What is Cardiology Clearance?

What is Cardiology Clearance?

Sheilah Bernard, MD, FACCDirector, Cardiac Amb Services

Sheilah Bernard, MD, FACCDirector, Cardiac Amb Services

9:30-10:00am9:30-10:00am

2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future

Boston University School of Medicine

May 19, 2006

Boston University School of Medicine

May 19, 2006

Eight Steps to Best Possible Outcome

Eight Steps to Best Possible Outcome

• Assess the patient’s clinical features

• Evaluate functional status

• Consider the patient’s surgery-specific risk

• Decide if further noninvasive evaluation is needed

• Decide when to recommend invasive evaluation

• Optimize medical therapy

• Perform appropriate perioperative surveillance

• Design maximal long-term therapy

• Assess the patient’s clinical features

• Evaluate functional status

• Consider the patient’s surgery-specific risk

• Decide if further noninvasive evaluation is needed

• Decide when to recommend invasive evaluation

• Optimize medical therapy

• Perform appropriate perioperative surveillance

• Design maximal long-term therapy

2002, Eagle K et al. www.acc.org or www.americanheart.org

AHA/ACC Practice Guidelines Perioperative

CV Evaluation for Noncardiac Surgery

AHA/ACC Practice Guidelines Perioperative

CV Evaluation for Noncardiac Surgery

Fleisher: N Engl J Med, Volume 345(23).December 6,

2001.1677-1682

Implementing GuidelinesImplementing Guidelines

• Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI)

– Resources: ETT 88%47%; Cath 24%11%; revascularization 25%2%

– Costs: $1087$171

• Effect was sustained 2 years after guideline implementation

• Implementation of ACC/AHA cardiac risk assessment guidelines reduced resource use and costs in patient who underwent elective aortic surgery without affecting outcomes (death/MI)

– Resources: ETT 88%47%; Cath 24%11%; revascularization 25%2%

– Costs: $1087$171

• Effect was sustained 2 years after guideline implementation

Froelich JB, J Vasc Surgery 2002 36L758-63

B&W Preadmission Testing Center (PATC) and last minute Cardiology

consults for:

B&W Preadmission Testing Center (PATC) and last minute Cardiology

consults for:

Dudley JC et al, AM HEART J 1996;131:245-9.

Sources of “last-minute” cardiology consults

Sources of “last-minute” cardiology consults

Improved survival with atenolol after noncardiac surgery

Improved survival with atenolol after noncardiac surgery

Lindenauer, P. K. et al. N Engl J Med 2005;353:349-361

Adjusted Odds Ratio for In-Hospital Death Associated with Perioperative Beta-Blocker Therapy among Patients Undergoing Major Noncardiac Surgery, According to the RCRI Score and the Presence of Other Risk Factors in the Propensity-Matched Cohort and the

Entire Study Cohort

Adjusted Odds Ratio for In-Hospital Death Associated with Perioperative Beta-Blocker Therapy among Patients Undergoing Major Noncardiac Surgery, According to the RCRI Score and the Presence of Other Risk Factors in the Propensity-Matched Cohort and the

Entire Study Cohort

Beta blocker guidelinesBeta blocker guidelines

Limitations in the perioperative beta blocker literature

Limitations in the perioperative beta blocker literature

• Most trials inadequately powered

• Few randomized trials of medical therapy have been performed

• Few randomized trials have examined titration to effect (e.g. target heart rate)

• Few randomized trials have examined the role of perioperative beta blocker therapy

• Studies to determine role in intermediate and low risk populations are lacking.

• Optimal beta blocker

• No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom)

• Most trials inadequately powered

• Few randomized trials of medical therapy have been performed

• Few randomized trials have examined titration to effect (e.g. target heart rate)

• Few randomized trials have examined the role of perioperative beta blocker therapy

• Studies to determine role in intermediate and low risk populations are lacking.

• Optimal beta blocker

• No studies look at care-delivery mechanisms in the perioperative setting (how, when, by whom)

McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804

Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major

Vascular Surgery

Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major

Vascular Surgery

McFalls, E. O. et al. N Engl J Med 2004;351:2795-2804

Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization

Long-Term Use of Medical Therapy in the Revascularization and No-Revascularization Groups at 24 Months after Randomization

?CABG/PCI before major elective vascular surgery? NO

?CABG/PCI before major elective vascular surgery? NO

• In conclusion, this multicenter, randomized trial shows that

coronary-artery revascularization before elective vascular surgery does not alter long-term survival.

• Although the study was not powered to detect a beneficial effect in the short term, there also appears to have been no reduction in the number of postoperative myocardial infarctions, deaths, or days in the hospital.

