Cardiac Perioperative Risk Assessment American Heart Association Guidelines Dr Gary Liew, MBBS, PhD, FRACP US Board Certified in Cardiovascular CT Executive Committee, Cardiac Institute, Epworth Healthcare Senior Fellow, University of Melbourne Clinical Senior Lecturer, University of Adelaide
Perioperative Cardiac Guidelines American - AHA/ACC 2014 European - ESC / ESA 2014 2
U.S. Perioperative Guidelines Fleisher et al, JACC 2014
European Perioperative Guidelines Kristensen et al, Eur Heart J, (2014) 35, 2383 243
ESC Perioperative Guidelines App
Topics Coronary Artery Disease Heart Failure Atrial Fibrillation & Arrhythmias Valvular Disease Pacemakers & ICDs Stepwise approach to Pre-Op testing Treatment options in Peri-Op period
Coronary Artery Disease Current ACS or unstable angina Timing surgery since previous AMI < 1 Month 1 2 Months 2 3 Months 3 6 Months AMI 32% 18% 8% 6% Death 14% 11% 10% 9%
Heart Failure Patients with active / clinical heart failure have higher post-op death (9%) than patients with stable CAD (3%). Patients with LVEF < 30% highest risk 30-Day MACE rate based on symptoms: Symptomatic Heart Failure Asymptomatic LV systolic Heart Failure Asymptomatic LV Diastolic Heart Failure MACE 49% 23% 18%
Valvular Heart Disease
Valve stenosis worse than valve regurgitation Severe symptomatic AS or MS should be fixed prior to elective surgery Severe asymptomatic AS may be go ahead with caution and HDU monitoring Severe AS = AVA < 1.0cm 2 or mean gradient > 40 mmhg (normal LVEF) Severe asymptomatic AR or MR with normal LVEF may go ahead with caution and HDU monitoring
Atrial Fibrillation Rate control is key continue pre-op beta-blocker or digoxin. Diltiazem can be useful in asthmatics. Consult with cardiologist about stopping anti-coagulants. No bridging with clexane / heparin unless previous stroke or high CHADs-Vasc score or valvular. NOACs only stop 48 72 hours pre-op.
Other arrhythmias Isolated RBBB or LBBB are fine to proceed (ie. No new CCF or CAD) 2 nd degree 2:1 AV block or CHB may require temporary pacing or pacemaker Beware Trifascicular Block = RBBB + 1 st degree AV block + left or right axis deviation (LAFB or LPFB) No pacing if asymptomatic but CHB.
Trifascicular Block - one step away from CHB RBBB + 1 st degree AV block + left or right axis deviation (LAFB or LPFB) RBBB Left Axis Deviation 1 st Degree AV Block = PR > 1 Big Square
Cardiac Implantable Electronic Devices (CIEDs) INVOLVE CIED TECHNICIAN PRE / PERI-OP Electro-cautery can cause inhibition of pacing, oversensing in ICDs = inappropriate shocks Magnet application and/or reprogramming can avoid these problems Mono-polar cautery can reduce EMI (electromagnetic interference)
Stepwise Approach 1. Urgent Surgery 2. ACS or unstable cardiac conditions 3. What is the risk of the procedure? 4. What is the functional capacity of patient? Good (> 4 METS = proceed) 5. Poor functional capacity then consider risk of surgery 6. Clinical risk factors for High Risk Surgery 7. Functional testing
Step 1: Urgent Surgery Emergency / Urgent Surgery will proceed no time to order investigations Patient or surgical factors will dictate strategy Cardiac monitoring and surveillance for complications eg. MI, arrhythmias Continuation of medical therapy for chronic conditions eg. Aspirin, B-blocker
Step 2: Active / Unstable cardiac Unstable Angina Recent MI (< 60 days) or residual ischaemia Acute heart failure Significant cardiac arrhythmias Symptomatic valvular heart disease Delay procedure Consultation with relevant specialists Investigate and optimize treatment
Step 3: Risk of surgery 30-Day risk of MI and death No further testing needed; proceed to surgery
Step 4: Functional Capacity Good > 4 METs & Asymptomatic Proceed to surgery
Step 5: Poor function < 4 METS If Moderate or High Risk Surgery then consult and consider functional test Stress Echocardiogram Stress Nuclear Perfusion
Step 6: Clinical Risk Factors Revised Cardiac Risk Index (RCRI) Lee et al, Circulation 1999: 100, 1043-1049 IHD angina or previous AMI Heart Failure Stroke or TIA CKD Cr > 170 or CrCl < 60 Diabetes requiring insulin 2 factors = rest echo +/- stress 3 factors = Stress testing
RCRI Calculator App
Step 7: Functional testing Stress Echo (treadmill vs. dobutamine) LBBB, obesity, severe COAD Stress Nuclear Perfusion Treadmill / bike vs Persantin or Adenosine, Dobutamine Cardiac MRI access issue & cost Coronary CTA not indicated for routine pre-op testing. Routine coronary angiogram not indicated
Routine ECG or Echo?
Medications Peri-Op Beta-blockers Statins ACEi / ARBs
Beta-blockers
Other therapies 28
Stents and Dual-Antiplatelets Bare metal stents min. 4 weeks DES min. 12 months but? 6 months If surgery urgent, keep Aspirin going. Risk of MI = <30 days 15%, <6 months 8%
Summary Consider surgical & patient risk Patient functional status Low risk procedures no need to test Mod High risk surgery = consider patient status / risk factors Continue aspirin, statins, ACEi, ß blockers for chronic, stable patients. Not start new aspirin or ß blockers routinely unless indicated 30