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Guilherme Brauner Barcellos
• 12 casos onde a melhor abordagem permanece
indefinida;
• Opinaram cardiologistas membros da ACC;
• Avaliaram sumário do caso, ECG’s,
cintilografia e cateterismo.
• Prevaleceu a discordância de
opiniões;
• Estimou-se que a chance de
um 2º cardiologista concordar
com uma 1ª avaliação era menor
do que 50%.
- RCT
- 510 patients scheduled
for vascular procedures
- Stable cardiac symptoms
- 74% would have been
considered to be at
least at intermediate
risk
- Revascularization before
surgery or no
revascularization
- Short and long-term
outcomes
Coronary-artery Revascularization Before Elective Major Vascular Surgery.
McFalls, Edward O.; Ward, Herbert B.; et al. N Engl J Med 2004;351: 2795-804.
CARP STUDY
Coronary-artery Revascularization Before Elective Major Vascular Surgery.
McFalls, Edward O.; Ward, Herbert B.; et al. N Engl J Med 2004;351: 2795-804.
CARP STUDY
A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive
Approach in High-Risk Patients Undergoing Major Vascular Surgery
The DECREASE-V Pilot Study
J Am Coll Cardiol, 2007; 49:1763-1769,
RM; 43%
RM; 49%
No RM; 33%
No RM; 44%
0%
10%
20%
30%
40%
50%
60%
Morte +IM 30 dias Morte +IM 1 ano
Não Significante
The findings from this small study suggest that the CARP trial’s conclusions can be extended to high-risk
patients undergoing major noncardiac vascular surgery. In the present trial, 43% of patients had ejection
fractions <35%, and 75% of those who underwent coronary angiography had three-vessel or left main artery
disease.
PCI; 9%
PCI; 5,10%
Sem PCI;
8,20%
Sem PCI;
6,90%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
IM+angina Morte
Does Preoperative Coronary Angioplasty Improve
Perioperative Cardiac Outcomes?
Godet G, et al. Anesthesiology. 2005;102: 739-46
- Retrospective cohort
- 1.152 patients
- AAA
- 1996-2002
- 78 PCI
- Surgery in 5 – 8 weeks
Long-term outcome of prophylactic coronary revascularization in cardiac
high-risk patients undergoing major vascular surgery
Secondary analisys of the data from the DECREASE-V Study
Am J Cardiol 2009 Apr 1; 103:897
At the median follow-up time of 2.8 years, the overall
survival rate was 64% in the nonrevascularization
group and 61% in the revascularization group. In the
revascularization group, no difference in long-term
event-free survival was found between patients who
underwent percutaneous coronary intervention and
those who underwent coronary artery bypass
grafting.
Perioperative Complications After Vascular Surgery Are Predicted by the
Revised Cardiac Risk Index But Are Not Reduced in High-Risk Subsets
With Preoparative Revascularization
Secondary analisys of the data from the CARP trial
Circ Cardiovasc Qual Outcomes. 2009;2:73-77
The Effects of Prophylactic Coronary Revascularization or Medical
Management on Patients Outcomes After Noncardiac Surgery
– A Meta-Analysis.
Can J Anesth 2007;54:705-17.
2007
Active cardiac disease
• Unstable coronary disease
• Decompensated heart failure
• Significant arrhythmias
• Severe Valvular disease
Require treatment, with or without surgery
Clinical Risk Factors
(replaces intermediate risk factors)
• History of ischemic heart disease
• History of congestive heart failure
• Diabetes Mellitus
• Renal insufficiency (Cr>2.0 mg/dl or 175
µmol/L)
Lee TH, Marcantonio ER, Mangione CM et al. Derivation and Prospective Validation of a Simple Index for
Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 1999; 100;1043-1049.
a break for an English class
 To consider (by the The Free Online Dictionary) means:
 To think carefully about
 To form an opinion about; judge
 To take into account; bear in mind
 To look at thoughtfully.
Consider testing IF IT WILL CHANGE MANAGEMENT!
Take Home Messages
 Surgery by itself in NOT and indication for cardiac investigation or
therapy.
