Pre-Operative Cardiopulmonary Assessment: 2013 - University of ...

Pre-Operative
Cardiopulmonary Assessment:
2013
Russell Vinik, M.D.
Associate Professor of Medicine
University of Utah School of Medicine

Case
!! 71 year old man presents for pre-operative
evaluation for Hip Arthroplasty.
!! He is severely limited by his symptoms and wants to
get the hip fixed ASAP
!! PMH: DM, Htn, CKD (creatinine 1.5)
!! No previous MI
!! Meds: glargine, metformin, lisinopril
!! Never had a stress test.
!! Echo 2 years ago was “normal”
!! Ambulation is limited by pain in his hip.

Questions
1.! What is this patients risk of having a
peri-operative cardiac event?
!! Will additional tests help to predict his risk?
2.! Should we order a stress test?
!! If positive, should we revascularize?
3.! Other than revascularization, what other
strategies might reduce his risk?
!! Beta-blockers, Statins

Clinical Risk Stratification

Risk Factors: Revised Cardiac Risk
Index (Lee Index)
!! Developed in 4,315 patients age 50 or over
!! Subsequently validated in cohort of 108, 593 patients
!! 6 Risk factors
!! High-risk Surgery*
!! Ischemic Heart Disease
!! History of CHF
!! History of Cerebrovascular disease
!! Insulin therapy for Diabetes
!! Preoperative Creatinine >2.0 mg/dl
!! 0 Factor Event rate= .4%
!! 1 Factors = .9%
!! 2 Factors = 7%
!! 3 or more = 11%
*High risk=intraperitoneal, intrathoracic, suprainguinal vascular
Circulation. 1999;100:1043-1049 Am J Med2005;118:1134-41

ACC/AHA Perioperative Guidelines
Active Cardiac Conditions

Clinical risk factors: CAD, CHF, DM, CVA/TIA, renal insufficiency
ACC/AHA
Algorithm
Circulation 2007;116:e418-e499

- Used fictitious data
- Submitted knowingly unreliable data
- Inconsistency between source documents and case report forms
- Source documentation missing
- Adverse Events Committee did not exist
JACC- “ We have elected not to retract these manuscripts. However, given
the uncertainty regarding the accuracy of the data, readers should be
cautioned in the application of the findings of these manuscripts to
clinical practice.”
J Am Coll Cardiol. 2012;60(25):2696-2697. Forbes Pharma & Healthcare 11/17/2011

Poldermans Articles
!! Decrease- Bisoprolol reduced cardiac death/MI 3.4% vs. 34%
NEJM 1999
!! Decrease II- No benefit for cardiac testing in intermediate risk
patients undergoing vascular surgery if beta blockers are given JACC
06
!! Decrease III – 497 patients- Fluvastatin reduced cardiac death/MI
by 50% in vascular surgery patients NEJM 09
!! Decrease IV- 1066 patient 2x2 study- bisoprolol assoc with 30 day
reduction in cardiac death MI with trend for reduction with
fluvastatin Ann Surg 09
!! Decrease V- No benefit for prophylactic revascularization in
patients with extensive ischemia if given B blockers JACC 07
!! ESC Guidelines- Beta blockers and statins in high risk surgery
(Class I) EurheartJ 09

Lets Start Over
Can we better predict our
patients risk of cardiac events

Pre-Op BNP helps to predict
Cardiac Events in Vascular Surgery
BNP Major Cardiac Event (%) OR
372 36.7% 45
•!Patients were re-classified using the Revised Cardiac Risk index
•!NP < 116 moved down 1 risk group
•!NP >116 moved up 1 risk group
RCRI Risk MACE Total
Low Risk (0) 5.9% 320
Int Risk (1-2) 9.5% 476
High Risk (3+) 20% 54
Re-Classified MACE Total
Low 3.7% 596
Int 15.1% 93
High 24% 161
J Am Coll Cardiol 2011;58:522-9

Non Invasive Testing:
Dypyridamole-thallium
J Am Coll Cardiol 1996;27:787-98

Non Invasive Testing: Stress Echo
!! Meta analysis of 68 studies with 10,049
patients showed better negative predictive
ability for stress echo compared to thallium
imaging
J Am Coll Cardiol 1996;27:787-9 Anesth Analg 2006;102:8-6

Management Strategies for High
Risk Patients

Pre-Op Revascularization
!! Reviewed 1600 patients in CASS registry who
underwent non-cardiac operations
!! Group 1 – no angiographic evidence of CAD
!! Group 2 – CAD but prior CABG
!! Group 3 – significant angiographic CAD (70%
stenosis) but no prior bypass surgery.
!! Operative mortality rates:
!! Group 1 -No CAD= 0.5%
!! Group 2- Prior CABG= 0.9%
!! Group 3 = CAD without CABG=2.4%
Ann Thorac Surg 1986; 41:42-50

CARP Trial
!! Prospective Randomized trial
!! Indication was AAA or arterial occlusive
disease of the legs
!! 510 patients randomized to revascularization
vs no-revascularization
!! All patients had at least 70% stenosis on cath
!! Excluded Left Main dz, Severe AS, EF

