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Azienda Sanitaria Locale Roma CUNITÀ OPERATIVA COMPLESSA DI CARDIOLOGIA          Direttore: Prof. Achille Gaspardone    Ho...
Magnitude of the problem• Annually:  – 40,000,000 surgical procedures  – 400,000 myocardial infarction (1%)  – 133,000 car...
Assessing Risk Pre-Operatively• Surgery Based  – Type of surgery  – Duration of surgery  – Emergency surgery• Patient Base...
Surgery Specific Risk     for Cardiac Death or Nonfatal MI• High Risk ( > 5% )  – Aortic, Major vascular• Intermediate Ris...
Risk of surgical procedureRisk of MI and cardiac death within 30 days after surgery                                   Boer...
Major Clinical Predictors of Increased Perioperative Cardiovascular Risk          …who is too sick?Predictors of risk for:...
Risk Stratification       Lee’s Revised Cardiac Risk IndexCan surgical risk be identified on the basis of history, examina...
Lee’s Revised Cardiac Risk Index    Risk factors                                  Points•   High-risk surgery             ...
Lee’s Revised Cardiac Risk Index  Number of              Cardiac Risk Risk of Major  Risk Factors              Class     C...
Preoperative Clinical Evaluation• Always   – Medical history   – Physical examination   – Laboratory tests• No adjunctive ...
12-lead Electrocardiography• The 12-lead ECG is commonly performed as part of  pre-operative cardiovascular risk assessmen...
Exercise treadmill testingAuthor              n        Abnorm Criteria Events         PPV   NPVMcCabe 1981         314    ...
Assessing Functional capacity                    Can You…                                               Can You… 1 Met    ...
Assessing Functional capacity     How does this relate to Surgery?• Functional Capacity     Complication Rate     < 4 METs...
Putting the puzzle together           A stepwise approach• Step 1:   Urgent surgery?• Step 2:   Active or Unstable cardiac...
Step n°1:                                              NO                       Step n°2Urgent surgery              YES• P...
Step n°2:     Active or unstable                                      NO                    Step n°3     cardiac condition...
Step 3: Risk of surgical procedure• Low risk of surgical procedure  – Identify risk factors & provide    recommendations o...
Step 4: Functional capacity         of the patient scheduled for      intermediate or high-risk surgery• Good (≥4 METS): c...
Step 5: Intermediate or High-risk        surgery with a moderate or less,               functional capacity• Intermediate ...
Step 6: Cardiac risk factors in high-risk Surgery1. Angina             Number of risk factors ≤ 2:   pectoris           • ...
Step 6: Cardiac risk factors                                                                              (%)Clinical outc...
Step 7: Pre-operative testing                           Cardiac stress test        No or moderate                         ...
Step 7b: Extensive                Stress induced ischaemia                       Extensive ischaemia Balloon            Ba...
Conclusions• Pre-operative evaluation requires an integrated  multidisciplinary approach from anesthesiologists,  cardiolo...
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Remoli Romolo. Rischio Cardiologico Preoperatorio. ASMaD 2012

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Remoli Romolo. Rischio Cardiologico Preoperatorio. ASMaD 2012

  1. 1. Azienda Sanitaria Locale Roma CUNITÀ OPERATIVA COMPLESSA DI CARDIOLOGIA Direttore: Prof. Achille Gaspardone Hot Topics in CardiologiaPre-operative Cardiac Risk Romolo Remoli Roma, 12-05-2012
  2. 2. Magnitude of the problem• Annually: – 40,000,000 surgical procedures – 400,000 myocardial infarction (1%) – 133,000 cardiovascular death (0,3%)• Ageing population: – Cardiovascular diseases and co-morbidities are increasing – Over the next 10 yrs the elderly population will increase by 50% – The elderly require surgery more often than young people (4 times) – Lower threshold for performing major procedures on elderly ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  3. 3. Assessing Risk Pre-Operatively• Surgery Based – Type of surgery – Duration of surgery – Emergency surgery• Patient Based – Unstable conditions – Risk stratification – Functional capacity ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  4. 4. Surgery Specific Risk for Cardiac Death or Nonfatal MI• High Risk ( > 5% ) – Aortic, Major vascular• Intermediate Risk ( 1 – 5% ) – Carotid, Head, Neck, Intraperitoneal, Intrathoracic, Orthopedic, Prostate• Low Risk ( < 1% ) – Ambulatory surgery, Endoscopy, Superficial procedure, Cataract surgery, Breast surgery• Emergency: x2-x5 times the perioperative risk Fleischer, LA et al, ACC/AHA 2007 Guidelines on perioperative cv evaluation... J Am Coll Cardiology 2007; 50:e159