 Do not order any test unless you are willing to intervene based on the
results.
Take Home Messages
Intervention is rarely necessary to
simply lower the risk of surgery
unless such intervention is
indicated irrespective of the
preoperative context.
• The past 25 years with evaluating and treating coronary artery disease in
patients undergoing noncardiac surgery:
– We began the journey by clearly enunciating that heart attacks were a major
cause of important and sometimes fatal postoperative outcomes.
– We derived a number of epidemiological and Bayesian methods for identifying
patients most likely to harbor underlying coronary artery disease.
– We then identified and confirmed that a number of noninvasive techniques
could be used to further stratify coronary risk in several clinical risk cohorts,
potentially allowing a rational approach to screening patients into low-,
moderate-, and high-risk subsets.
– The water looked right, our approach looked right, so we fished. It made
eminent sense that by revascularizing blocked or narrowed coronary arteries,
we could reduce the risk of postoperative heart attacks and coronary death.
• Why doesn’t coronary artery revascularization reduce the risk of
perioperative myocardial infarction and death?
– First, most heart attacks are caused not by severely stenosed epicardial
plaques (the kind one might “fix” before noncardiac surgery) but by disruption
or rupture of milder, heavily lipid laden, “vulnerable” plaques that may look
remarkably innocent on angiography.
• When we studied the coronary pathology of patients experiencing a fatal myocardial
infarction after noncardiac surgery, we found that the most severe coronary stenosis was
usually not the culprit lesion.
• We still do not know how to reliably identify apparently stable but vulnerable plaques.
• Second, we have discovered that our gold
standard for identifying the severity of
coronary artery disease and for planning its
therapy is not gold.
– The visual images we see on coronary angiography
provide us just one angle of repose on a
multifaceted pathophysiology.
• Third, we have increasingly come to know that
prophylactic coronary revascularization has a
dark side.
To consider means that we have options as:
 To cancel the surgery
 To delay the surgery
 To plan intensive care
 To run the risk
 ...
PERIOPERÁTORIO: CENÁRIO IDEAL PARA
ABORDAGEM MULTIDISCIPLINAR
MEDICINA HOSPITALAR
CIRURGIA ANESTESIOLOGIA
MEDICINA
INTENSIVA
ESPECIALIDADES
CLÍNICAS
Patients' Perceptions of the Benefits of Percutaneous Coronary
Intervention for Stable Coronary Disease
N Engl J Med 2011; 364:1607-1616April 28, 2011
The immense majority (around 80%) believed that the procedure would give to
them LIFE or at least to prevent acute myocardial infarction .
Coronary-Artery Bypass Surgery in Patients
with Left Ventricular Dysfunction
N Engl J Med 2011; 364:1607-1616April 28, 2011
Findings of the STICH Trial do not
support preferential indication of
CABG above medical therapy alone
for patients with left ventricular
dysfunction. All-cause mortality
(primary outcome) did not differ
between treatment groups. The
decrease in cardiovascular mortality
(secondary outcome) was marginal
(p=0.05), unadjusted for multiple
outcome comparisons, and clinically
irrelevant since overall mortality was
unaffected.
Por que rejeitamos evidências?
Sanjay Kaul, a prominent
cardiologist and researcher at
Cedars-Sinai Heart Institute in
Los Angeles, estimates that the
U.S. could save $5 billion of the
$15 billion it spends on stent
procedures each year if all
doctors followed Courage's
guidance—that is, putting
certain heart patients on
generic drugs and turning to
stents only if the pains persists.
Por que rejeitamos evidências?
 Mentalidade do Médico Ativo
 Apego ao Paradigma Mecanístico
 Conflitos de interesse
Há aqueles que insistem em pensar
como encanadores, ou seja,
desentupindo uma artéria o paciente
vai necessariamente melhorar.
OBRIGADO!

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Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Outcomes?

  • 2. • 12 casos onde a melhor abordagem permanece indefinida; • Opinaram cardiologistas membros da ACC; • Avaliaram sumário do caso, ECG’s, cintilografia e cateterismo.
