Update in Perioperative Medicine: Amish A. Dangodara, MD, FACP

Update in
Perioperative
Medicine
Amish A. Dangodara, MD, FACP

Professor of Medicine
UCI Hospitalist Program
9.16.14
Disclosures
Conflicts of Interest: None
UCI Hospitalist Program|

9.15.14
Objectives
Learning Objectives:
Review changes in latest guidelines for preoperative
evaluation from prior guidelines
Determine who needs preoperative cardiac risk
assessment
Outline the 7 step preoperative cardiac risk algorithm
Review guidelines for preoperative cardiac testing
Review guidelines for preoperative cardiac
intervention
Review guidelines for preoperative medical
optimization
9.15.14
The 2014 ACC-AHA Guidelines for

Perioperative Cardiovascular Evaluation
(Noncardiac Surgery)

9.15.14
Strength of Recommendation
Class of recommendation:
Level of Evidence:
Class I:
Benefit >>> Risk,
should be done or
administered
Class IIa: Benefit >> Risk,
reasonable to do or
administer
Class IIb: Benefit > Risk,
consider doing or
administering
Class III: No benefit (or
harm), not recommended
or harmful
Level A: Data from multiple

RCT or meta-analyses
Level B: Data from single
RCT or limited number of
non-RCT
Level C: Consensus
opinion, case report, or
standard of care only

9.15.14
Case
Ms. Dianne Young is a 56 year
old woman scheduled for
tumor debulking and
resection of ovarian mass
for suspected ovarian
cancer, referred for
evaluation of heart
murmur, arrhythmia,
HTN, TIA, and diabetes.
No other PMHx.
Does she need preoperative
cardiac risk assessment?
A) Yes
B) No
9.15.14
Who Needs Preoperative Cardiac Risk

Assessment?
Known CAD:
Risk Factors for CAD:
History of MI
Angina-type chest pain
relieved with NTG
EKG with pathological Q
waves
Abnormal non-invasive
cardiac stress test or
coronary angiogram
Prior coronary intervention
or CABG
Age >55
Diabetes
Stroke (CVA/TIA)
Heart failure
Moderate-severe valvular
disease
Significant arrhythmia

9.15.14
Case
Ms. Dianne Young is a 56 year old
woman scheduled for tumor
debulking and resection of
ovarian mass for suspected
ovarian cancer, referred for
evaluation of heart murmur,
arrhythmia, HTN, TIA, and
diabetes. No other PMHx.
What is the urgency of the
surgery?
A) Elective
B) Time sensitive
C) Urgent
D) Emergent
9.15.14
Urgency of Surgery
There is a new sense of
urgency:
Emergent: Life or limb
threat if no surgery <6
hours
Urgent: Life or limb threat if
no surgery within 6 - 24
hours
Time Sensitive: Delay of
surgery for >6 weeks will
negatively affect outcome
Elective: Surgery could be
delayed up to 1 year
without harm
9.15.14
Case
tumor debulking and
What is the risk of the surgery?
A) Low
B) Elevated
C) Intermediate
D) High
9.15.14
Low Risk for Surgery

Procedural Risk <1%
mortality:
Herniorrhaphy
Breast surgery
Superficial / Derm
procedures
Cosmetic surgery
Ophthalmologic surgery
Dental / oral surgery
Low risk surgery
Endoscopic / angiographic
Patient Risk Factors:

no unstable cardiac
conditions:
Recent MI (<1-6 months)

Class III-IV angina (<4
METs)
Decompensated HF < 1
week
Safe!
Unstable arrhythmia
Severe-critical valvular
disease

9.15.14
Risk of Surgery
A new risk emerges:
Risk: combined surgical and
patient risk factors to predict
major adverse cardiac event
(MACE) = ACS, MI, HF, unstable
arrhythmia, death
Low:
<1% MACE
Elevated: >1% MACE
Simplified risk assessment

reflects management decisions:
Low risk:
no intervention
Elevated risk: optimize or
cancel
For greater accuracy, use

validated clinical risk predictors
9.15.14
Does Risk Assessment Change

Management?
Will risk stratification affect the patients decision to
proceed with surgery? If yes, then accurate risk
assessment is needed.

