Risk reduction strategies for cardiac patients Abeer elnakera Lecturer of anesthesia Zagazig university` 2009
objectives <ul><li>preoperative risk reduction strategies in cardiac pt undergoing non cardiac surgery: </li></ul><ul><ul>...
1-Preoperative Coronary Revascularization <ul><li>The role of preoperative coronary revascularization to reduce the risk o...
Why this controversy <ul><li>In part this is due to the finding that the  path physiology of a perioperative MI is differe...
Why this controversy <ul><li>In a small angiographic study, most perioperative </li></ul><ul><li>MIs were found to be due ...
Pathogenesis of AMI
 
Added to the recommendations <ul><li>Although </li></ul><ul><li>prophylactic revascularization in patients with stable CHD...
continued <ul><li>Patients with  coexisting severe aortic stenosis and CHD  should be considered individually. Many of the...
Time after CABG <ul><li>No recommendation is made regarding the timing of noncardiac surgery after CABG, but the guideline...
PCI <ul><li>For patients who undergo preoperative PCI, the choice of  bare metal stents, drug-eluting stents, or balloon a...
 
Prior PCI <ul><li>The perioperative management of patients who have undergone a prior PCI is dealt with separately and als...
 
2-Pharmacological therapies <ul><li>1- Perioperative B-Blocker Therapy   </li></ul><ul><li>the guidelines authors opine th...
Continued   <ul><li>the guidelines suggest that longer-acting  </li></ul><ul><li>B-blockers may be more efficacious than s...
BB  <ul><li>A  large cohort study by Lindenauer et  al,(2005) suggested that  Β -blocker benefit is confined to the highes...
Perioperative  B-blocker therapy 2007 recommendations   <ul><li>Caution  is advised in prescribing B -blockers de novo to ...
 
So   <ul><li>The prudent  physician should most likely prescribe B-blockers perioperatively only to patients described in ...
 
2- Statin Therapy <ul><li>In addition to their lipid-lowering activity, statins improve endothelial function, stabilize at...
Continued  <ul><li>the guidelines provide </li></ul><ul><li>only 1  class I  recommendation to continue statins  </li></ul...
` <ul><li>Despite the generally convincing evidence that alpha-2 agonists reduce perioperative cardiac events and 1 recent...
4-Aspirin   <ul><li>. The lack of specific reference to aspirin therapy in settings rather than the context of preoperativ...
5-Calcium channel blockers <ul><li>The role of perioperative calcium channel blocker therapy is addressed briefly, and in ...
6- prophylactic intraoperative nitroglycerine   <ul><li>A  class IIb  recommendation </li></ul><ul><li>(usefulness unclear...
Anesthetic Considerations and Intraoperative Management   <ul><li>Choice of Anesthetic Technique and Agent: </li></ul><ul>...
<ul><li>Use of Transesophageal Echocardiography   </li></ul><ul><li>Class IIa   </li></ul><ul><li>The emergency use of int...
<ul><li>Maintenance of Body Temperature   </li></ul><ul><li>Class I   </li></ul><ul><ul><li>1 . Maintenance of body temper...
<ul><li>Perioperative Control of Blood Glucose Concentration   </li></ul><ul><li>Class IIa   </li></ul><ul><ul><li>1.  It ...
Perioperative Surveillance   <ul><li>Intraoperative and Postoperative Use of Pulmonary Artery Catheters (PACs)  </li></ul>...
<ul><li>Intraoperative and Postoperative Use of ST-Segment Monitoring   </li></ul><ul><li>Class IIa   </li></ul><ul><li>1....
<ul><li>Surveillance for Perioperative MI   </li></ul><ul><li>Class I   </li></ul><ul><li>Postoperative troponin  measurem...
?
Summery  <ul><li>the guidelines can serve as a useful framework for clinicians engaged in preoperative risk assessment and...
 