CARP Trial Results
!! Median Time from Randomization to surgery - 54 days in
revascularization group vs. 18 days no revascularization
!! Post-Op MI occurred in 12% in revascularization group
vs. 14% (p=.37)
!! Mortality at 2.7 years was 23% in the revascularization
group vs. 22% (p=.92)
!! Subsequent analysis:
!! Nonfatal MI occurred in 16.8% of patients who had PCI vs.
6.6% (p=.024) in CABG patients
!! Differences in mortality remained insignificant 3.8% vs. 2.2%
(p=.497)
NEJM 2004; 351:2794-804 Ann Thorac Surg. 2006;82:795-800

Pre-Op Revascularization: PCI
!! 40 patients undergoing non-cardiac surgery within 6-weeks of stent placement
!! 20% mortality, 18% risk non-fatal MI, 28% major bleeding risk
!! 216 patients who underwent surgery within 3 months of cardiac intervention
!! 13 of 94 (14%) of patients who had been treated with stent died
!! 13 of 122 (11%) of patients who had PTCA without stent died
!! 899 patients who underwent non-cardiac procedure after bare metal stent- rate
of major cardiac events:
!! 10.5% if procedure

Anti-Platelet Therapy
Fleisher, L. A. et al. Circulation 2007;116:e418-e499

Beta Blockers
The controversy got even bigger

Perioperative !-blockers: Atenolol
!! Randomized 200 patients undergoing non-cardiac
surgery to Atenolol vs. Placebo
!! Patients had either CAD or 2 or more risk factors*
!! Absolute mortality:
!! 0% vs 8%, (p < 0.001) at 6 months
!! 10% vs. 21%, (p = 0.019) at 2 years
!! Excluded in-hospital deaths
!! Mortality reduction became insignificant after inclusion of inhospital
deaths
!! 8% of control group was previously on beta blockers
and these were stopped possibly precipitating
withdrawal during the peri-operative period
*Risk factors: Age>65, Diabetes, Htn,
Smoking, Total Cholesterol >240mg/dl NEJM 1996;335:17 17-20.

Placebo-Controlled Metoprolol
Trials
!! DIPOM- 921 Diabetics undergoing major surgery
!! No benefit for metoprolol after 18 months
!! initiated within 24 hours before surgery
!! MAVS- 496 Patients undergoing vascular surgery
!! No difference in 30 day events
!! initiated within 2 hours of surgery
!! POBBLE- 103 patients with previous MI having
vascular surgery
!! No difference in 30 day events
!! initiated the day before surgery
BMJ. 2006 Jun 24;332(7556):1482
Am Heart J 2006 November;152:983-90, J Vasc Surg 2005;41:602-9

POISE Trial
!! Double Blind- Randomized trial of 8351 patients
!! Included:
!! High risk group: Over 80% of patients had either a history of CAD,
Peripheral Vascular Disease, or Stroke
!! Excluded patients already on a beta blocker
!! Procedure: patients given either extended release
metoprolol or placebo
!! 100mg pre-op
!! 100mg 6 hour post op
!! 200mg 12 hrs later and then 200mg daily for 30 days
!! Patients unable to take po were given metoprolol 15mg IV every 6 hours
!! Drug held if BP below 100mg Hg or HR

POISE Results
Outcome Metoprolol
n=4174
Placebo
n=4177
Nonfatal MI 152 (3.6) 215 (5.1) .04
A-fib 91 (2.2) 120 (2.9) .04
Significant Hypotension 626 (15.0) 404 (9.7)

Author
(Year)
Statins in the Peri-operative Setting:
Meta Analysis Results
Population Included Findings
Tabata (2009) Cardiovascular Surgery Mortality Benefit:
OR 0.67 (0.54-0.83)
Winchester
(2010)
Non cardiac surgery &
PCI
MI Reduction:
RR 0.57 (0.46-0.7)
All Cause Mortality:
RR 0.66 (0.37-1.17)
Tabata M et al. J Thorac Cardiovasc Surg 2008; 136:1510 & Winchester DE. J Am Coll Cardiol 2010; 56:000

Statins: A word of Caution
!! Several studies of patients with Acute Coronary Syndromes have
shown:
!! 2-3 fold increase in cardiac events in patients in whom statin was
acutely withdrawn during the hospitalization
!! These patients had a higher cardiac event rate than those who were
never started on a statin
!! There are no intravenous formulations of statins
!! What happens when the patient is NPO after surgery?
!! Retrospective cohort of 298 statin users undergoing major vascular
surgery:
!! Post-Op statin discontinuation associated with:
!! Hazard ratio 7.5 for cardiovascular death or MI
!! 50-75% fewer events in patients taking extended release fluvastatin
compared to other statins
!! 200 consecutive patients after CABG- Post-op a-fib developed:
!! 18% of patients who were re-initiated on statin within 48 hours after
surgery vs. 28% of patients who were not.
Arch Intern Med 2004;164:2162-8 Circ 2002;105:1446-52 Am J Cardiol 2007;100:316-20
Am J Cardiol 2011;108:220-222

Conclusions
! Risk stratification has good negative predictive
value
!! PCI as a bridge to surgery likely does more
harm than good
!! Consider stress testing if you would consider
CABG prior to elective surgery
!! Statins- likely good but keep them going
!! Beta blockers
!! Don’t stop them if the patient is already taking
!! Should you start them?????
!! If you do, start gently and give time to titrate.

Thank You.