Perioperative Cardiac Risk Assessment & Management for Noncardiac Surgery

STEVEN L. COHN, MD, FACP, SFHM

PROFESSOR EMERITUS

DIRECTOR-MEDICAL CONSULTATION SERVICE JACKSON MEMORIAL HOSPITAL

UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE

Disclosures

• Nothing relevant (except royalties from): • UpToDate (multiple topics)

• McGraw Hill (Perioperative Medicine-Just the Facts)

• Springer (Perioperative Medicine)

Objectives

• Review the American College of Cardiology (ACC) guidelines and algorithm for preoperative risk assessment

• Discuss various risk calculators and cardiac tests

• Evaluate risk reduction strategies (coronary revascularization & medical therapy)

Purpose of Preop Medical Consultation

• Identify risk factors and assess severity & stability

• Provide a clinical risk profile for informed and shared decision-making

• Make recommendations for any management changes, need for further testing, or specialty consultation

• NOT to CLEAR FOR SURGERY!

• Pt is in his/her OPTIMAL MEDICAL CONDITION for surgery.

Definitions of Urgency & Risk Urgency

• Emergency: <6 hours

• Urgent: 6-24 hours

• Time sensitive: can delay 1-6 weeks

• Elective: can delay up to 1 year

• ------------------------------------------------------------------------

Risk (combined surg & pt characteristics)

• Low risk: <1% MACE

• Elevated: >1% MACE

• Use RCRI, MICA, or ACS-SRC to calculate risk

Revised Cardiac Risk Index (RCRI) (Lee et al, Circulation 1999;100:1043-1049)

• 4315 pts, >50 y/o, LOS >2 days

• 6 independent predictors: high-risk surgery, hx ischemic heart disease, CHF, CVA, DM Rx with insulin, preop creat >2.0

# of risk factors % major cardiac complications

0 - 0.4-0.5% (in-hospital)

1 - 0.9-1.3%

2 - 4-7% >3 - 9-11%

Separates low vs high risk Underestimates risk-AAA/vasc surg

LOW

ELEVATED

Cardiac Risk Calculator (MICA) (http://www.surgicalriskcalculator.com/miorcardiacarrest)

• Used NSQIP database - multivariate logistic regression • Developed from 2007 data - 211,410 pts;

• Validated with 2008 data - 257,385 pts

• 5 predictors of MI/card arrest (30-day outcomes)

1) Type of surgery

2) Dependent functional status

3) Abnormal creatinine (>1.5 mg/dl)

4) ASA class

5) Increasing age • Risk calculator had better discriminative or

predictive ability for MI/CA than RCRI or VSGNE-CRI

Gupta, Circulation 2011

Database RCRI VSG Risk calculator

2007 0.747 0.884

2008 0.874

Vasc surg 0.591 0.71 0.746

ACS NSQIP Surgical Risk Calculator (30-day outcomes)

http://riskcalculator.facs.org

Bilimoria et al. J Am Coll Surg 2013

BNP/NT-proBNP

BNP pg/mL

NT-proBNP pg/mL

30-d death/MI

<92 <300 4.9%

>92 >300 21.8%

Can J Cardiol 2017; 33:17-32 Anesthesiology 2015; 123:264-71

Recommended by Canadian Cardiovascular Society Guidelines for patients: • >65 yrs old, 45-64 yrs old with CV disease, RCRI>1

• Elevated BNP/NT-proBNP preop, postop, or both, is associated with increased postop death/MI

• Adding preop BNP to RCRI improves risk prediction.

Clinical Risk Factors

• CAD • Isch Sx/NYHA, prior MI/timing, CABG/PCI, elevated

biomarkers

• HF • Decompensated + depressed LV funct worst;

• Sx > asympt; syst (EF<30-40%) > diastolic

• Valvular disease • Type (stenotic>regurg), severity, symptoms

• Arrhythmias • Hemodynamic effects, underlying structural heart disease

2014 ACC/AHA ALGORITHM

ACC/AHA 2014: Periop Cardiac Assessment for CAD

Step 1

Step 2

Step 3

Step 6

Need for emergency noncardiac surgery?