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Risk reduction strategies for cardiac patients

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Risk reduction strategies for cardiac patients

  1. 1. Risk reduction strategies for cardiac patients Abeer elnakera Lecturer of anesthesia Zagazig university` 2009
  2. 2. objectives <ul><li>preoperative risk reduction strategies in cardiac pt undergoing non cardiac surgery: </li></ul><ul><ul><li>Risk stratification </li></ul></ul><ul><ul><li>Preoperative coronary revascularization </li></ul></ul><ul><ul><li>perioperative pharmacological therapies </li></ul></ul><ul><ul><li>Anesthetic Considerations and Intraoperative Management </li></ul></ul><ul><ul><li>Perioperative Surveillance </li></ul></ul>
  3. 3. 1-Preoperative Coronary Revascularization <ul><li>The role of preoperative coronary revascularization to reduce the risk of perioperative cardiac morbidity and mortality has been controversial since the advent of revascularization surgery </li></ul>
  4. 4. Why this controversy <ul><li>In part this is due to the finding that the path physiology of a perioperative MI is different than that of a nonoperative MI . Pathological studies have shown that the majority of non-operative MIs are due to plaque rupture and coronary thrombosis, whereas this mechanism is responsible for only approximately half of the perioperative MIs, with the remaining half resulting from a prolonged imbalance between </li></ul><ul><li>myocardial oxygen supply and demand generated by the stresses of surgery in the setting of obstructive coronary artery disease </li></ul>
  5. 5. Why this controversy <ul><li>In a small angiographic study, most perioperative </li></ul><ul><li>MIs were found to be due to inadequate collateralization </li></ul><ul><li>of previously totally occluded coronaries, with </li></ul><ul><li>a smaller </li></ul><ul><li>number occurring without significant coronary obstruction. </li></ul><ul><li>These findings suggest that preoperative revascularization of severe coronary stenoses may not prevent perioperative </li></ul><ul><li>ischemic event </li></ul>
  6. 6. Pathogenesis of AMI
  7. 8. Added to the recommendations <ul><li>Although </li></ul><ul><li>prophylactic revascularization in patients with stable CHD </li></ul><ul><li>simply to lower the risk of surgery is explicitly discouraged, </li></ul><ul><li>there are specific clinical and anatomic patient subsets that </li></ul><ul><li>may derive long-term survival benefit from revascularization irrespective of their preoperative status. These are the patients listed under class I recommendations. </li></ul><ul><li>. </li></ul>
  8. 9. continued <ul><li>Patients with coexisting severe aortic stenosis and CHD should be considered individually. Many of these patients will benefit from preoperative valve surgery and coronary revascularization </li></ul><ul><li>selected high-risk patients with extensive myocardial ischemia on preoperative stress testing who are to undergo high-risk surgery may benefit from revascularization even if stable </li></ul>
  9. 10. Time after CABG <ul><li>No recommendation is made regarding the timing of noncardiac surgery after CABG, but the guidelines authors refer to the DECREASE-V study in which vascular surgery took place at a median of 29 days after CABG </li></ul>
  10. 11. PCI <ul><li>For patients who undergo preoperative PCI, the choice of bare metal stents, drug-eluting stents, or balloon angioplasty depends on the timing and the risk of bleeding of the planned noncardiac surgery. The risks of perioperative antiplatelet therapy interruption are integrated into a simple decision-making algorithm that includes specific recommendations regarding the desirable interval between PCI and noncardiac surgery. The guidelines caution against premature discontinuation of antiplatelet therapy. </li></ul>
  11. 13. Prior PCI <ul><li>The perioperative management of patients who have undergone a prior PCI is dealt with separately and also in accordance with the 2005 ACC/AHA/Society for Cardiovascular Angiography and Interventions PCI guidelines. The proposed management of such </li></ul><ul><li>patients is summarized in an algorithm </li></ul><ul><li>that lists specific time intervals between PCI and </li></ul><ul><li>noncardiac surgery and antiplatelet therapy recommended depending on the type of prior intervention. </li></ul>
  12. 15. 2-Pharmacological therapies <ul><li>1- Perioperative B-Blocker Therapy </li></ul><ul><li>the guidelines authors opine that the weight </li></ul><ul><li>of evidence favors the use of perioperative B-blockers in reducing perioperative ischemia and possibly MI and death, especially in high-risk patients undergoing vascular and other high-risk surgery </li></ul>
