ACC/AHA 2007 Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery Doris Lin,...

ACC/AHA 2007 ACC/AHA 2007 Update on Update on

Perioperative Perioperative Cardiovascular Cardiovascular Evaluation for Evaluation for

Noncardiac Noncardiac SurgerySurgeryDoris Lin, M.D.Doris Lin, M.D.

OutlineOutline

RecommendationsRecommendations Algorithm 2002 vs 2007Algorithm 2002 vs 2007 Misc Misc

IntroductionIntroduction

In US, millions of pts undergo In US, millions of pts undergo surgical procedures each yrsurgical procedures each yr

Most morbidity & death occur in the Most morbidity & death occur in the post-op period & is of cardiac, pulm, post-op period & is of cardiac, pulm, neurologic, or infectious originneurologic, or infectious origin

MI usually occurs w/in the first 4 MI usually occurs w/in the first 4 days after surgery & is assoc with a days after surgery & is assoc with a 15-25% mortality rate15-25% mortality rate

IntroductionIntroduction

Nonfatal post-op MI is an Nonfatal post-op MI is an independent risk factor for future independent risk factor for future infarction and death w/in 6 months infarction and death w/in 6 months after surgeryafter surgery

ACP guidelines similar to ACC/AHA ACP guidelines similar to ACC/AHA except that ACP does not except that ACP does not recommend use of exertional recommend use of exertional capacity (METs) to guage cardiovasc capacity (METs) to guage cardiovasc riskrisk

Purpose of the Purpose of the GuidelinesGuidelines

Goal is not to “medically clear” ptGoal is not to “medically clear” pt Provide a risk profile based on pt’s Provide a risk profile based on pt’s

medical status and make medical status and make recommendations concerning the recommendations concerning the management and risk of cardiac management and risk of cardiac problems over the entire problems over the entire perioperative periodperioperative period

Methodology and Methodology and EvidenceEvidence

ACC/AHA conducted literature ACC/AHA conducted literature searches in PubMed, MEDLINE, and searches in PubMed, MEDLINE, and Cochrane Library from 2002-2007Cochrane Library from 2002-2007

Searches limited to English Searches limited to English language and human subjectslanguage and human subjects

Applying Classification of Applying Classification of Recommendations and Level of Recommendations and Level of

Evidence (LOE)Evidence (LOE)

Class I- Evidence that procedure is Class I- Evidence that procedure is beneficial, useful, and effectivebeneficial, useful, and effective

Class II- Conflicting EvidenceClass II- Conflicting Evidence Class IIa- Weight is in favor of Class IIa- Weight is in favor of

usefulness/efficacyusefulness/efficacy Class IIb- Efficacy is less well Class IIb- Efficacy is less well

establishedestablished Class III- Evidence that procedure is Class III- Evidence that procedure is

not useful and may be harmfulnot useful and may be harmful

Applying Classification of Applying Classification of Recommendations and Level of Recommendations and Level of

EvidenceEvidence Level of Evidence A- Data from Level of Evidence A- Data from

multiple, randomized, clinical trialsmultiple, randomized, clinical trials Level of Evidence B- Data from Level of Evidence B- Data from

single-randomized trial or non-single-randomized trial or non-randomized trialrandomized trial

Level of Evidence C- Only consensus Level of Evidence C- Only consensus opinion of experts, case studies, or opinion of experts, case studies, or standard-of-carestandard-of-care

Cardiac Risk Stratification Cardiac Risk Stratification for Surgical Proceduresfor Surgical Procedures

High (cardiac risk > 5%)High (cardiac risk > 5%) Aortic and major vascular surgeryAortic and major vascular surgery Peripheral vascular surgeryPeripheral vascular surgery Emergent major operations, esp in Emergent major operations, esp in

elderlyelderly Prolonged surgeries associated with Prolonged surgeries associated with

large fluid shifts or blood losslarge fluid shifts or blood loss


Intermediate (cardiac risk 1-5%)Intermediate (cardiac risk 1-5%) Intraperitoneal/intrathoracic surgeryIntraperitoneal/intrathoracic surgery Carotid endarterectomyCarotid endarterectomy Head and neck surgeryHead and neck surgery Orthopedic surgeryOrthopedic surgery Prostate surgeryProstate surgery


Low (cardiac risk < 1%)Low (cardiac risk < 1%) Endoscopic proceduresEndoscopic procedures Superficial procedureSuperficial procedure CataractCataract Breast surgeryBreast surgery Ambulatory procedureAmbulatory procedure

Recommendations- Recommendations- Who Who needs these tests prior to surgery?needs these tests prior to surgery?