9.15.14
Cardiac Risk Stratification: RCRI

Criteria
Validation Set, N=1422
ROC Curves
0.8
Goldman (0.70)
0.6
0.4
Detsky (0.58)
ASA (0.71)
0.2
RCRI (0.81)
0.5
Specificity
Lee, TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk
of Major Noncardiac Surgery, Circulation, 1999; 100: 1043.
9.15.14
Revised Cardiac Risk Index (RCRI)

Criteria
Compensated CHF = OR 4.3
Known coronary artery disease = OR 3.8:
angina or CP with NTG
remote MI > 3 -6 months 0 RCRI = <1% mortality
1-2 RCRI = 2-7% mortality
EKG: pathological Q waves
3-4 RCRI = 9-18% mortality
abnormal stress test
>5 RCRI = >32% mortality
abnormal cardiac cath
BNP & CRP improve RCRI
prior CABG or PCI
accuracy
Hx TIA or CVA = OR 3
Intra-abdominal or high risk surgery = OR 2.6
DM requiring insulin = OR 1
Renal insufficiency, Cr >2 = OR 0.9
Lee, TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major
Noncardiac Surgery, Circulation, 1999; 100: 1043.
9.15.14
Cardiac Risk Stratification: NSQIP 21

Questions
ACS NSQIP calculator: http://riskcalculator.facs.org/

9.15.14
Cardiac Risk Stratification: Role of

Cardiac Testing
When is it indicated?
Cardiac Testing
Surgery: non-emergent,
elevated risk procedure
Patient: suspected moderatesevere valvular heart disease
or unstable cardiac conditions
Unknown or poor functional
capacity
Testing will change
management
Patient may decline surgery
Preoperative coronary
intervention is needed
Echocardiography
Exercise testing +/imaging
Noninvasive
pharmacological stress
testing
Coronary angiography
(Insufficient evidence for
CT coronary angiogram)

9.15.14
Cardiac Risk Assessment Algorithm

Steps 1 - 3:
Steps 4 - 7:
MACE = major adverse cardiac event

MET = metabolic equivalent time
GDMT = guideline directed medical therapy
CPG = clinical practice guideline

9.15.14
Comparing Previous and Current

Guidelines
2007 ACC-AHA Guideline:
2014 ACC-AHA Guideline:
1.
1.
2.
2.
3.
4.
5.
6.
7.
8.
Known CAD, cardiac symptoms,

and/or exam findings
Urgency of surgery
If emergent, proceed with

medical optimization
Treat unstable cardiac
conditions
Proceed if low risk surgery
Proceed if >4 METs
Clinical risk (RCRI) if <4 METs
or ?
Cardiac testing if change in
management based on RCRI &
vascular surgery if RCRI not zero
Medical optimization & risk
assessment
3.
4.
5.
6.
7.
Known CAD or risk factors

Urgency of surgery (time sensitive)
If emergent, proceed with

hemodynamic monitoring
If not emergent, treat unstable

cardiac conditions
Clinical risk (any tool +/- BNP) for
MACE
Proceed if surgery and medical risk
factors indicate low risk <1% MACE
Assess METs if elevated risk surgery
>10 METs, proceed [Class IIa]
4-10 METs, proceed [Class IIb]

Cardiac testing if change in
management
Medical optimization & risk
assessment
9.15.14
Case
tumor debulking and
evaluation of heart
murmur, arrhythmia, HTN,
TIA, and diabetes. No other
PMHx. She is only able to
walk around the house, but
without cardiac symptoms.
Does she need an EKG?
A) Yes
B) No
9.15.14
Indications for EKG

Class III-B (No Benefit, Not
Indicated):
Low risk surgery <1% MACE
Class IIb-C Recommendation:
Preoperative EKG useful as

baseline
Q waves, ST changes, long QTc,

LVH, & BBB may be predictive
Obtain EKG <3 months if

indicated & patient is stable
[UCI guide <6m]
Class IIb-B Indication:
Asymptomatic patient without

CAD (+ cardiac risk factors)
Class IIa-B Indication:
Known CAD
Significant arrhythmia
PAD
Stroke (CVA/TIA)
Major structural heart disease

9.15.14
Case
She is only able to walk
around the house. Exam
reveals III/VI systolic murmur
at apex radiating to axilla &
clear lungs. No prior
echocardiogram done.
Does she need an
echocardiogram?
A) Yes
B) No
9.15.14
Indications for Echocardiogram

