Noon conference

1. PREOPERATIVE
CARDIOVASCULAR
EVALUATION AND TREATMENT
FOR NONCARDIAC SURGERY
Michael J. Longo M.D.
Virginia Mason Medical Center

2. VMMC SURGERY DEPARTMENT
“Is Mrs. XX cleared for surgery”?

4. MAJOR THEME
•Indications for testing/treatment are the
same as in the non operative setting
•Revascularization (PCI/CABG) rarely
required prior to non cardiac surgery
•Less is more

5. WHO NEEDS?
• Go directly to the OR without testing
• Stress test
• Revascularization (PCI or CABG)
prior to non cardiac surgery
• Beta blocker

7. REVISED CARDIAC RISK INDEX
Lee Circulation 1999:100;1043
1. Ischemic heart disease
2. CHF
3. Cerebrovascular disease
4. DM requiring insulin
5. Cr > 2.0 mg/dl
6. High risk surgery

8. ISCHEMIC HEART DISEASE
• History of MI or abnormal q waves
• Positive stress test
• Use of nitroglycerin
• Chest pain thought to be ischemic
• NOT INCLUDED: previous CABG or stent,
and TRADITIONAL CARDIAC RISK
FACTORS

9. REVISED CARDIAC RISK INDEX
SCORE CARDIAC EVENTS*
0 0.5%
1 1.0%
2 5 %
> 3 10%
* MI, CHF, Cardiac arrest, VF, CHB

10. REVISED CARDIAC RISK INDEX

12. LOW RISK SURGERY (< 1%)
• Cataract
• Breast
• Skin
• Ambulatory
• Endoscopy

13. ELEVATED RISK SURGERY(> 1%)
• Vascular surgery
• Intraperitoneal
• Intrathoracic
• Head and neck
• Prostate
• Orthopedic

14. OVERALL ASSESSMENT
• Low risk: no clinical factors and low
risk surgery
• Elevated risk: > 1 clinical risk factor
and/or elevated risk surgery

15. NO FURTHER TESTING
SEND TO THE OR
• Emergent surgery
• Low risk: no clinical factors and low
risk surgery
• Elevated risk
– Excellent functional capacity (IIa)
– Moderate/good IIb

16. ISCHEMIC EVENTS

17. PERIOPERATIVE TRIGGERS
• Tachycardia
• Hypotension
• Blood loss
• Fluid shifts
• Catecholamine surges
• Hypercoagulable state

18. STRESS TESTING
Test Sensitivity(%) Specificity(%)
ETT 68 77
Echo 80-85 80-85
Nuclear 85-90 75-80
PREOPERATIVE SETTING
• HIGH NPV 95%
• LOW PPV 10-20%

20. STRESS TESTING
• Elevated risk and poor functional
capacity (< 4 METs) pharmacologic
stress test (class IIa)
• Activities > 4 METS: climbing a flight
of stairs, walking up a hill, walking on
level ground at 4mph

22. CARP: RESULTS

24. REVASCULARIZATION
• Indications for PCI and CABG are the
same as in the non operative setting

25. TIMING AFTER PCI
• Class I
– POBA: > 14 days
– BMS > 30 days
– DES > 365 days
• Class IIb: elective surgery can be
considered 180 after days DES if
benefit > risk

26. BETA BLOCKERS

27. POISE
Lancet 2008;371:1839
N=8351

29. POISE
• Low risk patients: most RCRI < 2
• Protocol
– Metoprolol XL100mg am pre surgery
– Metoprolol XL 100mg < 6hrs post op
– POD #1: metoprolol XL 200 mg daily

31. BETA BLOCKERS
• Class I: chronically on beta blockers
• Class IIb
– Intermediate or high risk ischemia
– > 3 RCRI risk factors
• Class III (harm): should not be started
on the day of surgery

32. BETA BLOCKERS

34. CASE # 1
• 45 yr old man
• HTN, high cholesterol, smoker, FH
• Good exercise tolerance without
symptoms
• Pre Op for prostatectomy

35. ECG

36. The most appropriate next step:
• OR
• OR with beta blockers
• Exercise echo or MPI
• Pharmacologic stress test
• Cardiac Cath

37. EVALUATION
•Elevated risk: prostate surgery
•No clinical risk factors
•Good exercise tolerance
•Asymptomatic
•Markedly abnormal ECG

38. STRESS ECHO
• Exercised 13 minutes no chest pain
• Abnormal ECG with ST depression
• EF 75% LVH no ischemia

40. CASE # 2
• 75 yr old man
• Pre op for fem pop bypass
• Hx MI, HFpEF, prior L CEA
• No cardiac symptoms
• Claudication with half block

41. The most appropriate next step
is:
• Send to OR
• Send to OR with beta blocker
• Exercise echo or MIBI
• Pharmacologic stress test
• Cardiology consult

42. EVALUATION
• Elevated risk: high risk surgery
CAD, CVD, CHF
• Poor functional capacity
• Even though asymptomatic
NEEDS STRESS TEST

43. LEXISCAN MIBI
• EF 63% small area inferior ischemia
Send to OR on beta blockers
• EF 40% large area anterior ischemia
CATH
3V CAD: CABG before vascular surgery