EKGEKG Assess LV functionAssess LV function Noninvasive stress testingNoninvasive stress testing Pre-op coronary revascularizationPre-op coronary revascularization Beta-blocker therapyBeta-blocker therapy

Recommendations for Pre-Recommendations for Pre-op EKGop EKG

Class I & IIClass I & II 0-1 0-1 clinical risk factorclinical risk factor & vasc surgery & vasc surgery

(LOE: B)(LOE: B) 1 risk factor & intermediate risk 1 risk factor & intermediate risk

surgery (LOE: B)surgery (LOE: B) Class IIIClass III

Not indicated in asymptomatic persons Not indicated in asymptomatic persons & low risk procedure (LOE: B)& low risk procedure (LOE: B)

Clinical Risk FactorsClinical Risk Factors

Ischemic heart diseaseIschemic heart disease Compensated or prior heart failureCompensated or prior heart failure Cerebrovascular diseaseCerebrovascular disease Diabetes mellitusDiabetes mellitus Renal insufficiencyRenal insufficiency

Recommendation for Recommendation for Noninvasive Eval of LV Noninvasive Eval of LV

functionfunction Class IIaClass IIa

Dyspnea of unknown origin (LOE: C)Dyspnea of unknown origin (LOE: C) Current or prior HF with worsening dyspnea Current or prior HF with worsening dyspnea

or other change in clinical status (LOE: C)or other change in clinical status (LOE: C) Class IIbClass IIb

Stable cardiomyopathy may not need (LOE: Stable cardiomyopathy may not need (LOE: C)C)

Class IIIClass III Routine echo in pts not recommended (LOE: Routine echo in pts not recommended (LOE:

B)B)

Recommendatons for Recommendatons for Noninvasive Stress Testing Noninvasive Stress Testing

Class IClass I Active cardiac conditionsActive cardiac conditions should be should be

treated prior to surgery (LOE: B)treated prior to surgery (LOE: B) Class IIaClass IIa

3+ clinical risk factors & < 4 METS 3+ clinical risk factors & < 4 METS who require vascular surgery (LOE: B)who require vascular surgery (LOE: B)

Active Cardiac Active Cardiac ConditionsConditions

Unstable coronary syndromesUnstable coronary syndromes Decompensated heart failureDecompensated heart failure Significant arrythmiasSignificant arrythmias

High grade AV blocks, symptomatic High grade AV blocks, symptomatic arrythmiasarrythmias

Severe valvular diseaseSevere valvular disease Severe AS (mean pressure gradient > 40 Severe AS (mean pressure gradient > 40

mmHg or valve area < 1.0 cm2, or mmHg or valve area < 1.0 cm2, or symptomatic)symptomatic)

Symptomatic MSSymptomatic MS

Energy RequirementsEnergy Requirements

1 MET1 MET Take care of selfTake care of self Eat, dress, use toiletEat, dress, use toilet

2-3 METs2-3 METs Walk indoors around the houseWalk indoors around the house Walk a blockWalk a block

4 METs4 METs Light housework like dusting or washing Light housework like dusting or washing

dishesdishes


4-5 METs4-5 METs Climb stairs, walk up a hillClimb stairs, walk up a hill

6-9 METs6-9 METs Run a short distanceRun a short distance Heavy houseworkHeavy housework Moderate recreational activitiesModerate recreational activities

10 METs10 METs Strenuous activities (swimming, tennis, Strenuous activities (swimming, tennis,

skiing)skiing)

Recommendatons for Recommendatons for Noninvasive Stress TestingNoninvasive Stress Testing

Class IIb- considered for:Class IIb- considered for: 1-2 clinical risk factors & < 4 METS & 1-2 clinical risk factors & < 4 METS &

intermediate risk surgeryintermediate risk surgery 1-2 clinical risk factors & > 4 METS & 1-2 clinical risk factors & > 4 METS &

vascular surgeryvascular surgery Class IIIClass III

Not needed if no risk factors & Not needed if no risk factors & intermediate surgeryintermediate surgery

Not needed if low risk procedureNot needed if low risk procedure

Recommendations for Pre-Recommendations for Pre-op Revascularization with op Revascularization with