ACS?

Estimate risk of MACE (combined clin/surg risk –

RCRI or ACS-NSQIP)

Moderate or greater (>4METS) functional capacity

(<4METS) Will further testing impact decision

making or periop care?

Clinical risk stratification &

proceed to surgery

Evaluate & treat according to GDMT

Proceed to surgery

(no further testing)

Proceed to surgery

(no further testing)

No

No

No or unknown

Yes

Yes

Yes

Yes

Pharmacologic stress testing

Fleisher et al. JACC 2014

Low risk (<1%)

Elevated risk

Step 4

Step 5

No Proceed to surgery (GDMT) or

alternative strategies

Yes

Coronary revascularization (as per clinical practice guidelines)

Abnormal

Step 7

Valve dis HF Arrhythmias as per GDMT

Which Test? (if indicated)

• (Exercise if possible) • Aerobic but need to achieve target heart rate

• Pharmacologic (if unable to exercise) • DSE: fewer false positives, incr HR/BP, more physiologic • Dipyridamole/adenosine nuclear: with LBBB; -COPD/bronchospasm • PPV 15-20%; NPV 95-99%

• Cardiac CTA?

• Cardiac catheterization • Abn NIT, Class III/IV unstable angina, high pretest probability

• Resting 2D Echo • Only for valvular disease or heart failure

Assessment of LV Function

Supplemental Preoperative Evaluation

Recommendations COR LOE It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function.

IIa C

It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function.

IIa C

Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if there has been no assessment within a year.

IIb C

Routine preoperative evaluation of LV function is not recommended.

III: No Benefit

B

?

Noninvasive Pharmacological Stress Testing

Before Noncardiac Surgery

Supplemental Preoperative Evaluation

Recommendations COR LOE It is reasonable for patients who are at an elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo noninvasive pharmacological stress testing (DSE or pharmacological stress MPI) IF it will change management.

IIa B

Routine screening with noninvasive stress testing is not useful for patients undergoing low-risk noncardiac surgery.

III: No Benefit

B

Recommendation COR LOE

Routine preoperative coronary angiography is not recommended.

III: No Benefit

C

Preoperative Coronary Angiography

Perioperative Cardiac Risk Reduction Strategies

Prophylactic Coronary Intervention

• CABG and PCI – no evidence of better outcome vs medical therapy alone (need to consider risk of revascularization)

• RCTs: • CARP (McFalls et al. N Engl J Med 2004;351:2795-2804)

• Stable cardiac disease, elective vascular surgery (510 pts)

• Medical Rx +/- revascularization

• No difference in 30-day MI/death or long-term mortality (22 vs 23%)

• CABG better than PCI

• DECREASE V (Poldermans et al. J Am Coll Cardiol 2007 49:1763-1769)

• Abnormal DSE (5 segments or more) – 101 pts • Medical Rx +/- revascularization • No difference in 30-day MI/death or long-term mortality

• If previously revascularized (survived, asymptomatic), potentially beneficial (CASS)

Coronary Revascularization Prior to Noncardiac

Surgery

Perioperative Therapy

Recommendations COR LOE Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs.

I C

It is not recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events.

III: No Benefit

B

Circulation, 2016

Timing of Noncardiac Surgery after PCI

• Risk of stent thrombosis if DAPT is interrupted Timeframe 6 months irrespective of stent type

Lower with 2nd generation DES

Higher if placed in setting of MI

• Consequences of delaying surgery

• Increased periop bleeding risk if DAPT is continued

Individualize

Urgency of surgery

Type of surgery

Patient clinical risk factors

Risk factors for stent thrombosis

• Patient (ACS, low EF, DM, age) • Procedure (LAD/LM, multiple stents/vessels) • Lesion (bifurcation, length, diameter, multiple)

Management of antiplatelet therapy

• Continue both, stop one, stop both

Timing of Elective Noncardiac Surgery in Pts With Previous PCI (Levine et al, Circulation 2016)

Possibly after 1 month as per ESC

Antiplatelet Agents (cont’d)

Recommendations COR LOE In patients undergoing nonemergency/nonurgent noncardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased bleeding.

