Evaluating the Heart before Non-Cardiac Surgery
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1 Evaluating the Heart before Non-Cardiac Surgery Dr Rob Stephens Anaesthetist UCLH + UCL the centre for Anaesthesia
2 Google UCL Stephens
3 Google UCL Stephens
4 Contents Introduction Basic Principles Guidelines: Decisions Guidelines: Putting it all together Which test? ECHO CPEx B Block? Summary
5 Introduction You re all experts! Seems big, complex Conflicting, absent and changing evidence! Problem: Assessing CVS system vs Lack of effectiveness of interventions
6 Background: Basic Principles Why assess the CVS system? Assess risk: consent + patient decisions Assess risk: specific interventions Diagnose conditions : caution Cancer surgery- time limited Test: what next? Ischaemia vs Heart Failure Probably, reasonable, is not well established
7 Guidelines ACC/AHA guideline revision ACC/AHA 2007 (small revision 2009) ESC 2009 Guidelines - Cardiology Fraud of Poldermans B Blocker story Individual Studies?ASA / RCoA / AAGBI?
8 2014 Guidelines + others MACE Major Adverse Cardiac Event Different Order to risk asses Risk Asses using NSQIP CPEX considered for elevated risk procedures in unknown functional capacity Coronary Stent Guidelines POISE 2 study no benefit in adding aspirin MINS myocardial injury after non-cardiac surgery Troponin uncertain usefulness in high risk patients
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10 ESC 2009
11 Mythen, Biccard
12 Wait for surgery after MI? Postoperative MI 0-30 days 32.8% days 18.7% days 8.4% days 5.9% 30-day mortality 0-30 days 14.2% days 11.5% days 10.5% days 9.9% Livhits 2011
13 Vascular Surgery CARP 5859 patients screened; 510 selected revascularization vs not Postoperative 30 day mortality 3.1% vs 3.4%, rev vs not; P =.87 Long term mortality 2.8 years 22% vs 24%, rev vs not P =.92 McFalls 2004
14 Guideline 2 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers
15 Guideline 3 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers
16 Guideline 4 Surgery Urgency Emergency/ Immediate proceed
17 Urgency AHA 2014 Emergency no/little time limited clinical evaluation life or limb is threatened if no surgery within <6 hours Urgent may be time for a limited clinical evaluation when life or limb is threatened if no surgery within 6-24 Time-sensitive a delay of >1-6 week for evaluation / treatment will negatively affect outcome. Elective the procedure could be delayed for up to 1 year.
18 NCEPOD 2004
19 Guideline 5 Surgery Urgency Truly Elective time to treat / discuss Treat/refer broadly as according to nonpreoperative guidelines warn about possible delay to surgery evidence of benefit for subsequent surgery?
20 Guideline 6 Surgery Urgency (US vs NCEPOD) Cancer = time limited Consider lack of benefit from CVS interventions potential delay after CVS intervention coronary stent anticoagulation
21 Guideline 7 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers
22 Guideline 8 ACC AHA Patient Risk factors 3 levels: Serious / Intermediate / Minor Serious ; active cardiac conditions Recent MI/Unstable Angina New /Acute Ht Failure Serious abnormal rhythm Severe valve disease Pause and discuss with teams
23 Guideline 8 ACC AHA Patient Risk factors 3 levels: Serious / Intermediate / minor Intermediate - same as Lees rcri or Calculate NSQIP MACE score
24 Lee s rcri revised Cardiac Risk Index Major Surgery and Bowl cutting Pelvic Vascular Ischemic heart disease Cardiac Failure Cerebrovascular disease Diabetes on Insulin Renal insufficiency (>177 μmol / litre) No CVS % % % % Boersma 2005 Lee 1999
25 Guidelines 9 NSQIP Risk Calculator >1%? Think about Preoperative testing IHD If it will change your management
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28 Guideline 10 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers
29 Guideline 11 Severity of surgery Minor Anything else proceed consider further
30 Assessing CVS disease: Guideline 4 ESC 2009
31 Guideline 12 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Surgery Severity Patient Exercise Capacity ESC 2009 Biomarkers
32 Guideline 13 Patient Exercise Capacity 4 METS without significant symptoms Operations proceed No Chest Pain No SOB Less than 4 METS consider testing
33 Guideline 14 Patient Exercise Capacity Metabolic Equivalent of Task - MET 1 MET is 0 2 uptake at rest = = 3.5 ml/min/kg 0 2 uptake 2 METS ~ 2x 0 2 uptake of 1 METS Easily Quantified by CPEx Mostly quantified by history
34 Guideline 15 Patient Exercise Capacity 2 MET Strolling 4 MET Fast flat walking, up 1 flight stairs?do everything in a normal day walking a dog, moderate gardening 6+ Most sports, running No Chest Pain No SOB Playing a heavy musical instrument while actively running in a marching band
35 Maximum 3900ml/min 0 2 uptake 82kg 3900/82 =47ml/min/kg 11 3/4 METS Rest 330ml/min 0 2 uptake 82kg 330/82 =4ml/min/kg= 1 MET
36 Guideline 16 ACC AHA Surgery Urgency Patient Specific risks / Comorbidities Patient Exercise Capacity Surgery Severity ESC 2009 Biomarkers
37 Guideline 17 Biomarkers in Guidelines 2009 and 2014 a characteristic that can be objectively measured that is an indicator of pathology or an abnormal response to treatments Troponin - myocardial cell injury BNP + pro NT BNP CRP - myocardial wall stress increases - liver and smooth muscle ESC, Biccard, Devereaux 2012