CABG or PCICABG or PCI Class IClass I

Stable angina & left main stenosisStable angina & left main stenosis Stable angina & 3 vessel diseaseStable angina & 3 vessel disease Stable angina & 2 vessel disease (prox Stable angina & 2 vessel disease (prox

LAD stenosis) & either EF < 50% or LAD stenosis) & either EF < 50% or ischemia on stress testischemia on stress test

High risk unstable angina or NSTEMIHigh risk unstable angina or NSTEMI Acute STEMIAcute STEMI

PCI: angioplastyPCI: angioplasty

Delay surgery for > 14 days to allow Delay surgery for > 14 days to allow healing of vessel injuryhealing of vessel injury

Should continue aspirin Should continue aspirin perioperatively (vs bleeding risk)perioperatively (vs bleeding risk)

PCI: bare-metal stentPCI: bare-metal stent

Delay surgery for 4-6 wks to allow Delay surgery for 4-6 wks to allow for at least partial endothelializationfor at least partial endothelialization

Clopidogrel usually not needed after Clopidogrel usually not needed after 4 wks4 wks


PCI: Drug-eluting stentsPCI: Drug-eluting stents

Delay surgery for 12 months due to Delay surgery for 12 months due to risk of in-stent thrombosisrisk of in-stent thrombosis


Thrombosis may occur up to 1.5 Thrombosis may occur up to 1.5 years after implantation, particularly years after implantation, particularly in the context of discontinuing in the context of discontinuing antiplatelet agents before surgeryantiplatelet agents before surgery

Beta-blocker therapyBeta-blocker therapy

Class IClass I Continue if already on beta-blockerContinue if already on beta-blocker Vascular surgery & high cardiac risk Vascular surgery & high cardiac risk

(ischemia on pre-op testing)(ischemia on pre-op testing) Class IIa- probably recommended for:Class IIa- probably recommended for:

Vascular surgery & coronary diseaseVascular surgery & coronary disease Vascular surgery & > 1 clinical risk factorVascular surgery & > 1 clinical risk factor Intermediate surgery & > 1 clinical risk Intermediate surgery & > 1 clinical risk

factorfactor

Beta-blocker therapyBeta-blocker therapy

Class IIb- uncertain for:Class IIb- uncertain for: Intermediate/high risk surgery & 1 clinical risk Intermediate/high risk surgery & 1 clinical risk

factorfactor High risk/Vascular surgery & no clinical risk High risk/Vascular surgery & no clinical risk

factorsfactors Class IIIClass III

Contraindication to beta-blockersContraindication to beta-blockers Routine administration of high-dose beta blockersRoutine administration of high-dose beta blockers

w/o dose titratiw/o dose titration is not useful and may be harmful is not useful and may be harmful

to ptsto pts not currently taking beta blockers (POISE not currently taking beta blockers (POISE trial)trial)

Beta-blockersBeta-blockers

Since 2002, few randomized trials Since 2002, few randomized trials have not demonstrated efficacy of have not demonstrated efficacy of beta-blockers but weight of evidence beta-blockers but weight of evidence still suggests benefit esp high-risk still suggests benefit esp high-risk ptspts

Should be started 7-10 days before Should be started 7-10 days before elective surgeryelective surgery

Long-acting agents may be better Long-acting agents may be better than short-actingthan short-acting

Beta-blockersBeta-blockers

Accumulating evidence suggests HR Accumulating evidence suggests HR target is 60-80 beats/mintarget is 60-80 beats/min

Should continue beta-blocker Should continue beta-blocker therapy through peri-op period & therapy through peri-op period & titrate to tight HR controltitrate to tight HR control

Algorithm for 2007Algorithm for 2007

20022002

Active Cardiac Active Cardiac ConditionsConditions

Unstable coronary syndromesUnstable coronary syndromes Decompensated heart failureDecompensated heart failure Significant arrythmiasSignificant arrythmias

High grade AV blocks, symptomatic High grade AV blocks, symptomatic arrythmiasarrythmias

Severe valvular diseaseSevere valvular disease Severe AS (mean pressure gradient > 40 Severe AS (mean pressure gradient > 40

mmHg or valve area < 1.0 cm2, or mmHg or valve area < 1.0 cm2, or symptomatic)symptomatic)