  5. 5. Risk of surgical procedureRisk of MI and cardiac death within 30 days after surgery Boersma E. et al. Am J Med 2005;118:1134–1141
  6. 6. Major Clinical Predictors of Increased Perioperative Cardiovascular Risk …who is too sick?Predictors of risk for: myocardial infarction, heart failure, death:• Unstable coronary syndromes – Acute or recent myocardial infarction – Unstable or severe angina• Decompensated heart failure – New onset, worsening HF, NYHA Class IV• Significant arrhythmias – High-grade AV block or symptomatic bradycardia – Symptomatic or new ventricular arrhythmias – SVT’s with uncontrolled ventricular rate• Severe valvular heart disease ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  7. 7. Risk Stratification Lee’s Revised Cardiac Risk IndexCan surgical risk be identified on the basis of history, examinationand the ECG?• 4315 patients (throughout 1989-1994)• Mean age = 66±10 years• Elective major, non-cardiac procedure• All patients had serial CK enzymes and EKG’s post-op• 2,1% patients suffered major cardiac complication defined as: – cardiac death – myocardial infarction – pulmonary edema – ventricular fibrillation – complete heart block Lee, TH et al, Circulation 1999, 100:1043-1049
  8. 8. Lee’s Revised Cardiac Risk Index Risk factors Points• High-risk surgery 1• History of coronary artery disease 1• History of congestive heart failure 1• History of cerebrovascular disease 1• Diabetes mellitus treated with Insulin 1• Preop serum creatinine > 2.0 mg/dL 1 Total 6 Lee, TH et al, Circulation 1999, 100:1043-1049
  9. 9. Lee’s Revised Cardiac Risk Index Number of Cardiac Risk Risk of Major Risk Factors Class Cardiac Event 0 I 0.4% 1 II 0.9% 2 III 6.6% ≥3 IV 11%Major cardiac events were defined as MI, pulmonary edema, ventricularfibrillation, complete heart block or other primary cardiac arrest Lee, TH et al, Circulation 1999, 100:1043-1049
  10. 10. Preoperative Clinical Evaluation• Always – Medical history – Physical examination – Laboratory tests• No adjunctive predictive value – Resting and Holter ECG – Echocardiography – Exercise stress testing• Very rarely indicated – Cardiopulmonary exercise testing – Stress echocardiography – Nuclear imaging “The fact that you’re a – CT/MRI malpractice lawyer aside, I’m – Coronary angiography going to schedule every medical test known to ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  11. 11. 12-lead Electrocardiography• The 12-lead ECG is commonly performed as part of pre-operative cardiovascular risk assessment. ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  12. 12. Exercise treadmill testingAuthor n Abnorm Criteria Events PPV NPVMcCabe 1981 314 36% STD CP A 38% 81% 91%Cutler 1981 130 39% STD 7% 16% 99%Arous 1984 808 17% STD NR 21% NRGardine 1985 86 48% STD 11% 11% 90%Carliner 1985 200 16% STD 32% 16% 93%von Knorring 1986 105 25% STD CP A 3% 8% 99%Kopecky 1986 114 57% <400kpm 7% 13% 100%Leppo 1987 60 28% STD 12% 25% 92%McPhail 1988 100 70% <85% max 19% 24% 93%Urbinati 1994 121 23% STD 0 - 100%STD: ST depression, CP: chest pain, A: cardiac arrhythmiaMax: maximum predicted heart rate• Positive predictive value ≈ 10-15%• Negative predictive value ≈ 98%• Estimate functional capacity (METs)• Many patients cannot exercise
  13. 13. Assessing Functional capacity Can You… Can You… 1 Met Take care of yourself? 4 Mets Climb two flight of stairs or walk up a hill? Eat, dress, or use the toilet? Run a short distance? Walk indoors around the Do heavy work around the house? house like scrubbing floors or lifting or moving heavy furniture? Walk 100 m on level ground Participate in moderate at 3 to 5 km per h? recreational activities like golf, bowling, dancing?4 Mets Do light work around the > 10 Participate in strenuous sports house like dusting or washing Mets like swimming, singles tennis, dishes? football, basketball, or skiing?MET indicates metabolic equivalent ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  14. 14. Assessing Functional capacity How does this relate to Surgery?• Functional Capacity Complication Rate < 4 METs > 5% 4 – 10 METs 1 – 5% > 10 Mets < 1%• < 4 METs significantly Increases risk myocardial infarction, heart failure, arrhythmia regardless of surgical risk Eagle, KA, et al, J Am Coll Cardiol, 2002; 39, 542-553