38 Guideline 18 Biomarkers in ESC Guidelines 2009 Troponin Postop small associated mortality VISION Preop predictive, no ideal cut off BNP + pro NT BNP Ht Failure /IHD / ACS - rises relate to outcome Preop adds predictive ability >48 pg/ml CRP inflammatory marker ESC, Biccard, Devereaux 2012
39 Guideline 19 AHA/ACC 2014 no data to suggest that targeting biomarkers for treatment or intervention will lower postoperative risk. Biomarkers in ESC Guidelines 2009 Higher in patients that have postoperative cardiac events or die Troponin BNP CRP
40 Assessing CVS disease: Together
41 ACC/AHA 2014
42 ACC/AHA 2009
43 ESC 2009
44 Putting it together 1: Urgency Emergency or Urgent operation Time- limited or Elective consider further
45 Putting it together 2: Active Cardiac Condition
46 Putting it together 2: Active Cardiac Condition Serious = active cardiac condition Recent MI/Unstable Angina Acute LVF Serious abnormal rhythm Severe valve disease
47 Putting it together 2: Active Cardiac Condition Putting it together: 2 Active Cardiac Condition Yes Emergency operation and Rx Urgent pause & consider refer Time- limited pause & consider refer Elective pause & refer/ix/rx No Urgent Time- limited Elective consider further
48 Putting it together 3: Patient Risk Factors Patient Risk of MACE > 1%? Lees revised Cardiac Risk Index Any Ischaemic Ht Disease Any Ht Failure Any Cerebro-Vascular Disease Diabetes insulin Renal Injury (Cr 177+) More than 1% Less than 1% consider further proceed with surgery
49 Putting it together 4: Operation risk?low risk surgery Proceed operation Intermediate high consider further
50 Putting it together 5: Exercise capacity Can they do > 4 METS without symptoms probably operation Less than 4 METS or can t tell consider further
51 Putting it together: Investigations Always in the context of what next? ie will/should it change management? Consider testing ACC/AHA Stress ECHO Myocardial Perfusion Scan CPEx includes Exercise ECG Exercise ECG MRI or CT
52 ECHO Evidence Valves, Function, estimates pulmonary pressures Degree of dysfunction, regional wall motion abn LVEF <40% - 2x higher risk sensitivity 43% positive predictive 13% resting LV function was not found to be a consistent predictor of perioperative ischemic events or death But ECHO enthusiasts in preassessment.. 30% new CVS disease, Mx 20% Mx 34% Halm, Rofdhe, Canty
53 ECHO indication Routine Evaluation NO Dyspnea of unknown origin reasonable New murmur - reasonable Ht Failure with symptoms - reasonable Ht Failure clinically stable - may be considered Valves clinically stable - recommended > 1 year ACC/AHA
54 CPEx / CPET Background Functional assessment Population data survival VO 2 peak, AT, VE/VCO 2, ECG ischaemia etc But Associations with outcome and complications Most studies unblinded, small Await results of only RCT Prehabilitation studies- some positives Older, Hennis, Snowden, O Doherty
55 CPEx / CPET Background n=548 Lower anaerobic threshold worse: Raised Respiratory Equivalent: higher mortality higher mortality Mortality AT more 14 ml/min /kg 0% AT more 11 ml/min /kg but other badness 1.7% AT less 11 ml/min /kg 4.6% Older 1999
56 CPEx / CPET Background Complication AT < 10.1 AT > 10.1 p= on day 7 n= 51 n=65 Pulmonary 57% 15% < Renal 40% 11% GI 33% 11% Infective 27% 11% Cardiovascular 25% 3% Neurological 10% 5% 0.29 Hematology 8% Pain 8% Wound 4% Snowden 2010
57 CPEx / CPET use ACC/AHA 2014 considered for patients undergoing elevated risk procedures with unknown functional capacity Awaiting RCT on CPEx vs Dr Use very variable, increasing Best not to emphasise one single value VO 2 peak, AT, VE/VCO 2, ECG ischaemia Enthusiasts vs sceptics
58 B Block? background B blockers in community reduce adrenergic activity + myocardial 0 2 use associated with survival RCT Perioperative studies Mangano POISE DECREASE, Others Observational perioperative data US and European Perioperative Guidelines Mangano, London, Sear, Devereaux, Bouri
59 B Block? ESC 2009
60 Devereaux B Block?: Endpoints important! POISE Lancet patients with/at risk of, atherosclerotic disease non-cardiac surgery B Block 24 hrs preoperatively 30 days postop Metoprolol vs Placebo MI 4 2% vs 5 7% 0 84 p=0 002 Deaths 3 1% vs 2 3% 1 33 p=0 03 Stroke 1 0% vs 0 5% 2 17 p=0 005 BP 15.0% vs. 9.7% p < Bradycardia 6.6% vs. 2.4% p <
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63 B Block Maintain current B Blockade Treat concomitant anaemia Meta-analysis / prospective studies don t support May use in high risk people only Those that may be on B Blockers anyway rcri >1?Atenolol or Bisoprolol Start /titrate bpm?7+ days before
64 VISION : MINS 15,065 patients > 45+ yrs; in-patient non-cardiac surgery MINS myocardial injury after non-cardiac surgery= Troponin T level of > 0.03 ng/ml MINS 30-day mortality 3.87x (adjusted hazard ratio; 95% CI, ) 8.0% had MINS 58.2% of these did not fulfill a conventional MI definition 15.8% of patients with MINS had ischemic symptoms Botto 2014
65 Summary Introduction Basic Principles Guidelines: Decisions Guidelines: Putting it all together Which test? ECHO CPEx B Block? Summary
66 Thank you For listening Please Google stephens UCL for website This full talk Some References AHA/ACC and European Guidelines
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