IIb B

Initiation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting,… III: No

Benefit

B

…unless the risk of ischemic events outweighs the risk of surgical bleeding. C

Perioperative Therapy

Results

25

Outcome

Aspirin (4998)

Placebo (5012)

HR (95% CI)

P

1O outcome: death or MI

351 (7.0)

355 (7.1)

0.99 (0.86-1.15)

0.92

2O outcome: death, MI, or stroke death, MI, revasc, or VTE

362 (7.2)

402 (8.0)

370 (7.4)

407 (8.1)

0.98 (0.85-1.13)

0.99 (0.86-1.14)

0.80

0.90

3O outcomes: MI

309 (6.2)

315 (6.3)

0.98 (0.84-1.15)

0.85

Safety outcome Major bleeding

230 (4.6)

188 (3.8)

1.23 (1.01-1.49)

0.04

Antiplatelet Therapy • Secondary prophylaxis – continue ASA

• Recent stent – continue DAPT

• Any PCI after completing DAPT – continue ASA (POISE-2 subgroup)

• If surgery mandates discontinuation, stop: • ASA – 3-7 days before surgery

• Clopidogrel – 5-7 days before

• Prasugrel – 7 days before

• Ticagrelor – 5 days before

Irreversible

Reversible

BETA-BLOCKERS

CONTROVERSY:

- Poldermans – question about scientific integrity of DECREASE trials

- POISE – question regarding dosing of metoprolol

Perioperative beta-blockers (RCTs) Author # pts Drug Duration Endpoint Outcome*

Mangano (NEJM 1996)

200 (noncard)

Atenolol (titrated)

<7 days 2 yr death 10 vs 21% RR 0.5

Poldermans (NEJM 1999)

DECREASE-I

112 (vasc;abn

DSE)

Bisoprolol (titrated)

30 days 30 d cardiac

death/MI

3.4 vs 34% RR 0.1

Dunkelgrun (Ann Surg 2009)

DECREASE-IV

1066 (noncard)

Bisoprolol (titrated)

30 days 30 d cardiac

death/MI

2.1 vs 6%

HR .34

Juul (DIPOM)

(BMJ 2006)

921DM

(noncard)

Metoprolol (not titrated)

7 days In-hosp CV

events

21 vs 20%

Brady(POBBLE)

(J Vasc Surg 2005)

103 (vasc)

Metoprolol (not titrated)

7 days 30 day CV

events

32 vs 34%

Yang (MaVS)

(Am H J 2006)

497 (vasc)

Metoprolol (not titrated)

5 days 30 day CV

events

10.1 vs 12%

Devereaux

(POISE)

(Lancet, 2008)

8351 (noncard)

Metoprolol

ER;High-dose

30 days 30 day CV

events:

1° MI, CA, CV death;

2° CVA,death,AF,revasc

1° 5.8 vs 6.9%

CVA: 1 vs 0.5%

Total mort: 3.1 vs 2.3%

*all statistically significant

Periop Beta-Blocker – Efficacy/Safety Mixed results depending on studies in meta-analyses.

Outcome Beta-blocker use

Ischemia Beneficial

MI Beneficial

CVA Harmful based primarily on POISE;

neutral/possible harm without POISE

Hypotension

& bradycardia

Harmful

Total mortality Possibly beneficial without POISE;

detrimental with POISE

Perioperative Therapy

Perioperative Beta-Blocker Therapy

Recommendations COR LOE Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically.

I BSR

It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started.

IIa BSR

In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers.

IIb CSR

In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery.

