AHA/ACC Guidelines (2007)

AHA/ACC Guidelines (2007) – Perioperative Cardiovascular Evaluation of the Patient undergoing Non-cardiac Surgery

Take Home Message = if assessment and evaluation not indicated irrespective of perioperative context then just crack on (its all about symptoms).

3 factors involved in risk stratification:

  1. Patient risk factors (high, intermediate and low risk)
  2. Functional capacity (<4METS= low, >4METS= high)
  3. Surgery (high, intermediate and low risk)

CLINICAL ASSESSMENT

Active Medical Problems/Major Risk Factors

  • unstable angina
  • recent MI (< 1 month)
  • uncontrolled heart failure
  • significant arrhythmias (high grade AV block, symptomatic arrhythmias, supraventricular arrhythmias with a rapid ventricular rate)
  • severe valvular disease
  • recent CABG or PCI (<6 weeks)

Clinical Predictors (Lee’s Criteria)/Intermediate Risk Factors

  • previous MI (>1 month)
  • stable mild angina
  • compensated heart failure
  • renal impairment (Cr > 170)
  • DM (on insulin)

Risk of Perioperative Cardiac Events (AMI,APO, CVA, arrhythmia, death)

  • 0 factors = 0.4%
  • 1 = 1%
  • 2 = 6.6%
  • 3-5 = 11%

Minor Risk Factors

  • advanced age
  • abnormal ECG
  • arrhythmia
  • low functional capacity
  • previous CVA
  • uncontrolled HT

FUNCTIONAL CAPACITY

  • 1MET= personal cares
  • 2METS = walk indoors
  • 3METS = walk a block on level ground, dusting and washing dishes
  • 4METS = climb a flight of stairs or walk up hill
  • 5METS = run a short distance
  • 6METS = scrubbing floors or lifting heavy objects
  • 7-9METS = golf, bowling, dancing, doubles tennis, throwing rugby ball
  • >10METS = swimming, singles tennis, basketball, skiing

SURGERY

High Risk (>5%)

  • major emergency surgery
  • aortic or major open vascular surgery

Intermediate Risk (1-5%)

  • intraperitoneal and intrathoracic surgery
  • carotid endarterectomy
  • head and neck surgery
  • orthopaedic surgery
  • prostate surgery

Low Risk (<1%)  

  • endoscopic procedures
  • superficial procedure
  • cataract surgery
  • breast surgery
  • ambulatory surgery

 INVESTIGATIONS

  • FBC; anaemia
  • 12 lead ECG; conduction abnormalities, arrhythmia, Q waves, ischaemic change
  • U+E; renal function
  • ECHO; LV function, valvulopathy
  • Radionucleotide angiography (not predictive of intraoperative ischaemia)
  • ETT; good assessment as assesses symptoms and workload but only indicated if there are pre-existing symptoms of concern (sensitivity 70% and specificity 80%).
  • Dobutamine stress ECHO;
  • Radionucleotide stress testing; can quantify the areas of myocardium that is @ risk
  • ANGIO: anatomical nature of lesion and ability to revascularise

MANAGEMENT  

Preoperative

Preoperative CABG – if symptoms are stable, CABG doesn’t change risk of MI of death  (CARP study & DECREASE study).

Preoperative PCI – again, unless intervention is indicated in and of itself it doesn’t change risk.

  • balloon angioplasty -> delay surgery 2-4 weeks and keep anti-platelet agents going.
  • bare metal stent -> delay surgery 4-6 weeks (will be on clopidogrel for this time too).
  • drug eluting stents -> delay surgery for 12 months (will be on dual platelet therapy).
  • if patients must undergo therapy keep aspirin going and restart clopidogrel as soon as possible.

Perioperative management of patients with prior PCI

  • see above time frames (4 weeks, 6 weeks & 12 months) -> try and keep dual anti-platelet therapy going.
  • if can’t, keep aspirin going and reinstitute clopidogrel as soon as possible -> there is no evidence that other agents decrease risk of stent thrombosis.

Perioperative management of patients who have received intracoronary brachytherapy

  • gamma or beta brachytherapy used to treat recurrent in-stent restenosis.
  • continue anti-platelet agents if possible.

Perioperative management of the patient who requires PCI and surgery soon after

Use same time lines based on when surgery indicated:

  • 4 weeks -> balloon
  • 6 weeks -> bare metal stent
  • 12 months -> drug eluting stent
  • can put stents in and then deal with restenosis if it takes place
  • also CABG + non-cardiac surgery is an option

Perioperative Beta-blockers

  • aim = to decrease perioperative MI and death
  • should start weeks prior to surgery
  • use longer acting agents
  • aim for a HR <65/min
  • continue perioperatively
  • POISE trial: showed that introduction of betablockers on the day of surgery resulted in an increase in adverse events and mortality therefore acute commencement not advised.

Perioperative Statins

  • keep going
  • decreased risk of MI and death

Alpha 2 Agonists

  • reduction in perioperative MI and mortality

Perioperative Calcium channel blockers

  • reduced SVTand ischaemia.
  • trend towards decreased MI and death.

Intraoperative

Electomagnetic Interference + ICD’s and Pacemakers

  • recent evaluation (within 3-6 months)
  • reprogram to an asynchronous mode (D00 or V00)
  • ICD -> turn off their tachyarrhythmia treatment algorithms, place defibrillation paddles far away from device (AP ideal)
  • otherwise standard care

Postoperative

  • monitor clinically for MI.
  • if develops PCI needs to considered in context of bleeding risk.
  • manage acutely with early consultation with cardiology.

References and Links

Journal articles and textbooks

  • Fleisher LA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Anesth Analg. 2008 Mar;106(3):685-712. Mar;106(3):685-712. PMID: 18292406
  • POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47. PMID: 18479744
  • Fleisher LA et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009 Nov 24;54(22):e13-e118. PubMed PMID: 19926002
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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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