Ross S. Pacini, M.D. - mcpipa.org S. Pacini, M.D. A Classic Example ... Pt is an active,...
Transcript of Ross S. Pacini, M.D. - mcpipa.org S. Pacini, M.D. A Classic Example ... Pt is an active,...
A Classic Example
71 y/o male with recent onset
hematochezia
Colonoscopy done showing a large, friable
upper rectal mass
Biopsy shows a moderately differentiated
invasive adenocarcinoma
Suspicious lymph node also noted
Possible liver mets (too small to be sure)
Invasion of the muscularis propria
A Classic Example
Cardiology consulted for pre-op
“clearance”
Pt is an active, asymptomatic retired
engineer
Jogs 2-3 times/week around a lake (0.5-1
mile)
Has “diet-controlled” HTN
No h/o CP or SOB
A Classic Example
A stress echo is ordered which shows evidence of ischemia in the distribution of the LAD (anterior wall defect)
Due to abnormal stress, he gets a cardiac cath
40% distal LM
95% prox LAD, 100% mLAD
75% OM 2 (LCx distribution)
95% prox RCA, 100% mRCA
EF=55%; no MR or AS
A Classic Example
Undergoes CABG x 5
Goes to cardiac rehab
Undergoes Surgery for Colon Cancer
~60 days after CABG
Subsequently undergoes chemotherapy
and does OK
….but was it all necessary?
History of Pre-Op Evalaution
Cardiac complications from surgery are
fairly common (between 2-7%
depending on the population studied)
Modern medicine and surgical
techniques have greatly reduced risk
compared to 20-30 years ago
Goal of evaluation is to help minimize
these risks; ultimate question is just how
much can these risks be modified?
History of Pre-Op Evaluation
Traditionally, it was felt that many
patients needed a full cardiac evaluation
before elective surgery
In the 90’s ACC/AHA started publishing
guidelines on how to perform risk
stratification
Guidelines were updated in 2002
Complex algorithms
History of Pre-Op Evaluation
Up through the 2002 guidelines, there
was no good published trial to actually
evaluate outcomes
Older data had suggested a clinical
benefit to pre-op revascularization, but
nothing had been done in the modern
era
History of Pre-Op Evaluation
In 2007, we got greatly simplified guidelines based on very good trial data (2 very important trials in particular: CARP and DECREASE V).
Radically changed our approach to evaluation Acceptance has been slow for a variety of
reasons.
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it” –Upton Sinclair [cynical view]
CARP Trial
During my externship at Emory, I was asked to do a pre-op evaluation on a cardiac patient
Desperately wanting to impress and suck up, I asked my attending, “Even if we prove he has significant CAD, can we lower his risk of complications by ‘fixing him’?”
He assigned me to read a trial (of course) and present it the next day
CARP Trial*
Randomized trial of 510 patients at VA’s.
Pt’s undergoing AAA repair or major LE
(fem-pop, etc) surgery [these are classically
the highest risk surgeries]
Pt’s had to have at least 70% stenosis of at
least one major coronary artery and be
suitable for revascularization (PCI or CABG)
Exclusion criteria: >49% LM disease,
LVEF<20%, or severe AS
*New England J of Med, 2004: 351 (2795-2804)
CARP Trial
Patients were then randomized to either
have revascularization (PCI or CABG) or
go straight to their surgery
Primary endpoint was mortality
Secondary endpoints were MI, CVA,
limb loss, and need for dialysis
CARP Trial: Results
Groups were well matched
Most patients underwent assigned treatments
No difference in death (3.1% vs. 3.4%), MI, CVA, Dialysis, days in ICU, or days in hospital between revascularization and no-revascularization
CARP Trial: Results
There were 2 important differences in the group
In the revasc group, 10 patients died before they could have their vascular surgery vs. only 1 in the non-revasc group
Those in the revasc group waited an average of 54 days before getting their surgery vs. 18 days in the non-revasc group
Definitive trial that suggested pre-op revasc didn’t make a difference
CARP or CRAP
Critics have suggested that
study was was underpowered
(screened 5,859 pt’s to get
510 enrolled)
Most excluded for not having
severe enough CAD or needed
emergent surgery
More importantly, critics said,
“What about severe CAD (3v
CAD, LM disease)?”