  • 3. • Prevaleceu a discordância de opiniões; • Estimou-se que a chance de um 2º cardiologista concordar com uma 1ª avaliação era menor do que 50%.
  • 4. - RCT - 510 patients scheduled for vascular procedures - Stable cardiac symptoms - 74% would have been considered to be at least at intermediate risk - Revascularization before surgery or no revascularization - Short and long-term outcomes Coronary-artery Revascularization Before Elective Major Vascular Surgery. McFalls, Edward O.; Ward, Herbert B.; et al. N Engl J Med 2004;351: 2795-804. CARP STUDY
  • 5. Coronary-artery Revascularization Before Elective Major Vascular Surgery. McFalls, Edward O.; Ward, Herbert B.; et al. N Engl J Med 2004;351: 2795-804. CARP STUDY
  • 6. A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients Undergoing Major Vascular Surgery The DECREASE-V Pilot Study J Am Coll Cardiol, 2007; 49:1763-1769, RM; 43% RM; 49% No RM; 33% No RM; 44% 0% 10% 20% 30% 40% 50% 60% Morte +IM 30 dias Morte +IM 1 ano Não Significante The findings from this small study suggest that the CARP trial’s conclusions can be extended to high-risk patients undergoing major noncardiac vascular surgery. In the present trial, 43% of patients had ejection fractions <35%, and 75% of those who underwent coronary angiography had three-vessel or left main artery disease.
  • 7. PCI; 9% PCI; 5,10% Sem PCI; 8,20% Sem PCI; 6,90% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% IM+angina Morte Does Preoperative Coronary Angioplasty Improve Perioperative Cardiac Outcomes? Godet G, et al. Anesthesiology. 2005;102: 739-46 - Retrospective cohort - 1.152 patients - AAA - 1996-2002 - 78 PCI - Surgery in 5 – 8 weeks
  • 8. Long-term outcome of prophylactic coronary revascularization in cardiac high-risk patients undergoing major vascular surgery Secondary analisys of the data from the DECREASE-V Study Am J Cardiol 2009 Apr 1; 103:897 At the median follow-up time of 2.8 years, the overall survival rate was 64% in the nonrevascularization group and 61% in the revascularization group. In the revascularization group, no difference in long-term event-free survival was found between patients who underwent percutaneous coronary intervention and those who underwent coronary artery bypass grafting.
  • 9. Perioperative Complications After Vascular Surgery Are Predicted by the Revised Cardiac Risk Index But Are Not Reduced in High-Risk Subsets With Preoparative Revascularization Secondary analisys of the data from the CARP trial Circ Cardiovasc Qual Outcomes. 2009;2:73-77
  • 10. The Effects of Prophylactic Coronary Revascularization or Medical Management on Patients Outcomes After Noncardiac Surgery – A Meta-Analysis. Can J Anesth 2007;54:705-17.
  • 11. 2007
  • 12. Active cardiac disease • Unstable coronary disease • Decompensated heart failure • Significant arrhythmias • Severe Valvular disease Require treatment, with or without surgery
  • 13.
  • 14.
  • 15.
  • 16. Clinical Risk Factors (replaces intermediate risk factors) • History of ischemic heart disease • History of congestive heart failure • Diabetes Mellitus • Renal insufficiency (Cr>2.0 mg/dl or 175 µmol/L) Lee TH, Marcantonio ER, Mangione CM et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 1999; 100;1043-1049.
  • 17.
  • 18. a break for an English class  To consider (by the The Free Online Dictionary) means:  To think carefully about  To form an opinion about; judge  To take into account; bear in mind  To look at thoughtfully.
  • 19. Consider testing IF IT WILL CHANGE MANAGEMENT!
  • 20. Take Home Messages  Surgery by itself in NOT and indication for cardiac investigation or therapy.  Do not order any test unless you are willing to intervene based on the results.
  • 21. Take Home Messages Intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.