Indicated):
Routine preoperative
screening
Low risk surgery <1% MACE
Class IIb-C Indication:
Known LV dysfunction in stable

patient with study >1 year ago
Class IIa-C Indication:
Unknown cause of dyspnea (or

new Dx of clinically suspected HF)
Known HF with worsening

dyspnea
Class IIb-B Recommendation:
EF <30-35% predictive of MACE

but no better than clinical
prediction
High specificity but poor

sensitivity
Class I-C Indication:
Clinically suspected moderatesevere valvular disease if no

study <1 year, or if change in
clinical status

9.15.14
Case
diabetes. No other PMHx. She
is only able to walk around the
house, but without symptoms.
Exam shows apical murmur
and clear lungs.
What is her functional capacity?
A) Unknown
B) <4 METs
C) 4-10 METs
D) >10 METs
9.15.14
Functional Capacity
Poor:
1 MET = ADLs (3.5 mL O2/Kg/min)
2 METs = walk around house
3 METs = walk 1-2 blocks, carry 5-10 lbs
Good:
4 METs = light yard/house work (sweep)
5 METs = climb >1 floor stairs, lift >20 lbs.,
walk >4 blocks
6 METs = heavy yard/house work (mow)
7 METs = golf, bowling, dance, carry 60 lbs,
walk uphill or >1 mile
8 METs = carry weight upstairs, move
heavy furniture
9 METs = bike at moderate pace, jump rope
10 METs = bike uphill, brisk swim, jog
quickly
Excellent:
>10 METs = sustained fast run,
competitive sport
Hlatky, M.A., Boineau, R.E., et. al. "A Brief Self-Administered Questionnaire to Determine Functional Capacity
(The Duke Activity Status Index)." American Journal of Cardiology, 1989; Vol. 64: 651 - 654.
Case
diabetes. No other PMHx. She
is only able to walk around the
Exam shows apical murmur
and clear lungs. EKG shows
sinus rhythm & non-specific ST
changes.
Does she need a stress test?
A) Yes
B) No
9.15.14
Indications for Exercise Stress Testing

Indicated):
screening for low risk surgery
<1% MACE
If it will change management &

elevated risk surgery, then:
<4 METs functional capacity,

stress test with imaging may
help
Unknown functional
capacity, exercise stress test
(no imaging) may help
4-10 METs functional

capacity, stress test not
needed
>10 METs functional

capacity, stress test not
needed
9.15.14
Indications for Pharmacological Stress

Testing
Indicated):
screening for low risk surgery
<1% MACE

<4 METs functional capacity,

then dobutamine
echocardiogram or
pharmacological nuclear stress
test is helpful
Drug:
Nuclear Agent:
Dipyridamole (Persantine)
Adenosine (Adenocard)
Regadenoson (Lexiscan)
Thallium-201 (Mibi)
Technitium-99m (Cardiolyte or
Sestamibi)
Moderate to large reversible

defect predicts increased risk of
MACE
Fixed defect is not predictive
9.15.14
Case
debulking and resection of ovarian
mass for suspected ovarian
cancer, referred for evaluation of
heart murmur, arrhythmia, HTN,
TIA, and diabetes. No other PMHx.
She is only able to walk around
the house, but without
symptoms. Exam shows apical
murmur and clear lungs. EKG
shows sinus rhythm & non-specific
ST changes. She prefers chemoTx
to surgery if she is very high risk
for surgery but does not want to
consider CABG.
Will a stress test change
management?
A) Yes
B) No
9.15.14
Case
diabetes. No other PMHx. She is
only able to walk around the
Exam shows apical murmur and
clear lungs. EKG shows sinus
rhythm & non-specific ST
changes.
What type of stress test should she
get?
A) Exercise only
B) Exercise with imaging
C) Dobutamine echocardiogram
D) Pharmacological nuclear
9.15.14
Exercise or Pharmacological Stress Test?

Choice of stress:
Patients ability to exercise
Baseline EKG (i.e. BBB or
paced)
Choice of drug:
Adenosine and Dipyridamole
cause bronchospasm, transient
AV block, hypotension, and are
inhibited by xanthine use
Dobutamine causes elevated BP
and/or HR, increasing ischemia,
and is inhibited by beta-blocker
Regadenoson is contraindicated
in high grade AV block or sinus
node dysfunction

9.15.14
Case
clear lungs. Dob Echo shows
RWMA in mid-distal LAD & LCx
distribution. She does not want
to consider CABG.
Does she need a cardiac
catheterization?
A) Yes
B) No
9.15.14
Indications for Preoperative Coronary

