Canadian Society of Internal Medicine Annual Meeting 2017 Toronto, ON CCS Perioperative Guidelines When to order a BNP and What to do with a Positive Troponin Dr. Vikas Tandon Associate Professor, Cardiology McMaster University November 1, 2017
CSIM Annual Meeting 2017 Conflict Disclosures I have the following conflicts to declare: Company/Organization Details Advisory Board or equivalent X X Speakers bureau member X X Payment from a commercial organization. X X (including gifts or other consideration or ‘in kind’ compensation) Grant(s) or an honorarium X X Patent for a product referred to or X X marketed by a commercial organization. Investments in a pharmaceutical X X organization, medical devices company or communications firm. Participating or participated in a clinical Participated in periop research studies McMaster University trial including VISION, POISE-2, MANAGE
CSIM Annual Meeting 2017 The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. Learning Objectives: • Understand the importance of perioperative risk assessment • Review the utility of current risk stratification tools • Examine the utility of BNP/nt - pro - BNP in the preoperative setting • Understand the significance of the postoperative troponin elevation and develop an approach to management
Perioperative Care Congress: Science, Evidence and Practice Save the date: Perioperative Care Congress 2018 May 11-13, 2018 Toronto, Ontario CANADA Visit our website http://periopcongress.org/ or follow us on twitter @periopcongress More information to follow!
Case – Mrs. B.W. • 72 y/o F with significant OA • Referred for upcoming total knee arthroplasty • Cardiac risk factors • DM, HTN, Chol, previous NSTEMI 2003 • Otherwise asymptomatic, N vitals, N labs • Meds: ASA, Atorvastatin, Coversyl, Bisoprolol • OR date – July 19, 2016
Case – Mrs. B.W. • What should be done next? 1. Send for cath 2. Take pt straight to the OR, no other consult required 3. Cancel surgery – too high risk 4. Consider for a perioperative consult by medicine and/or cardiology teams
Is the preoperative consult useful?
Scope of problem • Worldwide >200,000,000 major noncardiac surgical procedures annually • 1:20 suffer myocardial injury/infarction or cardiac arrest/death within 30 days • Perioperative cardiac complications account for ≥ 1/3 of perioperative deaths
Is the preoperative consult useful?
Is the preoperative consult useful? Yes! 1. Patients: – ethical obligation to patients to give accurate risk assessment for informed decision making 2. Physicians: – Gauge CV risk to guide management Further testing if needed – Instructions re: medications – – Postop monitoring Shared care model –
Good Pre-op Consults Specify: 1. Clear estimation of risk 2. Clear recommendation re: further testing 3. Clear recommendations for medications 4. Clear direction as to degree of post op monitoring – i.e. ward bed w tele vs CCU/ICU/Step down bed, trops 5. Clear communication of who will do what
Risk Scores • RCRI – most validated; simplest to use – CAD, stroke, CHF, DM, high risk surgery, Creatinine – Does not take into account emergency surgeries – underestimates cardiac risk by 50% • NSQIP – likely superior to RCRI – Requires an online calculator – Underestimates risk as routine troponin screening not done • All risk scores – will underestimate in >40% pts – Limited mobility so pts won’t manifest symptoms
CCS Recommendation When evaluating cardiac risk, we suggest clinicians use RCRI over other available clinical risk prediction scores Conditional recommendation low-quality evidence
Revised Cardiac Risk Index Variables Pts Hx of IHD 1 Total RCRI Risk of MI, cardiac 95% CI points arrest, or death 30 Hx of CHF 1 days after surgery Hx of CVD 1 0 3.9% 2.8%-5.4% Insulin for diabetes 1 Crt >177 µ mol/L 1 1 6.0% 4.9%-7.4% High-risk surgery 1 2 10.1% 8.1%-12.6% ≥3 15.0% 11.1%-20.0% * based on high-quality external validation studies
Is Non-Invasive Testing Useful? • Current guidelines: – Pts with low functional capacity – Pts with risk of MI/death ≥ 1% – When result will change management • Stress Nuclear and Stress Echo most common – 9% of adults ≥ age 40 with int/high risk tested
Pharmacological stress echocardiography and radionuclide imaging • Several studies, mostly small sample size and small number of events • Low quality of evidence – most retrospective, few reported risk adjusted associations • No study adequately assessed incremental value of stress tests over well-established perioperative cardiac risk factors (e.g., RCRI)
CCS Recommendations We recommend against performing preoperative exercise stress test, pharmacological stress echocardiography, or preoperative radionuclide imaging to enhance perioperative cardiac risk estimation
Is Cardiac CT Angiography Useful?
