19): PMID: Devereaux PJ, Sessler DI. Cardiac Complications and Major Noncardiac Surgery. N Engl J Med. 2016;374(14): PMID: UpToDate (multiple topics)

38 GUIDELINES Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila- Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN; American College of Cardiology; American Heart Association ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e PMID: Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10): PMID: Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck- Brentano C; Authors/Task Force Members ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on noncardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35(35): PMID: Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1): PMID:

39

40 Questions? Perioperative Medicine Precourse