  15. 15. Putting the puzzle together A stepwise approach• Step 1: Urgent surgery?• Step 2: Active or Unstable cardiac conditions?• Step 3: What is the risk of the surgical procedure?• Step 4: What is the functional capacity of the patient?• Step 5: In patients with moderate or low functional capacity consider the risk of surgical procedure• Step 6: Consider cardiac risk factors• Step 7: Consider non invasive tests ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  16. 16. Step n°1: NO Step n°2Urgent surgery YES• Patient or surgical specific factors dictate the strategy and do not allow further cardiac testing or treatment.• The consultant provides: – recommendations on perioperative management – surveillance for cardiac events – continuation of chronic cardiovascular medical therapy – If applicable, discuss the discontinuation of chronic aspirin treatment (only in patients with difficult control of hemostasis during surgery) Surgery ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  17. 17. Step n°2: Active or unstable NO Step n°3 cardiac condition• Unstable/severe angina or recent MI (< 30 days + ischemia)• Decompensated heart failure• Significant cardiac arrhythmias• Severe valvular heart disease YES• If possible, postpone or cancel the procedure• Treatment options and priority should be discussed in a multidisciplinary team involving Surgery all perioperative care physicians ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  18. 18. Step 3: Risk of surgical procedure• Low risk of surgical procedure – Identify risk factors & provide recommendations on life style and Surgery medical treatment according to the ESC guidelines for postoperative care to improve long term outcome• Intermediate or high risk surgical Step n°4 procedure ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  19. 19. Step 4: Functional capacity of the patient scheduled for intermediate or high-risk surgery• Good (≥4 METS): climb two flight of stairs or walk up a hill. – If coronary artery disease or risk factors: Surgery • statin therapy • titrated low dose of β-blocker• Moderate or poor (<4 METs) Step n°5 ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  20. 20. Step 5: Intermediate or High-risk surgery with a moderate or less, functional capacity• Intermediate risk surgery: abdominal – Statin therapy – Titrated low dose β-blocker Surgery – If systolic LV dysfunction: ACE-inhibitors – If ≥ 1 cardiac risk factors → Baseline ECG• High risk surgery (aortic vascular) Step n°6 ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  21. 21. Step 6: Cardiac risk factors in high-risk Surgery1. Angina Number of risk factors ≤ 2: pectoris • Statin therapy2. MI • Titrated low dose β-blocker • If systolic LV dysfunction: ACE- Surgery3. Heart failure inhibitors4. Stroke/Tia • Baseline ECG5. Diabetes Number of risk factors ≥ 3 mellitus Step n°76. Renal dysfunction ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  22. 22. Step 6: Cardiac risk factors (%)Clinical outcome of 1,2 million procedure Boersma E. et al. Am J Med 2005;118:1134–1141
  23. 23. Step 7: Pre-operative testing Cardiac stress test No or moderate Extensive stress stress-induced induced ischaemia ischaemiaProceed with the procedure – Statin therapy – Titrated low dose β-blocker Step n°7b – If systolic LV dysfunction: ACE-inhibitors Surgery ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  24. 24. Step 7b: Extensive Stress induced ischaemia Extensive ischaemia Balloon Bare metal Drug eluting CABGAngioplasty stent stentSurgery > 2 weeks Surgery > 6 weeks Surgery > 12 mo with Aspirin Dual antiplatelet Dual antiplatelet drugs > 6 we-3 mo drugs ≥ 12 months Surgery ESC Guidelines for pre-operative cardiac risk assessment. EHJ (2009) 30, 2769–2812
  25. 25. Conclusions• Pre-operative evaluation requires an integrated multidisciplinary approach from anesthesiologists, cardiologists, internists, pulmonologists, surgeons and other specialists.• Unstable cardiac syndromes require management prior to surgery.• Clinically assessed functional tolerance is the best single predictor of outcome.• In the majority of patients, surgical risk can be adequately assessed by Lee’s cardiac risk index without routine appeal to instrumental tests.
  26. 26. Thank you

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