• On the basis of these data, coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

• In conclusion, this multicenter, randomized trial shows that

coronary-artery revascularization before elective vascular surgery does not alter long-term survival.

• Although the study was not powered to detect a beneficial effect in the short term, there also appears to have been no reduction in the number of postoperative myocardial infarctions, deaths, or days in the hospital.

• On the basis of these data, coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

Kaplan-Meier Survival Curves to One YearKaplan-Meier Survival Curves to One Year

Sandham, J. et al. N Engl J Med 2003;348:5-14

The Statins for Risk Reduction in Surgery (StaRRS) study

The Statins for Risk Reduction in Surgery (StaRRS) study

• Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece

• 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization

– 157 complications occurred• 9.9% statin vs 16.5% non-statin

• Retrospective trial BIDMCH/Hygeia Hospital Athens, Tufts, Loannina School of Medicine Greece

• 1163 patients undergoing carotid endarterectomy, aortic surgery, lower extremity revascularization

– 157 complications occurred• 9.9% statin vs 16.5% non-statin

O’Neil-Callahan et al JACC 2005; 336-42

The Statins for Risk Reduction in Surgery

(StaRRS) study The Statins for Risk Reduction in Surgery

(StaRRS) study

Optimization before the OROptimization before the OR

• Pacing/ICD “Electrical” issues

– Turn off ICD/magnet for VVI pacing

• Valvular “Coagulation” issues

– Reverse, hold or bridge warfarin

– SBE prophylaxis

• Myocardial “CHF” issues

– PA catheter/CHF management

• Coronary “ischemia” issues

– Per AHA/ACC algorithm

• Pacing/ICD “Electrical” issues

– Turn off ICD/magnet for VVI pacing

• Valvular “Coagulation” issues

– Reverse, hold or bridge warfarin

– SBE prophylaxis

• Myocardial “CHF” issues

– PA catheter/CHF management

• Coronary “ischemia” issues

– Per AHA/ACC algorithm

Is patient high CV risk (>5%)?Is patient high CV risk (>5%)?

• Unstable coronary syndromes

– Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing

– Unstable or severe angina CC III or IV

• Decompensated heart failure

• Significant arrhythmia

– High degree AV block

– Symptomatic ventricular arrhythmias in the presence of underlying heart disease

– Supraventricular arrhythmia with uncontrolled ventricular rate

• Severe valvular disease

• Unstable coronary syndromes

– Acute <7 d or recent <30 d MI with evidence of important ischemia by clinical symptoms or noninvasive testing

– Unstable or severe angina CC III or IV

• Decompensated heart failure

• Significant arrhythmia

– High degree AV block

– Symptomatic ventricular arrhythmias in the presence of underlying heart disease

– Supraventricular arrhythmia with uncontrolled ventricular rate

• Severe valvular disease

Special “surgeries”….Special “surgeries”….

Hemodynamic changes with laborHemodynamic changes with labor

• Uterine contractions cause up to 500 cc autotransfusion

• C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR)

• Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change

• HR, volume, CO normalize by 5-6 weeks postpartum

• Uterine contractions cause up to 500 cc autotransfusion

• C-section CO lower than with vaginal delivery (anesthetics affect preload, afterload, inotropy, HR)

• Post-delivery, intravascular volume increases due to caval release, HR decreases, BP does not change

• HR, volume, CO normalize by 5-6 weeks postpartum

Hemodynamic changes with pregnancy

Hemodynamic changes with pregnancy

Classification of Valvular Heart Lesions according to

Maternal, Fetal, & Neonatal Risk*

Classification of Valvular Heart Lesions according to

Maternal, Fetal, & Neonatal Risk*

Areas in further need of researchAreas in further need of research

• Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness

• Cost-effectiveness of the various methods of noninvasive testing

• Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients

• Establishment of optimal guidelines for selected patient subgroups, especially elderly

• Establishment of monitoring guidelines in treatment decisions and outcomes

• Role of prophylactic revascularization in reducing periop and postop MI/death and cost-effectiveness

• Cost-effectiveness of the various methods of noninvasive testing

• Establishment of efficacy and cost-effectiveness of various medical therapies for high-risk patients

• Establishment of optimal guidelines for selected patient subgroups, especially elderly

• Establishment of monitoring guidelines in treatment decisions and outcomes

Aortic StenosisAortic Stenosis

What is cardiology clearance?What is cardiology clearance?

• Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management

• Interdisciplinary management

• Considerations in delivering the pregnant cardiac patient

• Future operational strategies

• Perioperative evaluation of cardiac and surgical risks with paradigm shift from risk stratification to risk management

• Interdisciplinary management

• Considerations in delivering the pregnant cardiac patient

• Future operational strategies