  • 22. • The past 25 years with evaluating and treating coronary artery disease in patients undergoing noncardiac surgery: – We began the journey by clearly enunciating that heart attacks were a major cause of important and sometimes fatal postoperative outcomes. – We derived a number of epidemiological and Bayesian methods for identifying patients most likely to harbor underlying coronary artery disease. – We then identified and confirmed that a number of noninvasive techniques could be used to further stratify coronary risk in several clinical risk cohorts, potentially allowing a rational approach to screening patients into low-, moderate-, and high-risk subsets. – The water looked right, our approach looked right, so we fished. It made eminent sense that by revascularizing blocked or narrowed coronary arteries, we could reduce the risk of postoperative heart attacks and coronary death. • Why doesn’t coronary artery revascularization reduce the risk of perioperative myocardial infarction and death? – First, most heart attacks are caused not by severely stenosed epicardial plaques (the kind one might “fix” before noncardiac surgery) but by disruption or rupture of milder, heavily lipid laden, “vulnerable” plaques that may look remarkably innocent on angiography. • When we studied the coronary pathology of patients experiencing a fatal myocardial infarction after noncardiac surgery, we found that the most severe coronary stenosis was usually not the culprit lesion. • We still do not know how to reliably identify apparently stable but vulnerable plaques.
  • 23.
  • 24. • Second, we have discovered that our gold standard for identifying the severity of coronary artery disease and for planning its therapy is not gold. – The visual images we see on coronary angiography provide us just one angle of repose on a multifaceted pathophysiology. • Third, we have increasingly come to know that prophylactic coronary revascularization has a dark side.
  • 25.
  • 26. To consider means that we have options as:  To cancel the surgery  To delay the surgery  To plan intensive care  To run the risk  ...
  • 27.
  • 28. PERIOPERÁTORIO: CENÁRIO IDEAL PARA ABORDAGEM MULTIDISCIPLINAR MEDICINA HOSPITALAR CIRURGIA ANESTESIOLOGIA MEDICINA INTENSIVA ESPECIALIDADES CLÍNICAS
  • 29. Patients' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease N Engl J Med 2011; 364:1607-1616April 28, 2011 The immense majority (around 80%) believed that the procedure would give to them LIFE or at least to prevent acute myocardial infarction .
  • 30. Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction N Engl J Med 2011; 364:1607-1616April 28, 2011 Findings of the STICH Trial do not support preferential indication of CABG above medical therapy alone for patients with left ventricular dysfunction. All-cause mortality (primary outcome) did not differ between treatment groups. The decrease in cardiovascular mortality (secondary outcome) was marginal (p=0.05), unadjusted for multiple outcome comparisons, and clinically irrelevant since overall mortality was unaffected.
  • 31. Por que rejeitamos evidências? Sanjay Kaul, a prominent cardiologist and researcher at Cedars-Sinai Heart Institute in Los Angeles, estimates that the U.S. could save $5 billion of the $15 billion it spends on stent procedures each year if all doctors followed Courage's guidance—that is, putting certain heart patients on generic drugs and turning to stents only if the pains persists.
  • 32. Por que rejeitamos evidências?  Mentalidade do Médico Ativo  Apego ao Paradigma Mecanístico  Conflitos de interesse Há aqueles que insistem em pensar como encanadores, ou seja, desentupindo uma artéria o paciente vai necessariamente melhorar.

Editor's Notes

  1. Exclusion critiria: Active disease; stenosis of the left main coronary artery, a left ventricular ejection fraction of less than 20 percent, and severe aortic stenosis
  2. Sabemos que, à luz das melhores evidências científicas, angioplastia coronária não previne morte, nem infarto do miocárdio em pacientes com doença coronariana estável, sejam sintomáticos ou assintomáticos. Essa afirmação é embasada em ensaios clínicos randomizados de boa qualidade metodológica, como o estudo COURAGE e BARI-2D.
  3. O estudo foi apresentado no congresso do AHA com um viés de positividade, focado em desfechos secundários. O poder estatístico foi maior que 90%. Se o poder é maior que 90%, consideramos que a probabilidade do erro tipo II é menor que 10% - podemos aceitar um estudo negativo.