Symptomatic MSSymptomatic MS


1 MET1 MET Take care of selfTake care of self Eat, dress, use toiletEat, dress, use toilet

2-3 METs2-3 METs Walk indoors around the houseWalk indoors around the house Walk a blockWalk a block

4 METs4 METs Light housework like dusting or washing Light housework like dusting or washing

dishesdishes


4-5 METs4-5 METs Climb stairs, walk up a hillClimb stairs, walk up a hill

6-9 METs6-9 METs Run a short distanceRun a short distance Heavy houseworkHeavy housework Moderate recreational activitiesModerate recreational activities

10 METs10 METs Strenuous activities (swimming, tennis, Strenuous activities (swimming, tennis,

skiing)skiing)

Revised Cardiac Risk Revised Cardiac Risk IndexIndex

Ischemic heart diseaseIschemic heart disease Compensated or prior heart failureCompensated or prior heart failure Cerebrovascular diseaseCerebrovascular disease Diabetes mellitusDiabetes mellitus Renal insufficiency (creatinine > 2 Renal insufficiency (creatinine > 2

mg/dL)mg/dL) High risk surgical procedureHigh risk surgical procedure

Intraperitoneal/intrathoracic, vascularIntraperitoneal/intrathoracic, vascularBased on 4315 pts undergoing elective major surgeryLee, TH et al, Circulation 1999, 100:1043-1049

Risk of Major Cardiac Risk of Major Cardiac EventEvent

POINTSPOINTS CLASSCLASS RISKRISK

00 II 0.4%0.4%

11 IIII 0.9%0.9%

22 IIIIII 6.6%6.6%

≥ ≥ 33 IVIV 11%11%

“Major Cardiac Event” includes MI, pulm edema, vfib, cardiac arrest, complete heart block

Misc PointsMisc Points

Pre-op labsPre-op labs MedicationsMedications Chronic anticoagulationChronic anticoagulation

Pre-op lab testingPre-op lab testing

Order fewer selective, evidence Order fewer selective, evidence based testsbased tests

30-60% of abnormalities found on 30-60% of abnormalities found on pre-op tests are generally ignored pre-op tests are generally ignored anywayanyway

Lab tests normal in last 4 months Lab tests normal in last 4 months and no clinical change probably do and no clinical change probably do not require repeat testsnot require repeat tests

MedicationsMedications

Continue beta-blockers, oral nitrates, & most Continue beta-blockers, oral nitrates, & most antihypertensives until the morning of antihypertensives until the morning of surgerysurgery

Suggest holding ACE-I & ARBs on morning of Suggest holding ACE-I & ARBs on morning of surgery to decrease risk of renal dysfunctionsurgery to decrease risk of renal dysfunction

Aspirin, aggrenox, clopidogrel- stop 7 days Aspirin, aggrenox, clopidogrel- stop 7 days priorprior

Cilastazol, COX-1 inh cause reversible Cilastazol, COX-1 inh cause reversible platelet inhibition- stop 2-3 days priorplatelet inhibition- stop 2-3 days prior

COX-2 inh do not affect plateletsCOX-2 inh do not affect platelets


NSAIDS affect renal function- stop 1-3 NSAIDS affect renal function- stop 1-3 days priordays prior

SSRIs increase bleeding by depleting SSRIs increase bleeding by depleting serotonin stores- stop days prior serotonin stores- stop days prior depending on half-lifedepending on half-life

Hormones, Raloxifene, Tamoxifen Hormones, Raloxifene, Tamoxifen increase risk of thromboemboliincrease risk of thromboemboli

Anti-convulsant/psychotic/depressant Anti-convulsant/psychotic/depressant meds should be continuedmeds should be continued

Metformin held to reduce lactic acidosisMetformin held to reduce lactic acidosis


Supplements or herbal meds- stop 1 Supplements or herbal meds- stop 1 wk priorwk prior Ginger, ginkgo, ginseng, garlic, & Ginger, ginkgo, ginseng, garlic, &

feverfew can cause bleedingfeverfew can cause bleeding Ginseng assoc w/ hypoglycemiaGinseng assoc w/ hypoglycemia Garlic assoc w/ hypoglycemia, Garlic assoc w/ hypoglycemia,

hypotensionhypotension Kava, echinacea assoc w/ hepatotoxicityKava, echinacea assoc w/ hepatotoxicity