Angiogram
Class III-C (No Benefit, Not
Indicated):
screening

CT coronary angiography is
lower risk than invasive
angiogram, but insufficient
evidence
Indication is the same as

non-preoperative setting
(defer to Cardiologist)
Some Considerations if
Abnormal:
Will delay from PCI or CABG

increase risk of surgical
condition?
Can surgery be done safely

with anti-platelet therapy?
9.15.14
Indications for Preoperative PCI

Indicated):
revascularization
Class III-B (Harm, Not Indicated):
Candidate for CABG & poor
PCI anatomy

Class II-III, B-C Indications per PCI
CPG
Class IIb-B Recommendation:
DES: surgery >180 days if

urgent
Class IIa-C Recommendation:
Hold anti-platelet therapy if risk

of bleeding > risk of MACE
Class I-B Recommendations:
PTCA without stent: delay 14

days
BM stent: delay 30 days
DES: delay 365 days
Continue dual anti-platelet

therapy within above time
frames
9.15.14
Indications for Preoperative CABG

Indicated):
revascularization
If it will change management & elevated

risk surgery, then:
Class I-B Indication:
Significant LM disease
Complex CAD
3-vessel disease
2-vessel disease with proximal LAD
Survivor of sudden death

2-vessel disease without proximal

LAD and extensive ischemia
1-vessel disease with proximal LAD
1-vessel disease with EF 35 - 50%

2-vessel disease without extensive

ischemia
1-vessel disease without proximal

LAD and EF<35%
9.15.14
Case
clear lungs. Cardiac cath was
not done. Meds include ACE-I.
What medical optimization is
indicated?
A) Beta-blocker
B) Statin
C) Alpha-2-agonist
D) Anti-platelet
9.15.14
Beta-Blocker Controversy
Beta-blocker benefit: DECREASE
Trials
Lead researcher discredited
and data not used
Beta-blocker harm: POISE Trial
Clinically unsound study, but

good methodology & large
study

9.15.14
Perioperative Beta-Blocker &

Morbidity/Mortality
POISE Trial: High dose Toprol XL in Elderly Surgical Patients
Devereaux, P, et al. POISE Trial. Lancet, 2008; 371: 1839.
HF, brady
Sepsis
Hypotension
9.15.14
Indications for Beta-Blocker to Reduce

MACE
Class III-B (Harm, Not Indicated):
Do not initiate on day of
surgery
If elevated risk surgery:

Intermediate-high risk ischemia

seen on preoperative testing
>3 RCRI Criteria
<3 RCRI with primary longterm indication (CAD, HF, HTN)
Start >1 day preoperatively

Class IIa-B Recommendation:
May be continued
postoperatively if clinically safe
(SBP>100, HR>55, no acute
anemia or Hgb >10)
Class I-B Recommendation:
May be safely continued if

tolerated as chronic therapy
9.15.14
Perioperative Beta-Blocker & Mortality
Lindenauer, PK et. al. Perioperative Beta-Blocker Therapy and Mortality After Noncardiac Surgery,
NEJM, 2005; 353: 349.
9.15.14
Perioperative Beta-Blockers & Statins

9.15.14
RCRI Criteria & Beta-Blockers
RCRI Criteria:
CHF*
CAD*
CVA/TIA
DM
RF
Major surgery
100%
90%
80%
70%
60%
50%
40%
30%
20%
Total Criteria
Single Criteria
10%
0%
Single CriteriaTotal Criteria

9.15.14
Perioperative Beta-Blockers & Acute

Anemia
MACE= Major Adverse Cardiac Event
Beta-Blocker
- - - No Beta-Blocker
Lowest Hgb < 3d postop
(g/L)
Restrictive transfusion for Hgb <10 has same outcome as

liberal transfusion.
Maintain Hgb >7 if asymptomatic, Beattie,
or >8WS,
if etcardiac
symptoms
al. Anesthesiology,
2010; 112: 25.
UCI
Hospitalist
Program|
[Class IIb-C].
9.15.14
Indications for Perioperative Statin

If elevated risk surgery:
Consider initiating if
undergoing high risk
procedure
Initiate for vascular

surgery
Class I-B Indication:
Continue if chronically
using
RCRI-based indication was
discarded with DECREASE
data
9.15.14
Indications for Perioperative Alpha-2

Agonist
Class III-B (No Benefit, Not Indicated)
Insufficient data to recommend
Benefit seen in those also taking beta-blocker

Wallace, AW, et al. Anesthesiology, 2004; 101(2): 284.
Wijeysundera, DN, et al. Cochrane Database Syst Rev, 2009 Oct 7; (4): CD004126