DECREASE V*
Studied patients undergoing open AAA repair or infrainguinal arterial reconstruction
Enrolled patients had to have a large area of ischemia on stress testing (3/6 walls on nuc or 5/17 walls on stress echo)
Only patients with 3 or more risk factors actually had a stress test (those with 0-2 were excluded)
*J Amer Coll Cardiol 2007: 49 (1763-1769)
DECREASE V
Pt’s were then randomly assigned to
undergo cath and revascularization or
proceed straight to surgery
All patients got perioperative b-blockers
Primary outcome was death and MI that
occurred between randomization and 30
days post-op
DECREASE V
1,880 patients were screened. 1,779
were excluded for being too low risk
(1,450) or not having enough ischemia
(329). Eventually, 101 patients enrolled
Goal was to get the highest risk patients
going for the highest risk surgery
43% of the patients had an EF <35% (none
had severe AS)
DECREASE V
Of those enrolled for cath/revasc
24% had 2v CAD, 67% had 3v CAD, and 8% had LM disease
65% got PCI; 35% got CABG
CABG pt’s waited an average of 29 days for their vascular surgery; PCI patients waited 31 days
○ 2 CABG pt’s died while waiting for AAA surgery
○ 1 PCI pt had an MI before he could have vascular surgery
DECREASE V
Ultimate results
were no difference
between the two
groups
43% in the revasc
group vs. 33% in the
“straight to surgery”
group reached the
primary endpoint
(death or MI).
DECREASE V
Conclusion was that
pre-op revasc didn’t
help, even in high
risk patients
Criticized for small
sample size and
technically being
only a pilot study
Pre-Op Eval Guidelines*
Based on these trials and other
available data, ACC/AHA guidelines
were updated in 2007 and made much
simpler
Eval can be done in 5 easy steps
Vast majority of patients can proceed to
surgery
* J Amer Coll Cardiol 2007: 50 (e159-241)
Step 2
Active cardiac conditions:
Unstable coronary syndromes
Decompensated CHF
Significant arrhythmias
Severe valvular disease (usually stenosis)
In short…most of these patients should be seeing cardiology anyway and
most are probably already hospitalized.
Step 3
Low risk surgeries:
Endoscopic Procedures
Superficial Procedures
Cataract Surgery
Breast Surgery
Ambulatory Surgery
Step 4
Examples of 4 MET’s or more Climbing a flight of stairs
Walking up a hill
Walking on level ground at 4 MPH
Scrubbing floors/move furniture
Housework like dishes, dusting, vacuuming
Golfing without a cart, bowling, dancing, doubles tennis
Step 5
This is the first and only step that
requires any real thinking
If functional capacity of <4 MET’s or
unknown (wheelchair, etc), then 2
important criteria must be established
Is it intermediate or high risk surgery?
How many risk factors does the patient
have?
Step 5: Type of surgery
High risk surgery includes:
Aortic surgery
Peripheral Vascular surgery
Intermediate risk surgery includes:
Carotid Endarterectoy
Percutaneous AAA repair
Head and Neck Surgery
Orthopedic Surgery
Intraperitoneal/Intrathoracic Surgery
Any surgery not low or high risk
Step 5: Risk Factors
Revised Cardiac Risk Index
History of ischemic heart disease
History of CHF
History of CVA
DM treated with insulin
Renal Insufficiency (Cr >1.9)
Part 5: Step 2
In Short, if you have a patient with a functional capacity of <4MET’s
AND they have 3 or more risk factors AND they are going for high risk
vascular surgery, you might consider doing a stress test. As we’ve
seen from previous data, though, this probably will not be helpful.
Super short cut (for the gutsy)
Is the patient having an active acute
coronary syndrome, decompensated
CHF, severe valve disease, or
uncontrolled arrhythmia?
