Perioperative Medicine 2016 Some Answers, Even More Questions

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1 Learning Objectives Perioperative Medicine 2016 Some Answers, Even More Questions Kurt Pfeifer, MD, FACP, FHM Professor of Medicine Medical College of Wisconsin Outline changes to the ACC/AHA perioperative cardiovascular risk assessment guidelines Highlight challenges in perioperative cardiovascular disease management No conflicts of interest to disclose A Systematic Approach Screening diagnostic studies Cardiovascular Pulmonary Hematologic Endocrine Infectious diseases Other chronic conditions Medications A Systematic Approach Screening diagnostic studies Cardiovascular CAD CHF/cardiomyopathy Valvular disease Dysrhythmias Pulmonary vascular disease Pulmonary Hematologic Endocrine Infectious diseases Other chronic conditions Medications Cardiac Conundrum 75 y/o gentleman with a history of DM (on insulin), HTN, CKD and CAD (BMS to LAD 4 years ago) presents for evaluation before left total hip replacement. Other than his hip pain, he has been feeling fine, though unable to exercise, take stairs or walk for any significant distance for at least 2 years. His exam is normal except for BP 146/92 and BMI 38. His laboratory studies are normal except for his baseline CKD (creatinine 1.6) and A1c of 6.8%. Should you perform noninvasive coronary evaluation prior to this surgery? Yes maybe it depends 1

2 Out with the Old In with the New More to the Heart *See Sections 2.2, 2.4, and 2.5 for recommendations for patients with symptomatic HF, VHD, or arrhythmias. See UA/NSTEMI and STEMI CPGs (Table 2). The algorithm is NOT a one-stop shop for cardiac risk assessment Specific, separate recommendations now included for: Valvular disease Indications for echo Arrhythmias Intracardiac devices Cardiomyopathy/CHF Pulmonary vascular disease Initial Screening for Risk Assessment Necessity Urgency of Surgery Known or risk factors for CAD not explicitly defined Reasonable to infer these are the same as the risk factors in the Revised Cardiac Risk Index (RCRI) If you have an RCRI of 0, risk of major adverse events will definitely be <1% can proceed to OR Revised Cardiac Risk Index (RCRI) CAD CHF CKD DM CVA/TIA High-risk surgery Intraperitoneal Intrathoracic Suprainguinal vascular If surgery is an emergency, proceed to OR Even if it s not a true surgical emergency, the time frame for surgical intervention should always be part of your preoperative planning Hip fracture repair (72 hours) Cancer surgery (~few weeks?) When in doubt, talk it out If uncertain about how much time may be available until surgery must be done, speak with the surgeon 2

3 Acute Coronary Syndromes Now focused only on acute coronary disease, not all active cardiac conditions Logical step where chronic coronary disease should also be considered Patients with current unstable angina should be delayed MI without revascularization Wait at least 60 days Chronic CAD Angioplasty without stent Wait 14 days BMS Wait 30 days CABG 4-6 weeks? DES Optimally wait 1 year Drug-Eluting Stents Guidelines acknowledge recent studies that show stabilization of CV risk 6 months after DES placement 1-3 Between 6-12 months after DES, collaboration of cardiologist, surgeon and anesthesiologist (and PCP?!) to determine best balance of risks/benefits 1 Wijeysundera DN et al. Circulation. 2012;126: Hawn MT et al. JAMA. 2013;310(14): Holcomb CN et al. J Am Coll Cardiol. 2014;64(25): When you gotta go, you gotta go When possible and especially when surgery is necessary prior to optimal delay, continue dual antiplatelet therapy (DAPT) through surgery When continuing DAPT is not possible, continue aspirin (81 mg?) through surgery NO EVIDENCE FOR ANY TYPE OF BRIDGING (heparins, GIIbIIIa inhibitors) during antiplatelet cessation Estimated perioperative risk of MACE based on combined clinical/surgical risk (Step 3) 3

