Cardiac Issues With Noncardiac Surgery
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Cardiac Issues With Noncardiac Surgery

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Cardiac Issues With Noncardiac Surgery Cardiac Issues With Noncardiac Surgery Presentation Transcript

  • Cardiac Issues With Noncardiac Surgery Joseph F. Winget, MD FACC Clinical Assistant Professor University of Vermont Medical School Champlain Valley Cardiovascular Associates, P.C.
  • Objectives
    • Preoperative risk assessment
    • Anticoagulation and antithrombotic issues
    • Postoperative Management
    • Endocarditis prophylaxis
  • Disclosures
    • None
  • Surgery or not?
    • 87 year old white female with known critical AS fall and breaks her hip.
    • No CHF, MI, syncope
    • Stable and relatively independent before the fall.
    • LVEF 65%
    • 82 year old white male with known CAD. Stable angina pectoris.
    • Catheterization shows occluded LAD which was fed by collaterals
    • No CHF
    • AODM and HTN
    • Severe worsening spinal stenosis and weakness
    • LVEF 50%
  • Preoperative cardiac issues
    • How healthy is the patient?
    • How active is the patient?
    • How risky in the planned surgery?
    • Is preoperative cardiac testing necessary?
    • What preventive measures can be taken to reduce cardiac risk?
  • L’Italien JACC 1996;27:779
  • JACC 2002; 39:542
  •  
  •  
  • JACC 2002 39:542
  • Is testing predictive of outcomes? Circ 1997; 95: 53
  • Cardiac event rates and dobutamine echocardiography JAMA 2001; 285:1865
  • Who to test?
    • Intermediate risk patients undergoing intermediate or high risk surgery
    • Testing does not add additional information in low risk or high risk patient groups.
  • What test?
    • Well validated
      • Exercise or pharmacologic echocardiography
      • Exercise or pharmacologic Cardiolite
    • Not well validated
      • CTA
      • MRI
      • Cardiac angiography*
  • Therapies to reduce perioperative cardiac complications
    • Revascularization
      • Percutaneous revascularization
      • CABG
    • Medical therapy
  • Benefit of CABG Circ 1997; 96: 1882
  • McFalls E 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
  • McFalls E 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
  • Medical therapy to lower risk Lindenauer, PK JAMA. 2004 May 5; 291(17)2092
  • Beta blocker use? NEJM 1996; 335:1713
  • Beta blocker use?
  •  
  • Recommendations
    • Revascularization for appropriate clinical indications
    • Maximize adjuvant medical therapy
      • Aspirin
      • Statin
      • Beta blocker
    • Close perioperative follow-up
      • Prolonged telemetry monitoring
  • Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242 Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater
  • Surgery or not?
    • 87 year old white female with known critical AS fall and breaks her hip.
    • No CHF, MI, syncope
    • Stable and relatively independent before the fall.
    • 82 year old white male with known CAD. Stable angina pectoris
    • Catheterization shows occluded LAD which was fed by collaterals
    • No CHF
    • AODM
    • Severe worsening spinal stenosis and weakness
  •  
  •  
  • Cardiac Issues in noncardiac surgery
    • Establish patient risk
    • Assign procedural risk
    • Test intermediate risk patients undergoing intermediate or high risk surgery
    • Optimize medical therapy
    • Revascularization when clinically indicated
    • ACC/AHA Guidelines JACC 2007; 50: 1707-1732
  • Anticoagulation / Antiplatelet Agents
    • 55 year old male s/p CABG in 2000. Drug eluting stent placed to native vessel in August of 2008.
    • Needs colonoscopy
    • Can plavix and aspirin be safely stopped?
    • 70 year old white female with chronic AF needs shoulder surgery
    • History of CVA
    • Warfarin 5 mg daily
    • Does the patient need some form of bridging preoperatively?
  • Anticoagulation / Antithrombotic Issues
    • Anticoagulants – warfarin
      • Atrial fibrillation
      • Venous thrombosis
      • Prosthetic heart valves
    • Antithrombotic agents – clopidogrel
      • Bare metal stents vs. drug eluting stents
  • Do you need to stop antiplatelet / anticoagulation therapy?
    • Procedural risk for bleeding
      • Low risk for bleeding
        • Athrocentesis
        • Cataract surgery
        • Dental cleaning / extraction
        • Cutaneous surgery
  • CHADS score - AF Circulation 2004; 110:2287 JAMA 2001; 285:2864
  • Atrial fibrillation
    • Bridge
      • AF and prosthetic valves
      • AF and significant LV dysfunction (EF<40%)
      • AF and any prior thrombotic event (CVA, TIA, arterial emboli)
      • “ high risk” patients
    • No bridging
      • Low risk patients
  • How to bridge
    • Stop warfarin for 48 hours
    • Start lovenox at 1mg/kg SQ BID for 6 doses
    • Stop lovenox the morning before surgery
  • Prosthetic heart valves
    • Bioprosthetic valves
      • All, if in atrial fibrillation
    • Mechanical valves
      • All, regardless of rhythm
  • Venous thrombosis
    • Deep venous thrombosis
    • Pulmonary emboli
    • Hypercoagulable states
      • Factor V Leiden
      • Protein C / S deficiencies
      • Lupus anticoagulant
  • How to Bridge
    • Stop warfarin
    • Start replacement therapy once INR < 2.0
      • IV heparin
      • SQ low molecular weight heparin - lovenox
  • Coronary stents
  •  
  • Recommendations – stent patients
    • Bare Metal Stents
      • Delay elective procedures for at least 1 month and preferably 6 months
      • Restart clopidogrel as soon as possible
      • Loading dose?
    • Drug eluting stents
      • Delay elective procedures for 1 year
      • Continue aspirin
      • Restart clopidogrel as soon possible
      • Loading dose?
  • Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242 Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion
  • Improved cardiac care for noncardiac surgery? Yes, we can!
  •  
  • Perioperative Medication Management
    • Beta Blockers continue
    • Alpha agonists continue
    • Calcium blockers continue prn
    • ACE / ARB stop preoperatively start when stable
    • Statins continue
    • Diuretics as needed
  • Endocarditis prophylaxis
    • 70 year old female with rheumatic valvular heart disease and Bjork-Shiley MVR in 1984 needs dental work.
    • Are antibiotics required?
  • SBE prophylaxis
    • Antibiotics
      • All Prosthetic valves
      • Prior bacterial endocarditis
      • Cyanotic congenital heart disease (CHD)
      • Any repair CHD with prosthetic material *
    • No Antibiotics
      • Uncomplicated valvular heart disease
      • Pacemakers or defibrillators
      • Hypertrophic cardiomyopathy
    Circ 2007; 115