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ACC AHA Guidelines Dr. Wolfe

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					ACC/AHA Updated Practice Guideline 2002
Perioperative Cardiovascular Evaluation for Noncardiac Surgery
ww.acc.org or www.americanheart.org

Lee Wolfe, MD

Introduction
ACC/AHA joint task force on practice guidelines  Expert Panel charged with:

– –

literature review weighing of strength of evidence

Purpose:




Assist physicians involved in the pre-, intra-, and post-operative care of patients undergoing noncardiac surgery Provides a framework for considering cardiac risk in noncardiac surgery in a variety of patients and situations, e.g. urgency and special surgical considerations

Themes
  



Cost consciousness No test should be performed unless it is likely to influence management Intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context Preoperative evaluation not to “clear” the patient but rather to provide a clinical risk profile that can be used in making treatment decisions that may influence short and long term cardiac outcomes

Methodology

 

comprehensive literature review from 95-00
Class I: evidence for and/or general agreement that procedure/Rx useful & effective Class II: conflicting evidence and/or a divergence of opinion
– –

IIa: wt. of evidence in favor IIb: usefulness/efficacy less well established by evidence/opinion



Class III: not useful & in some cases may be harmful

Patient Evaluation
History  Physical Examination  Comorbid Diseases  Functional Capacity  Clinical Predictors


History
Urgency and type of Surgery  H/O CAD to include treatment and any recent change in symptomatology or functional capacity  Myocardium at risk  Functional Capacity  Ventricular Function


MONEY

 



WHAT IS THE AMOUNT OF MYOCARDIUM AT RISK? WHAT IS THE AMOUNT OF STRESS REQUIRED TO PRODUCE ISCHEMIA? WHAT IS THE PT’s VENTRICULAR FUNCTION?

Physical Examination
General appearance  Cardiopulmonary examination


Comorbidities
Pulmonary disease  Diabetes  Renal disease  H/H


Functional Capacity
defined in METs (metabolic equivalents)  VO2 of a 70kg male in a resting state  1 MET = 3.5 ml O2/kg/min  Excellent: > 10 METs  Good: 7-10 METs  Moderate: 4-7 METs  Poor: < 4 METs  unknown


<

4 METs: ADL’s, walking a block or two on level METs: raking leaves, weeding, pushing a power METs: walking 4 mph, social dancing, washing a METs: playing 9 holes of golf and carrying clubs,

ground at 2-3mph, *golfing with a cart* ------------------------------------------------------------------

4 5 6

mower

car, mopping using a push mower

7 8 9

METs: digging, spading soil, playing singles tennis, METs: moving heavy furniture, jogging slowly, rapidly METs: bicycling at moderate pace, sawing wood, METs: swimming briskly, bicycling uphill, jogging 6 METs:full court basketball, running @ 8mph

carrying 60lbs
climbing stairs, carrying 20lbs upstairs

slowly jumping rope

 10
mph

 >10

Myers, Am Heart J;142(6)1041-6, Dec 01

ACC/AHA Terminology:


Acute Coronary Syndrome:
–

Any constellation of clinical SSx suggestive of AMI or USA. This syndrome includes acute MI, STEMI, NSTEMI, enzyme-diagnosed MI, biomarker-diagnosed MI, late ECG-diagnosed MI, and USA. Generically refers to pt’s who ultimately prove to have one of these diagnoses to describe management alternatives at a time before the diagnosis is ultimately confirmed. This term is also used prospectively to identify those pt’s at a time of initial presentation who should be considered for treatment of acute MI or USA.

Acute Myocardial Infarction:


an acute process of myocardial ischemia with sufficient severity and duration to result in permanent myocardial damage. Clinically, the diagnosis of permanent damage is typically made when there is a characteristic rise and fall in cardiac biomarkers indicative of myocardial necrosis that may or may not be accompanied by the development of Q waves. Permanent myocardial damage may also be diagnosed when histologic evidence of myocardial necrosis is

observed on pathologic examination.

Angina:


clinical syndrome typically characterized by a deep, poorly localized chest, arm or jaw discomfort that is reproducible and assoc. w/ physical exertion or emotional stress and relived promptly (i.e. <5mins) by rest of SLNTG. Pt’s w/ USA may have discomfort w/all the qualities of typical angina except that episodes are more severe and prolonged and may occur at rest w/an unknown relationship to exertion or stress. In most, but not all, pt’s these sxs reflect myocardial ischemia resulting from sig. underlying CAD.

