Preoperative Evaluation of CABG Patient Needing Non- Cardiac Surgery. Scott Davis, M.D., F.A.C.C. BHHI Primary Care Symposium February 26, 2016
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1 Preoperative Evaluation of CABG Patient Needing Non- Cardiac Surgery Scott Davis, M.D., F.A.C.C. BHHI Primary Care Symposium February 26, 2016
2 DISCLOSURES Gilead Boston Scientific
3 I. The Components of Perioperative Stress Testing II. The 2014 Algorithm for Stress Testing III. Last Minute Philosophical Thoughts Outline
4 72 year old male with BPH sent by Urology for Clearance for a prostatectomy. No Regular Exercise other than walking his dogs for 20 minutes q AM Able to walk up and down stairs in his 2 story house w/o difficulty. PMH DM 2: A1C 7.5 HTN CABG x3: March 2013 (LIMA-LAD, SVG-OM1, SVG-PDA) NSTEMI October 2014: PCI SVG to PDA with DES Hyperlipidemia Former Tobacco Abuse: 100 pack year, D/C 1 year ago BPH Medications ASA 81, Ticagrelor 90 bid, atorvastatin 80, Tamsulosin Metoprolol discontinued by PCP when Tamsulosin was started due to hypotension Case
5 Exam: 155/75, HR 80, BMI 38 Normal lungs RRR S1, S2, No murmurs Normal distal pulses ECG: NSR 75, RBBB Pre Op Stress Test: A. Yes B. No Case
6
7 Elective: No time constraint for performing procedure. Urgent: Procedure does not need to be performed immediately, but must be performed in the same hospitalization or short time frame. Emergent: Procedure must be performed immediately. Guidelines Combine Urgent and Emergent into Emergency Category. Timing of Procedure JACC 2014;64:e77-e137
8 Risk stratification of the individual patient: High Risk Intermediate Risk Low Risk The Patient 2007 Perioperative Cardiovascular Guidelines
9 Risk stratification of the type of surgery being performed: High Risk Intermediate Risk Low Risk The Surgery 2007 Perioperative Cardiovascular Guidelines
10 2014 Risk Stratification Combines Patient and Surgery Risk The Use of Portable Technology
11 Functional Capacity
12 I. The Components of Perioperative Stress Testing II. The 2014 Algorithm for Stress Testing III. Modifying Perioperative CV Risk Outline
13 Stepwise Approach to Perioperative Cardiac Assessment for CAD JACC 2014;64:e77-e137
14 Stepwise Approach to Perioperative Cardiac Assessment for CAD (cont d) JACC 2014;64:e77-e137
15 Stepwise Approach to Perioperative Cardiac Assessment for CAD (cont d) JACC 2014;64:e77-e137
16 No Preoperative Stress Test Emergency Procedures <1% Perioperative MACE Risk. Good Functional Capacity (>4.0 METS) Preoperative Stress Test Greater than 1% Perioperative MACE Risk and: Unknown Functional Capacity Poor Functional Capacity (<4.0) Results of stress test must have some impact regarding decision making. Summary of 2014 Perioperative Algorithm JACC 2014;64:e77-e137
17 It may be possible to reduce perioperative MACE. Possible methods include: Perioperative Beta Blockade Perioperative ASA use Elective PCI Modifying Perioperative CV Risk
18 Patient is not currently taking a Beta-Blocker due to orthostatic hypotension when Tamsulosin was started. 155/75, HR 80 Start Beta-Blocker: A.Yes B.No Beta Blocker
19 Multiple randomized clinical trials have looked at the use of perioperative beta blocker use to reduce MACE. The results vary in terms of MI and mortality reduction. Perioperative Beta Blockade
20 Effect of Perioperative Beta Blockade on In-Hospital or 30 Day MI Rate: Randomized Control Trials JACC 2014;64:e77-e137
21 Effect of Perioperative Beta Blockade on In- Hospital or 30 Day Mortality: Randomized Control Trials JACC 2014;64:e77-e137
22 JACC 2014;64:e77-e137
23 JACC 2014;64:e77-e137
24 Randomized Multicenter trial to determine if perioperative use of ASA before noncardiac surgery reduces MACE. Low dose ASA (100mg) Patients with prior PCI included if: >1 year after DES placement >6 weeks after BMS placement Note: Only 1.1 and 2.6% of patients had prior DES and BMS respectively Perioperative ASA Use: POISE 2 Trial NEJM 2014;370:
25 POISE 2: Effect of ASA on 30-Day Outcomes NEJM 2014;370:
26 JACC 2014;64:e77-e137
27 JACC 2014;64:e77-e137
28 Medicine is a science of uncertainty and an art of probability. William Osler In the business world, the rearview mirror is always clearer than the windshield. Warren Buffet
29 Falk Circulation 1995;92:657
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