If the answer is no, go to surgery with
optimal medical therapy
Peri-Operative B-blockade
This has been an interesting evolution
Originally, quite controversial
Then, became fairly mainstream for almost
all patients
In 2008, however, we finally got a very large
trial on the matter
POISE
Inclusion criteria
>44 years old
Had a h/o CAD, PVD, CVA, h/o hospitalized
for CHF; or undergoing vascular surgery; or
3/7 risk factors (intrathoracic/intraperitoneal
surgery, h/o CHF, h/o TIA, DM, CKD, age
>70, or undergoing emergent surgery)
POISE
Exclusion criteria
HR <50 bmp, high grade (2nd or 3rd degree)
AV block, asthma, already on b-blocker,
CABG within 5 years and no evidence of
recent ischemia, low-risk surgery, on
verapamil, or allergy to b-blocker
POISE
Pt’s were randomized to receive a b-
blocker or placebo
B-blocker was metoprolol succinate (Toprol
XL®).
Pt’s got 100 mg 2-4 hours before surgery.
They then got another 100 mg within 6
hours of surgery. Pt’s then continued with
200 mg daily for a total of 30 days starting
12 hours after the first post-operative dose
Side note: That’s A LOT of b-blockade
POISE
Primary outcome was a composite of
death, MI, and non-fatal cardiac arrest
30 days after randomization
A total of 8,351 patients were
randomized
POISE
For the primary endpoint, 5.8% in
metoprolol group vs. 6.9% in placebo
group had composite death, MI, cardiac
arrest (HR 0.84; p=0.0399)
But, there was more to the story…
POISE
There were more deaths (3.1% vs. 2.3% p=0.0317) and more strokes (1.0% vs. 0.5% p=0.0123) in the metoprolol group
The primary outcome was driven solely by a lower incidence of MI in the metoprolol group (3.6% vs. 5.1% p=0.0008)
There was also more clinically significant hypotension and bradycardia with metoprolol (Duh!).
POISE
Conclusion was suddenly that b-
blockers are bad and are killing people,
but was that really the correct
conclusion?
Massive doses of b-blockers in b-
blocker naïve patients.
No titration at all
ACC/AHA Guidelines*
Because of this trial, in 2009, we got an
update to our previous guidelines
Authors took a more critical look at b-
blockade in the peri-operative setting
and made some very reasonable
recommendations based on POISE as
well as previous literature
*J Amer Coll Cardiol 2009: 54 (2102-2128)
Key Points to B-blockers
If pt is already on a b-blocker for a good
reason, continue it (Class I rec)
Reasonable (IIa) to give b-blockers to
pt’s with CAD undergoing high or
intermediate risk surgery
Reasonable to give b-blockers to pt’s
undergoing high or intermediate risk
surgery who have more than 1 risk
factor (CAD, CHF, CKD, CVA, DM)
Key Points to B-blockers
In pt’s with only 1 risk factor that is not
CAD undergoing intermediate risk
surgery, the utility of b-blockers is
questionable (IIb)
In pt’s with no risk factors undergoing
high risk surgery, the utility of b-blockers
is questionable
Key Points to B-blockers
Titration is critical
Start days-weeks before surgery and titrate
to a goal HR of 50-60 bmp
Routine use of b-blockers, especially
when not titrated, may be harmful
Statin Therapy
My take: It can’t hurt
Evidence is limited, but most points to
benefit
Guidelines suggest the following:
Continue pt’s who are already on a statin
Probably helpful in all vascular surgery pt’s
Can be considered for pt’s with at least 1
risk factor undergoing intermediate risk
surgery
A brief word on anti-platelets
Please never tell a cardiac patient to stop ASA+Plavix without talking to the cardiologist
Very dangerous; seen it more times than I care to admit
Pt’s with BMS need DAPT for at least 1 month; those with DES for 1 year
Most cardiac pt’s should be continued on ASA if possible
My cardiac surgeons do it…so can you
Summary
Virtually no ambulatory patients require
stress testing prior to non-cardiac
surgery
If folks are acutely ill with cardiac
issues, by all means, fix that before
elective surgery
Peri-operative b-blockers are useful in
carefully selected patients