  13. 16. Continued <ul><li>the guidelines suggest that longer-acting </li></ul><ul><li>B-blockers may be more efficacious than shorter-acting ones and that it is important to control the resting heart rate between 60 and 65 bpm, initiate B -blockers days to weeks before elective surgery, and continue -blocker administration during the </li></ul><ul><li>perioperative periods. </li></ul>
  14. 17. BB <ul><li>A large cohort study by Lindenauer et al,(2005) suggested that Β -blocker benefit is confined to the highest-risk patients and that low-risk patients may actually be harmed by perioperative Β -blockade, </li></ul>
  15. 18. Perioperative B-blocker therapy 2007 recommendations <ul><li>Caution is advised in prescribing B -blockers de novo to patients with decompensated heart failure, nonischemic cardiomyopathy, or severe valvular disease who are scheduled for noncardiac surgery. </li></ul><ul><li>Given the conflicting trial results and the uncertainty regarding potential harm from the perioperative use of B -blockers in low-risk patients and the preliminary results of the PeriOperative ISchemic Evaluation (POISE) trial </li></ul>
  16. 20. So <ul><li>The prudent physician should most likely prescribe B-blockers perioperatively only to patients described in the class I and IIa recommendations </li></ul>
  17. 22. 2- Statin Therapy <ul><li>In addition to their lipid-lowering activity, statins improve endothelial function, stabilize atherosclerotic plaques, and </li></ul><ul><li>reduce vascular inflammation and by these mechanisms may reduce perioperative events. </li></ul>
  18. 23. Continued <ul><li>the guidelines provide </li></ul><ul><li>only 1 class I recommendation to continue statins </li></ul><ul><ul><li>perioperatively in those already on this therapy. </li></ul></ul><ul><li>A class IIa recommendation states that it is reasonable to prescribe a statin to patients undergoing vascular surgery whether or not they have other risk factors, presumably because such patients have atherosclerotic vascular disease, and </li></ul><ul><li>1 class IIb recommendation suggests that statin therapy may be considered for patients with 1 or more clinical risk factors undergoing </li></ul><ul><ul><li>intermediate risk procedures. </li></ul></ul>
  19. 24. ` <ul><li>Despite the generally convincing evidence that alpha-2 agonists reduce perioperative cardiac events and 1 recent study that showed that they reduce long-term cardiovascular mortality, </li></ul><ul><li>the guidelines include a single class IIb recommendation that alpha -2 agonists may be considered for perioperative control of hypertension in patients with </li></ul><ul><ul><li>CHD or at least 1 clinical risk factor . </li></ul></ul>
  20. 25. 4-Aspirin <ul><li>. The lack of specific reference to aspirin therapy in settings rather than the context of preoperative revascularization and the lack of recommendations </li></ul><ul><li>regarding its uninterrupted administration, </li></ul><ul><li>if possible, in specific patient groups are unfortunate omissions in 2007 guidelines </li></ul>
  21. 26. 5-Calcium channel blockers <ul><li>The role of perioperative calcium channel blocker therapy is addressed briefly, and in the absence of convincing data, no </li></ul><ul><ul><li>specific recommendations are made by AHA 2007 GUIDELINES </li></ul></ul><ul><li>A meta-analysis assessing the effect of calcium channel blockers identified 11 trials including 1,007 patients. All studies were published prior to 2002. The analysis found that calcium channel blockers reduced the incidence of ischemia; postoperative supraventricular tachycardia (SVT); MI and major morbid events. The effects were almost entirely due to the experience with diltiazem. The dihydropyridine class of calcium channel blockers was found to increase ischemia, and the incidence of postoperative SVT.( Wijeysundera and Beattie .2003) </li></ul>
  22. 27. 6- prophylactic intraoperative nitroglycerine <ul><li>A class IIb recommendation </li></ul><ul><li>(usefulness unclear) for intraoperative nitroglycerin to prevent myocardial ischemia comes with a major caveat </li></ul><ul><li>regarding the possibility that nitroglycerin may aggravate the vasodilator actions of anesthetic agents. </li></ul>
  23. 28. Anesthetic Considerations and Intraoperative Management <ul><li>Choice of Anesthetic Technique and Agent: </li></ul><ul><li>Class IIa (AHA 2007) </li></ul><ul><ul><li>It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hem dynamically stable patients at risk for myocardial ischemia. ( Level of Evidence: B) </li></ul></ul><ul><li>The ACCAHA guidelines recommendations is the choice of anesthesia is best left to the discretion of anesthesia care team which will consider the need for postoperative mechanical ventilation, cardiovascular effects , pulmonary and neuromuscular comorbidities (Yao and Artusio 2008) </li></ul>