9.15.14
Indications for Perioperative

Antiplatelet
Class III-C Indication:
Consider if risk of coronary

ischemia outweighs
bleeding
Indicated):
Initiating in non-coronary
stent patient
Class I-C Indication:
Continue for coronary stent

or PTCA per stent
guidelines
9.15.14
Additional Considerations
Moderate-Severe Valvular Heart Disease:
Class I-C Recommendation:
Obtain echocardiogram if clinically suspected and none

<1 year or change in symptoms
Replace or repair valve for elective surgery

Aortic Stenosis:
Elevated risk surgery can be performed with

hemodynamic monitoring in asymptomatic patients if not
candidate for intervention [Class IIa-B]
TVAR is option for high risk patients [Class IIb-C]

Mitral Stenosis:
Elevated risk surgery can be performed with

hemodynamic monitoring in asymptomatic patients if not
candidate for intervention [Class IIb-C]
9.15.14
Additional Considerations
Moderate-Severe Valvular Heart Disease:
Aortic & Mitral Regurgitation:
Elevated risk surgery can be performed with hemodynamic

monitoring in asymptomatic patients if not candidate for
intervention [Class IIa-C]
Arrhythmias:
Asymptomatic PVCs, couplets, NSVT did not increase MACE and

require no therapy
Ventricular arrhythmias caused by structural heart disease should

be treated
High-grade AV block or sinus node dysfunction may require pacing
Beta-blocker can be used in BBB or bifascicular block

SVT should be rate-controlled
Anticoagulation for A-fib should be adjusted
perioperatively
9.15.14
Summary Recommendation for 2014

Guideline
2007 Guideline
2014 Guideline
Guidelines are used if easy

Evaluate urgency of surgery
Evaluate for unstable cardiac
conditions: ACS, recent MI,
ADHF, moderate-severe valvular
disease, significant arrhythmias
Use RCRI (easy) criteria; +/-EKG
If elevated risk, are METS >4?
If not, stress test if it changes
Tx
Medically optimize: beta-blocker
based on RCRI/indication, statin,
continue antiplatelet if stent
Estimate risk
9.15.14
Cardiac Risk Assessment Algorithm

Steps 1 - 3:
Steps 4 - 7:
MACE = major adverse cardiac event

MET = metabolic equivalent time
GDMT = guideline directed medical therapy
CPG = clinical practice guideline

9.15.14
Questions?

9.15.14

Update in Perioperative Medicine: Amish A. Dangodara, MD, FACP

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Update in

Amish A. Dangodara, MD, FACP

UCI Hospitalist Program|

The 2014 ACC-AHA Guidelines for

UCI Hospitalist Program|

Level A: Data from multiple

UCI Hospitalist Program|

Who Needs Preoperative Cardiac Risk

Risk Factors for CAD:

UCI Hospitalist Program|

Low Risk for Surgery

Patient Risk Factors:

Recent MI (<1-6 months)

UCI Hospitalist Program|

Simplified risk assessment

For greater accuracy, use

Does Risk Assessment Change

UCI Hospitalist Program|

Cardiac Risk Stratification: RCRI

Revised Cardiac Risk Index (RCRI)

Cardiac Risk Stratification: NSQIP 21

ACS NSQIP calculator: http://riskcalculator.facs.org/

Cardiac Risk Stratification: Role of

UCI Hospitalist Program|

Cardiac Risk Assessment Algorithm

MACE = major adverse cardiac event

UCI Hospitalist Program|

Comparing Previous and Current

2014 ACC-AHA Guideline:

Known CAD, cardiac symptoms,

If emergent, proceed with

Known CAD or risk factors

If emergent, proceed with

If not emergent, treat unstable

>10 METs, proceed [Class IIa]

4-10 METs, proceed [Class IIb]

Indications for EKG

Class IIb-C Recommendation:

Preoperative EKG useful as

Q waves, ST changes, long QTc,

Obtain EKG <3 months if

Asymptomatic patient without

Major structural heart disease

UCI Hospitalist Program|

Indications for Echocardiogram

Class IIb-C Indication:

Known LV dysfunction in stable

Unknown cause of dyspnea (or

Known HF with worsening

EF <30-35% predictive of MACE

High specificity but poor

Clinically suspected moderatesevere valvular disease if no

UCI Hospitalist Program|

Indications for Exercise Stress Testing

If it will change management &

<4 METs functional capacity,

4-10 METs functional

>10 METs functional

Indications for Pharmacological Stress

If it will change management &

<4 METs functional capacity,

Moderate to large reversible