Previous MI


indicates that a pt. has had at least 1 documented MI 8 or more days before examination. Documented evid. of previous MI is defined as at least 2 of the following: (1) prolonged (>20’) typical chest pain not relieved by rest or nitrates; (2) biochemical evidence of myocardial necrosis (this can be manifested as CKMB greater than upper limit of nl, total CK > 2X nl, or troponin > than the diagnostic limit); (3) new wall motion abnl; or (4) at least 2 serial ECGs with (a) elevation in ST-T segments documented in 2 or more contiguous leads and/or (b) Q waves that are 0.03 secs in width or greater than 1/3 of the total QRS complex documented in 2 or more contiguous leads.

Renal Failure


renal insufficiency resulting in an increase in serum creatinine to more than 2 mg per dl (or a 50% or greater increase over an abnormal baseline level) measured before the procedure or that requires dialysis.

Stable Angina


angina without a change in frequency or pattern for at least the past 6 weeks. Angina is controlled by rest and/or oral or transcutaneous medications

Clinical Predictors of Increased Perioperative Cardiovascular Risk
(MI, Heart Failure, Death)


Major: mandates intensive management, may delay/cancel case
–

Unstable Coronary Syndromes



Acute (w/in 7 days) or Recent MI (>7days but > or = 1 month) Unstable or severe angina (class III/IV) w/ evidence of risk

– –

Decompensated heart failure Significant arrhythmias
 



High grade AVB Sx ventricular arrhythmias in the presence of underlying heart disease SVT w/ uncontrolled rate

–

Severe valvular disease



Intermediate: well validated markers of enhanced risk of
perioperative cardiac complications, justifying careful assessment of the patient’s current status

– – –

– –

Mild angina (class I or II) Previous MI by history or pathologic Q waves Compensated or prior heart failure DM (particularly insulin-dependent) Renal Insufficiency (Cr >2.0)



MINOR: recognized markers for cardiovascular disease that
have NOT BEEN INDEPENDENTLY proven to increase peri-op risk

–

– – – –
–

advanced age abnormal ECG (LVH, LBBB, ST-T abnl) Rhythm other than sinus (e.g. A-fib) Low functional capacity History of stroke Uncontrolled systemic hypertension

Cardiac Risk Stratification for Noncardiac Surgical Procedures
 HIGH: (reported cardiac risk often >5%)
– –
– –

Emergent major operations, esp. in elderly Aortic or other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated w/ large fluid shifts and/or blood loss

*combined incidence of cardiac death and nonfatal MI

 Intermediate: (risk generally <5%)
– –
– –

–

CEA Head and neck surgery Intraperitoneal & Intrathoracic surgery Orthopedic surgery Prostate surgery

 LOW: (risk generally < 1%)
– –
– –

Endoscopic procedures Superficial procedures Cataract surgery Breast surgery

*do not generally require further preoperative cardiac
testing

New Table 5a. Shortcut to Noninvasive Testing in Preoperative Patients if Any Two Factors Are Present


Intermediate clinical predictors are present
(Canadian class 1 or 2 angina, prior MI based on history or pathologic Q waves, compensated or prior heart failure, diabetes, or renal insufficiency)

 

Poor functional capacity (less than 4 METs) High surgical risk procedure (emergency major
operations*; aortic repair or peripheral vascular surgery; prolonged surgical procedures with large fluid shifts or blood loss)

Recommendation for Preoperative Noninvasive Evaluation of LVF


Class I:
–

Pt’s w/current or poorly controlled HF. (If previous evaluation has documented severe LV dysfunction, repeat preoperative testing may not be necessary.)
Pt’s w/prior HF and w/dyspnea of unknown origin



Class IIa:
–

…preoperative LVF evaluation


Class III:
–

As a routine test of LVF in patients without prior HF.

Recommendations for Preoperative 12-Lead Resting ECG


Class I:
–

Recent episode of chest pain or ischemic equivalent in clinically intermediate- or highrisk patients scheduled for an intermediate- or high risk operative procedure
Asymptomatic persons with diabetes mellitus



Class IIa:
–

…Preoperative 12-Lead ECG


Class IIb:
– – –

Pt’s w/ prior coronary revascularization Asymptomatic male > 45 y.o. or female > 55 y.o. w/2 or more atherosclerotic risk factors Prior hospital admission for cardiac causes Routine test in asymptomatic subjects undergoing low-risk operative procedures



Class III:
–

Recommendations for Exercise or Pharmacologic Stress Testing


Class I:
– –

–

–

Diagnosis of adult pt’s w/ intermediate pretest probability of CAD Prognostic assessment of pt’s undergoing initial eval. for suspected or proven CAD; eval. of subjects w/ significant change in clinical status. Demonstration of proof of myocardial ischemia before coronary revascularization Eval. of adequacy of medical therapy; prognostic assessment after an ACS (if recent eval. unavailable).