Low Bleed RiskLow Bleed Risk

Continue warfarin (can consider lower Continue warfarin (can consider lower INR of 1.3-1.5)INR of 1.3-1.5) CataractCataract Endoscopy, colonoscopy, ERCP w/o Endoscopy, colonoscopy, ERCP w/o

sphincterotomysphincterotomy Superficial dermatologicSuperficial dermatologic Dental proceduresDental procedures Joint and soft tissue aspirations or Joint and soft tissue aspirations or

injectionsinjections Minor podiatric procedures (nail avulsions)Minor podiatric procedures (nail avulsions)

High Risk- Bridging High Risk- Bridging advisedadvised

DVT/PE or arterial thromboemboli < 3 moDVT/PE or arterial thromboemboli < 3 mo Thromboembolic event + hypercoaguable Thromboembolic event + hypercoaguable

problem (i.e. protein C or S def…)problem (i.e. protein C or S def…) Recurrent arterial or idiopathic VTERecurrent arterial or idiopathic VTE Rheumatic atrial fibRheumatic atrial fib Acute intracardiac thrombusAcute intracardiac thrombus Atrial fib + mech heart valve in any positionAtrial fib + mech heart valve in any position Older mech valves in mitral position (single disk Older mech valves in mitral position (single disk

or ball-in-cage)or ball-in-cage) Recently placed mech valve (<3 months)Recently placed mech valve (<3 months) Atrial fibrillation with h/o cardioembolismAtrial fibrillation with h/o cardioembolism

Intermediate Risk- Intermediate Risk- Bridging case-by-case basisBridging case-by-case basis

Newer model mech valve in mitral Newer model mech valve in mitral position (St. Jude)position (St. Jude)

Older model mech valve in aortic Older model mech valve in aortic positionposition

Atrial fib w/o cardioembolism but with Atrial fib w/o cardioembolism but with multiple risks for cardioembolism multiple risks for cardioembolism (CHADS2 ≥ 3)(CHADS2 ≥ 3)

VTE > 3-6 months agoVTE > 3-6 months ago

CHADS2 scoreCHADS2 score

1 pt each1 pt each Heart failure (EF < 30%)Heart failure (EF < 30%) HTNHTN age ≥ 75 yrsage ≥ 75 yrs diabetesdiabetes

2 pts2 pts Prior strokePrior stroke

Low risk- bridging not Low risk- bridging not advisedadvised

One remote VTE (>6 months ago)One remote VTE (>6 months ago) Intrinsic cerebrovascular disease Intrinsic cerebrovascular disease

(carotid atherosclerosis) w/o (carotid atherosclerosis) w/o recurrent stroke or TIArecurrent stroke or TIA

Atrial fib w/o multiple risks for Atrial fib w/o multiple risks for cardiac embolism (CHADS2 1-2)cardiac embolism (CHADS2 1-2)

Newer model mech valve in aortic Newer model mech valve in aortic position (St. Jude)position (St. Jude)

ConclusionsConclusions

Successful peri-op eval and Successful peri-op eval and management requires careful management requires careful teamworkteamwork

Use of noninvasive and invasive pre-Use of noninvasive and invasive pre-op testing should be limited to op testing should be limited to circumstances in which the results circumstances in which the results will affect pt managementwill affect pt management

Goal is to make recommendations to Goal is to make recommendations to lower immediate peri-op cardiac risklower immediate peri-op cardiac risk

ReferencesReferences Fleisher, LA, et al., ACC/AHA 2007 Guidelines on Fleisher, LA, et al., ACC/AHA 2007 Guidelines on

Perioperative Cardiovascular Evaluation and Care for Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary, Noncardiac Surgery: Executive Summary, CirculationCirculation, Oct , Oct 23, 2007, 1-26.23, 2007, 1-26.

Beckman, JA, et al., ACC/AHA 2006 Guidelines on Beckman, JA, et al., ACC/AHA 2006 Guidelines on Perioperative Cardiovascular Evaluation and Care for Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Focused Update on Perioperative Noncardiac Surgery: Focused Update on Perioperative Bets-Blocker Therapy, Bets-Blocker Therapy, JACCJACC, Vol. 47. , Vol. 47.

Lee, TH, et al., Derivation and prospective validation of a Lee, TH, et al., Derivation and prospective validation of a simple index for prediction of cardiac risk in major simple index for prediction of cardiac risk in major noncardiac surgery. noncardiac surgery. CirculationCirculation 1999;100:1043-1049. 1999;100:1043-1049.

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