4 Combined Clinicians understanding and assessment of surgery-specific risk was suboptimal No consistent, reliable system of categorizing low risk surgery Recent studies have shown superior predictive value of new risk calculators which combine surgical and patient risk predictors Guidelines recommend one of three tools: RCRI (+ an estimate of surgical risk) ACS NSQIP Surgical Risk Calculator ACS NSQIP PMICA Calculator RCRI Only one that is externally validated Cardiac outcomes: MI, cardiac death/vfib, pulmonary edema, complete heart block Easy to use and understand C-stat = NO ACCOUNTING FOR LOWER RISK SURGERIES 2 Revised Cardiac Risk Index (RCRI) CAD CHF CKD DM CVA/TIA High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular) 1 Gupta PK et al. Circulation. 2011;124: Davis C et al. Can J Anaesth. 2013;60(9): PMICA Calculator Validated on single, but large, study set from NSQIP database Cardiac outcomes: 30-day MI and cardiac arrest 5 variables plugged into protected calculator: Age Creatinine Funcational status Procedure 21 different ASA classification C-stat = Gupta PK et al. Circulation. 2011;124: ACS Surgical Risk Calculator Validated on single, but HUGE, study set from NSQIP database Assesses mortality, cardiac & 8 other outcomes Cardiac outcomes: 30-day MI and cardiac arrest 21 variables, including functional status, ASA classification & surgical type (>1500 different types) C-stat = Bilimoria KY et al. J Am Coll Surgeons. 2013;217(5):

5 Functional Status In newer models, functional status has been a consistent predictor of multiple complications, including cardiac, pulmonary & death Functional status = capacity to perform ADLs (personal hygiene, feeding, toileting, cooking) Best level of self-care within the 30 days prior surgery: Independent: No assistance from another person for any ADLs. Includes patients able to function independently with prosthetics, equipment, or devices. Partially dependent: Requires some assistance from another person for ADLs. Totally dependent: Total assistance for all ADLs Bilimoria KY et al. J Am Coll Surgeons. 2013;217(5): ASA Classification First developed in 1960s Intended as a patientspecific assessment of risk independent of procedure type Also consistently predictive of adverse outcomes Despite this, has wide inter-rater variability, even among anesthesiologists ASA Classification 1: Normal healthy 2: Mild systemic disease 3: Severe systemic disease 4: Severe systemic disease that is a constant threat to life 5: Not expected to survive 6: Brain dead Owens WD. Anesthesiology. 2001;94(2): ASA Classification: D e c l a s s i f i e d Class What it really means Examples No systemic or body system disease (ie, no GERD 1 HTN, DM) Chronic sinusitis 2 3 Controlled disease of one body system or Controlled HTN/DM Controlled disease of >1 body system or 1 major body system (heart or lungs) or Uncontrolled DM/HTN 4 Regularly symptomatic or end-stage disease Type 2 DM w/a1c<7-8 Pregnancy Mild obesity Smoking Mild, intermittent asthma HTN (BP<140/9) + CKD Compensated CHF Type 2 DM w/a1c>7-8 Asthma other than mild intermittent variety Unstable angina Symptomatic CHF Symptomatic COPD ESRD Cirrhosis If the risk of MI/cardiac arrest is <1%, further testing has no benefit proceed to the OR 5

6 If the risk of MI/cardiac arrest is 1%, functional capacity is the next determination For most surgeries, the CV stress comes from anesthesia, which studies have shown to be ~4 METs Functional Capacity Self-reported exertion that a patient regularly experiences without cardiac symptoms Duke Activity Status Index (DASI) validated as predictor of actual functional capacity 1 More accurate than clinicians assessments 2 Available at DUKE ACTIVITY STATUS INDEX 1 Hlatky MA et al. Am J Cardiol. 1989;64(10): Melon CC et al. JAMA. 2014;174(9): If patients can achieve 4 METs, no further coronary evaluation is indicated If such patients don t manifest coronary disease in their usual activities, they shouldn t manifest it during a procedure with less stress than they experience every day If patients cannot achieve 4 METs You re gonna die! If It Will Change Management Changing medical management? Can determine without further testing Informed decision making? High-risk option vs lower risk option Defer surgery Revascularization? Multiple studies have shown that preoperative revascularization in asymptomatic patients does not improve surgical outcomes No new data to suggest this helps Consistent with literature on intervention for stable CAD in general population no benefit 1 1 Sedlis SP et al. N Engl J Med. 2015;373:

7 Coronary Revascularization Before Noncardiac Surgery Indications are the same as for nonsurgical patients Symptomatic Asymptomatic Left main 50% stenosis LAD 70% stenosis with severe ischemia on stress testing 70% stenosis in 3 major coronary vessels 70% stenosis in 2 major coronary vessels with severe ischemia on stress testing For these indications, intervention reduces mortality in the general setting Circular Argument? We shouldn t stress test patients with the intent of revascularizing, but if we find a widow maker, we should revascularize? Should we stress test everyone since anyone may be hiding such disease? NO Costs: would spend millions to find few cases Harms: would cause many more cases of contrast-induced nephropathy (10%) and stroke (0.5%) to find one case of critical CAD Hillis LD et al. ACC/AHA Guidelines for CABG. Circulation. 2011;124: When Would I Stress Test Symptoms of cardiac disease AND timesensitive or elective surgery MACE risk 1%, poor functional capacity, elective surgery AND clear plan for how results will be used With old guidelines, obtained stress tests in <0.5% of asymptomatic patients With new guidelines, it s closer to 1-2% When Would I NOT Stress Test (Even Though the Algorithm Suggests It) Coronary evaluation within past year AND no cardiac symptoms since Coronary angiography without significant obstructive CAD Coronary CT angio without significant obstructive CAD Stress test with no ischemia Coronary revascularization within past year AND no cardiac symptoms since Asymptomatic & requires surgery in <6 weeks Wolk MJ et al ACC/AHA appropriate use criteria for evaluation of stable CAD. J Am Coll Cardiol. 2014;63(4): What Would I Do if the Stress Test is Abnormal Take a deep breath Explain to patient that results may or may not indicate a problem PPV ~20% Refer patient to cardiology Explain the situation that led to ordering the stress test Tactfully explain that your referral is not an inferred expectation of cath + intervention Cardiac Risk Management What else can be done? Appropriate antiplatelet management Beta-blockade Statin therapy Postoperative MI surveillance 7

8 Perioperative Beta-Blockers per the ACC/AHA Class I Continue chronic beta-blockers, including the morning of surgery Class IIa Reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started Wijeysundera D et al. J Am Coll Cardiol Jul 29. pii: S (14) Perioperative Beta-Blockers per the ACC/AHA Class IIb May be reasonable to start if ischemia preop risk stratification tests May be reasonable to start if 3 RCRI risk factors Uncertain benefit in patients with longterm indications for beta-blockers but RCRI =0 If starting beta-blocker, begin long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery Wijeysundera D et al. J Am Coll Cardiol Jul 29. pii: S (14) Perioperative Beta-Blockers per the ACC/AHA Class III: Harm Beta-blocker therapy should not be started on the day of surgery Perioperative Statins per the ACC/AHA Class I Continue chronic statin, including the morning of surgery (LOE: B) Class IIa Reasonable to start if undergoing vascular surgery (LOE: B) Class IIb May consider starting in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures (LOE: C) Wijeysundera D et al. J Am Coll Cardiol Jul 29. pii: S (14) Fleisher LA et al. J Am Coll Cardiol Jul 29. pii: S (14) Conclusions The last few years have produced much new data in the area of perioperative medicine, and the coming years will likely be similar Taken together, they continue to confirm the fundamentals of perioperative medical care: Be thorough Be thoughtful Be a strong communicator Do what you would do in the general practice setting Thank You Did a preop today Didn t use the word clearance For a copy of my guide to preop evaluation, kpfeifer@mcw.edu 8