IIb BSR

These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s

systematic review. See the ERC systematic review report, “Perioperative beta blockade in noncardiac surgery: a

systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of

patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.

Perioperative Beta-Blocker Therapy (cont’d)

Recommendations COR LOE In patients with a compelling long-term indication for beta-blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit.

IIb BSR

In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery.

IIb BSR

Beta-blocker therapy should not be started on the day of surgery. III: Harm

BSR

What they don’t tell you:

- Bisoprolol and atenolol may be better than metoprolol

- BB should probably be started at least 1 week before surgery

- BB were beneficial in several large observational studies

Perioperative Therapy

Perioperative Statins: RCTs

Study # pts Surgery Statin Started Outcome

Durrazo 100 vasc Atorvastatin 20 mg

2 wks preop

↓ composite endpoint UA,CVA,MI,CV death (8 vs 26%) at 6 mos

DECREASE III

497 vasc Fluvastatin XL 80 mg

>30 days preop

↓ isch (11 vs 19%) MI/CV death (5 vs 10%) at 30 days

DECREASE IV

1066 Interm risk

Fluvastatin XL 80 mg

>30 days preop

Statistically insignificant ↓ MI/CV death (3 vs 5%) at 30 days

Perioperative Statins: Newer Observational Studies

Study # pts Surgery Outcome

London

(2016)

180,478 pts

Prop cohort

48243 statin

48243 control

NCS All-cause 30d mortality: 0.82 [.75-.89] NNT: 244

Mod-high intensity statin better; discontinuation worse

Any complic: 0.82 [.79-.86]; Card: 0.73; Resp: 0.75

High intensity statin incr renal injury: 1.18 [1.02-1.37]

Berwanger

(2015)

VISION

15,478

Matched

2845 statin

4492 control

NCS Composite: all-cause mort,MINS,CVA@30d: 0.83 [.73-.95]

Mort: .58; CV mort: .42; MINS: .86;

NS for MI, CVA

STATINS

What they don’t tell you:

- Which statin? Longer-acting to prevent withdrawal, more potent statin

- What dose? Moderate to high

- When to start it? Unclear – may have some benefit early on

- Downside? No evidence of harmful effects (rhabdo/LFTs)

Recommendations COR LOE

Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery. I B

Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery. IIa B

Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures.

IIb C

OTHER MEDICAL THERAPY

POSTOP TROPONIN MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY (MINS)

MANAGE

PRACTICE POINTS • RISK ASSESSMENT – ACC algorithm

• Low vs elevated risk (RCRI, MICA, ACS) • If elevated & <4METS, stress testing only if it changes mgmt

• INTERVENTIONS • Prophylactic revascularization is rarely necessary just to get a

patient through surgery

• MED MANAGEMENT • NCS may be OK if >3 but<6 mos after newer DES - try to

continue ASA or DAPT • Beta-blocker data remains controversial • Statins are potentially helpful

• COMMUNICATION/COLLABORATION • Team approach - shared decision-making • Patient, surgeon, anesthesiologist, consultant

REFERENCES • Cohn SL. The cardiac consult for patients undergoing non-

cardiac surgery. Heart. 2016; 102(16):1322-32. PMID: 27325586.

• Cohn SL. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med. 2016; 165(11):ITC81-ITC96. PMID:27919097.

• Patel AY, Eagle KA, Vaishnava P. Cardiac risk of noncardiac surgery. J Am Coll Cardiol. 2015; 66(19):2140-2148. PMID: 26541926.

• Devereaux PJ, Sessler DI. Cardiac Complications and Major Noncardiac Surgery. N Engl J Med. 2016;374(14):1394-5. PMID: 27050228.

• UpToDate (multiple topics)

GUIDELINES • Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-

Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-137. PMID: 25091544.

• Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-115. PMID: 27036918.

• Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C; Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35(35):2383-431. PMID: 25086026.

• Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. PMID: 27865641.

Perioperative Medicine Precourse

Questions?

scohn@med.miami.edu