…Rec. for Stress Testing


Class IIa:
–

Evaluation of exercise capacity when subjective assessment is unreliable Diagnosis of CAD pt’s w/ high or low pretest probability; those with resting ST depression < 1 mm, those undergoing digitalis therapy, and those with ECG criteria for LVH. Detection of restenosis in high-risk asymptomatic subjects within the inital months after PCI



Class IIb:
–

–

…Rec. for Stress Testing


Class III:
–

–

– –

For exercise stress testing, diagnosis of pt’s w/ resting ECG abnormalities that preclude adequate assessment, e.g., pre-excitation syndrome, paced ventricular rhythm, rest ST depression > 1mm, or LBBB Severe comorbidity likely to limit life expectancy or candidacy for revascularization Routine screening of asymptomatic men or women w/o evidence of CAD Investigation of isolated ectopic beats in young patients

Rec. for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery


Class I: Pt’s w/ Suspected or Known CAD
– – –
–

Evidence for high risk of adverse outcome based on noninvasive test results Angina unresponsive to adequate medical therapy USA, particularly when facing intermediaterisk or high-risk noncardiac surgery. Equivocal noninvasive test results in pt’s at high clinical risk undergoing high risk surgery

…Angiography Rec’s


Class IIa:
–

– –

–

Multiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first) Moderate to large region of ischemia on noninvasive testing but w/o high risk features and w/o lower LVEF Nondiagnostic noninvasive test results in pt’s of intermediate clinical risk undergoing high-risk noncardiac surgery Urgent noncardiac surgery while convalescing from acute MI

…Angiography Rec’s


Class IIb:
– –

Perioperative MI Medically stabilized class III/IV angina and planned low-risk or minor surgery Low-risk noncardiac surgery w/known CAD and no high-risk results on noninvasive testing Asx exercise capacity (> or = 7 METs) Mild stable angina w/ good LVF and no high-risk noninvasive test results



Class III:
– – –

…Angiography Rec’s


…Class III:
–

–

Noncandidate for coronary revascularization owing to concomitant medical illness, severe LV dysfunction (EF<20%) or refusal to consider revascularization Candidate for liver, lung, or renal transplant > 40 y.o. as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome

Recommendation for Perioperative Medical Therapy


Class I:
–

–

Beta blockers req. in the recent past to control symptoms of angina or patients w/ sx arrhythmias or HTN Beta blockers: pt’s at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery
Beta blockers: preoperative assessment identifies untreated HTN, known CAD, or major risk factors for CAD



Class IIa:
–

...Rec on Periop Medical Therapy


Class IIb:
–

Alpha 2 agonists: perioperative control of HTN, or known CAD or major risk factors for CAD
Contraindication to beta blockers or alpha 2 agonists



Class III:
–

Rec. for Intraoperative NTG


Class I:
–

High-risk pt’s previously taking NTG who have active signs of ischemia w/o hypotension As a prophylactic agent for high-risk pt’s to prevent ischemia and cardiac morbidity, particularly in those who have req. nitrate therapy to control angina. The rec. for prophylactic use of NTG must take into account the anesthetic plan and pt. hemodynamics and must recognize that vasodilation and hypovolemia can readily occur during anesthesia and surgery.



Class IIb:
–

... Rec. for Intraoperative NTG


Class III:
–

Pt’s w/ signs of hypovolemia or hypotension

Recommendation for PAC


Class IIa:
–

Pt’s at risk for major hemodynamic disturbances that are most easily detected by a PAC who are undergoing a procedure that is likely to cause these hemodynamic changes in a setting w/experience in interpreting the results (e.g., suprarenal Ao aneurysm repair in a pt. w/ angina)
Either the pt.’s condition or the surgical procedure (but not both) places the pt at risk for hemodynamic disturbances (e.g., supraceliac Ao aneurysm repair in a pt. w/ a negative stress test).



Class IIb:
–

... Rec. for PAC


Class III:
–

No risk of hemodynamic disturbances

Recommendation for Perioperative ST-segment Monitoring


Class IIa:
–

When available, proper use of computerized St-segment analysis in pt’s w/known CAD or undergoing vascular surgery may provide increased sensitivity to detect ischemia during the perioperative period and may identify pt’s who would benefit from further postoperative and long-term interventions
Pt’s w/ single or multiple risk factors for CAD



Class IIb:
–

–
–

Class III:
Pt’s at low risk for CAD


				
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