  24. 29. <ul><li>Use of Transesophageal Echocardiography </li></ul><ul><li>Class IIa </li></ul><ul><li>The emergency use of intraoperative or perioperative transesophageal echocardiography is reasonable to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality. ( Level of Evidence: C ) </li></ul><ul><li>A category I indication is when TEE is expected to be useful in </li></ul><ul><li>improving the outcome. In 31% of patients who had cardiopulmonary resuscitation, major therapeutic decisions for pulmonary embolism,myocardial ischemia, and other etiology were based on TEE findings. (ASA 1996) </li></ul>
  25. 30. <ul><li>Maintenance of Body Temperature </li></ul><ul><li>Class I </li></ul><ul><ul><li>1 . Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (e.g., during high aortic cross-clamping). ( Level of Evidence: B ) </li></ul></ul><ul><li>Maintenance of Body Temperature </li></ul><ul><li>Class I </li></ul><ul><ul><li>1 . Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (e.g., during high aortic cross-clamping). ( Level of Evidence: B ) </li></ul></ul>
  26. 31. <ul><li>Perioperative Control of Blood Glucose Concentration </li></ul><ul><li>Class IIa </li></ul><ul><ul><li>1. It is reasonable that blood glucose concentration be controlled* during the perioperative period in patients with diabetes mellitus or acute hyperglycemia who are at high risk for myocardial ischemia or who are undergoing vascular and major noncardiac surgical procedures with planned intensive care unit admission. ( Level of Evidence: B ) </li></ul></ul><ul><li>*Blood glucose levels less than 150 milligrams/deciliter (mg/dL) appear to be beneficial. </li></ul><ul><li>Class IIb </li></ul><ul><ul><li>1. The usefulness of strict control of blood glucose concentration* during the perioperative period is uncertain in patients with diabetes mellitus or acute hyperglycemia who are undergoing noncardiac surgical procedures without planned intensive care unit admission. ( Level of Evidence: C ) </li></ul></ul>
  27. 32. Perioperative Surveillance <ul><li>Intraoperative and Postoperative Use of Pulmonary Artery Catheters (PACs) </li></ul><ul><ul><li>Class IIb </li></ul></ul><ul><li>1. Use of a PAC may be reasonable in patients at risk for major hemodynamic disturbances that are easily detected by a PAC; however, the decision must be based on 3 parameters: patient disease, surgical procedure and practice setting . ( Level of Evidence: B ) </li></ul><ul><ul><li>Class III </li></ul></ul><ul><li>1. Routine use of a PAC perioperatively, especially in patients at low risk of developing hemodynamic disturbances, is not recommended. ( Level of Evidence: A ) </li></ul>
  28. 33. <ul><li>Intraoperative and Postoperative Use of ST-Segment Monitoring </li></ul><ul><li>Class IIa </li></ul><ul><li>1. Intraoperative and postoperative ST-segment monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, with computerized ST-segment analysis, when available, used to detect myocardial ischemia during the perioperative period. ( Level of Evidence: B ) </li></ul><ul><li>Class IIb </li></ul><ul><li>1. Intraoperative and postoperative ST-segment monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery. ( Level of Evidence: B ) </li></ul>
  29. 34. <ul><li>Surveillance for Perioperative MI </li></ul><ul><li>Class I </li></ul><ul><li>Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome. ( Level of Evidence: C ) </li></ul><ul><li>Class IIb </li></ul><ul><li>1. The use of postoperative troponin measurement is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery. ( Level of Evidence: C ) </li></ul><ul><li>Class III </li></ul><ul><li>1. Postoperative troponin measurement is not recommended in asymptomatic stable patients who have undergone low-risk surgery. ( Level of Evidence: C ) </li></ul>
  30. 35. ?
  31. 36. Summery <ul><li>the guidelines can serve as a useful framework for clinicians engaged in preoperative risk assessment and perioperative management of patients with cardiac disease . . </li></ul><ul><li>Cardiac risk reduction can be applied via : </li></ul><ul><ul><li>Risk stratification </li></ul></ul><ul><ul><li>Preoperative coronary revascularization </li></ul></ul><ul><ul><li>perioperative pharmacological therapies </li></ul></ul><ul><ul><li>Anesthetic Considerations and Intraoperative Management </li></ul></ul><ul><ul><li>Perioperative Surveillance </li></ul></ul>

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