VISION CCTA • Prospective cohort study – 12 centers in 8 countries • Evaluated whether preop CCTA enhances perioperative risk prediction in 955 at-risk patients • Physicians were blinded unless LM detected • Systematic Postop Trop monitoring • Primary outcome - CV death and nonfatal MI – 74 patients (7.7%) within 30 days of surgery
Interpretation of VISION CCTA results • Although CCTA findings improve risk estimation – for patients who will suffer periop CV death or MI • CCTA findings are more than 5 X as likely to lead to inappropriate overestimation of risk – among patients who will not suffer these outcomes
CCS Recommendation We recommend against performing preoperative coronary CT angiography to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence
Biomarkers – NT pro-BNP
Individual data M-A of 2179 patients • 235 suffered death or MI within 30 days after noncardiac surgery • Preop NT-proBNP ≥300 ng/l or BNP ≥92 ng/l strongest independent preop predictor of death/MI – OR, 3.40; 95% CI, 2.57-4.47 • Compared to preop clinical model preop natriuretic peptide improved risk estimation among patients who did and did not suffer primary outcome • In sample of 1000 patients overall absolute NRI is 155 patients
NT-proBNP/BNP Risk of death or MI at 30 days after noncardiac surgery, based on patient’s preoperative NT-proBNP or BNP Test result Risk 95% CI estimate NT-proBNP <300 ng/L or BNP <92 mg/L 4.9% 3.9% - 6.1% 21.8% 19.0% - 24.8% NT-proBNP value ≥300 ng/L or BNP ≥ 92 mg/L – compared to RCRI, preop NT-proBNP/BNP results improved risk classification in 155 patients in 1000 patient sample – based on risk categories <5%, 5-10%, >10-15%, >15%
Biomarkers – NT pro-BNP • Compared to imaging, NT pro-BNP – More accurate – Less expensive – Convenient and faster due to availability of point of care NT pro-BNP assays – due to cost differential b/w NT pro-BNP and consult may have role in determining who needs preop consult
CCS Recommendation We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients ≥ 65 years of age, 45 to 64 years of age with significant cardiovascular disease, or who have RCRI score ≥ 1 Strong recommendation, moderate-quality evidence
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Case – Mrs. B.W. • 72 y/o F with significant OA • Referred for upcoming total knee arthroplasty • Cardiac risk factors • DM, HTN, Chol, previous NSTEMI 2003 • Otherwise asymptomatic, N vitals, N labs • Meds: ASA, Atorvastatin, Coversyl, Bisoprolol • OR date – July 19, 2016
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Troponin monitoring • POISE Trial (8351 patients) • 65% of patients suffering perioperative MI do not experience ischemic symptoms • Presence or absence of signs/symptoms does not change risk 30-day mortality – symptomatic MI: aOR 4.76 (95% CI, 2.68-8.43) – asymptomatic MI: aOR 4.00 (95% CI, 2.65-6.06)
VISION Study (Botto 2014) • Prospective international cohort study • 15,065 in-hospital noncardiac surgery patients TnT measured postop days 1,2,3 • MINS Criteria TnT ≥ 0.03 ng/ml due to myocardial ischemia • – death at 30 days: MINS - 9.8%, No MINS - 1.1% • 84% MINS asymptomatic – undetected without troponin monitoring • Asymptomatic perioperative TnT elevations adjudicated as myocardial injuries due to ischemia – that did not fulfill Universal Definition of MI – were also associated with increased risk of 30-day mortality – aHR, 3.30; 95% CI, 2.26–4.81
Recommendation We recommend obtaining daily troponin measurements for 48 to 72 hours after noncardiac surgery in patients with baseline risk >5%* for cardiovascular death or nonfatal MI at 30 days after surgery Strong recommendation, moderate-quality evidence * Patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥1, age 45 to 64 years with significant cardiovascular disease, or age ≥65 years
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