Clinical Controversies in Perioperative Medicine Hugo Quinny Cheng, - PowerPoint PPT Presentation

Clinical Controversies in Perioperative Medicine Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco

Predicting & Managing Cardiac Risk A 70-y.o. man with progressive weakness due to cervical myelopathy will have spinal decompression & fusion. He had a drug-eluting stent placed 8 months ago for stable angina. He also has insulin-requiring diabetes and a remote CVA. He uses a walker, needs help with some ADLs. 1. How do you assess his risk for cardiac complications? 2. What about his drug-eluting stent? 3. Should you start a beta-blocker?

70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. How would you estimate this patient’s cardiac risk? 1. I use the Revised Cardiac Risk Index (RCRI), so ~ 10% 2. I use the RCRI, so ~ 5% 3. I use the “NSQIP” prediction tool, so ~ 1% 4. I don’t need a prediction tool; my gut says he’s high risk

Revised Cardiac Risk Index # of RCRI Complications Predictors: Serious Predictors All – Ischemic heart disease – Congestive heart failure 0 0.5% 0.4% – Diabetes requiring insulin 1% 1 1.3% – Creatinine > 2 mg/dL 2 4% 2.4% – Stroke or TIA ≥ 3 9% – “High Risk” operation 5.4% (intraperitoneal, intrathoracic, All : MI, cardiac arrest, complete or suprainguinal vascular) heart block, pulmonary edema Serious : MI & cardiac arrest Devereaux PJ et al. CMAJ 2005; 173:627.

2007 ACC/AHA Guideline yes Good Functional Capacity? Go to OR no or ? ≥ 3 predictors no predictors* 1 or 2 predictors no Vascular surgery? yes Go to OR Consider stress test Control HR & or if results will change go to OR (IIa) (IIb) management (IIa) * CAD, CHF, DM, CKD, CVA/TIA

New Cardiac Risk Prediction Tool Derived from National Surgical Quality Improvement Program (NSQIP) database: • > 400 K patients in derivation & validation cohorts • Wide range of operations • “Complication” = 30-day incidence of MI & cardiac arrest Independent 1. Type of surgery Predictors 2. Age 3. Serum creatinine > 1.5 mg/dL 4. Functional status (dependency for ADLs) 5. American Society of Anesth (ASA) class Gupta PK et al. Circulation 2011; 124:681

ASA Class (a brief digression) American Society of Anesthesiologists Physical Classification 1. Healthy, normal 2. Mild systemic disease 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. Moribund patient not expected to survive without surgery • Subjective assessment • Moderate inter-observer variability

NSQIP Cardiac Risk Calculator www.qxmd.com/calculate-online/cardiology/gupta-perioperative- cardiac-risk

70-y.o. with h/o remote MI, stroke, IDDM undergoing cervical spine surgery. Needs help with some ADLs. Age 70 Cr < 1.5 ASA Class 3 Partially dependent Spine surgery www.qxmd.com/calculate-online/cardiology/gupta-perioperative- cardiac-risk

70-y.o. with h/o remote MI, stroke, IDDM undergoing cervical spine surgery for progressive weakness. 0.72% www.qxmd.com/calculate-online/cardiology/gupta-perioperative-cardiac-risk Other findings: • Excellent performance (AUC = 0.88) • MI/Cardiac arrest strongly predicts mortality (61% vs . 1%) Caveats: • Didn’t look at all possible variables (e.g., TTE, stress test)

Which Prediction Tool is Better? RCRI NSQIP Sample size ~4000 ~400,000 # of hospitals 1 > 200 ’89 −’94 ’07 − ’08 Currency of data Screen for MI? CK-MB, ECG No Changes to Practice & Guideline? • Suspect new ACC/AHA guideline will still use RCRI • Personal practice: use NSQIP when quantifying risk

70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. What about that stent? 1. Operate now, he can’t wait 2. Operate now only if he can continue antiplatelet therapy 3. Wait until 12 months after stent placement

ACC/AHA Guidelines for PCI • Avoid PCI if patient may have upcoming surgery that requires stopping dual antiplatelet therapy • Delay elective surgery in patients with recent PCI – Bare metal stent: 1 month – Drug eluting stent: 1 year

Surgical Outcomes After Stenting Question: How do stent type and time until surgery affect risk of cardiac complications? Study Design: Retrospective cohort analysis • Over 25,000 pts who had noncardiac surgery between 6 weeks & 2 years after BMS or DES placement • Identify risk factors for cardiac complications (all-cause mortality, MI, revascularization) Hawn MT et al. JAMA . doi:10.1001/jama.2013.278787

Time Since Stent Placement Time of surgery after PCI didn’t matter after first 6 months 20% Complications 6 months BMS DES 15% 10% 5% 60 120 180 240 300 360 Time between PCI & Surgery Hawn MT et al. JAMA . doi:10.1001/jama.2013.278787

Surgical Outcomes After Stenting Question: Does holding or continuing antiplatelet drugs affect risk of cardiac complications in patients with stents? Study Design: Case-control study • 284 patients with stents who had antiplatelet drugs held for noncardiac surgery matched with patients who had drugs continued Results: • Holding antiplatelet drugs did not increase risk of cardiac complications (O.R. for 0.86; 95%CI, 0.57-1.29). Hawn MT et al. JAMA . doi:10.1001/jama.2013.278787

Guidelines for DES Guideline Recommendation Wait 12 months before elective surgery if it ACC / AHA requires stopping dual therapy • Wait 6 months before surgery (strong) ACCP • If < 6 months, continue dual therapy (weak) • 6 - 12 months of dual therapy ESC • Continue ASA in favor of clopidogrel

70-y.o. with DES placed 8 months ago, IDDM and remote stroke undergoing cervical spine surgery for weakness. Would you start a beta-blocker? 1. Yes, I follow the guidelines 2. Maybe, I do this less often now 3. No, I’ve stopped doing this 4. No, I’ve never done this because I don’t trust the Dutch

2009 ACC / AHA Guideline for β -blockers Definite indications (Class 1): • Already using β -blocker to treat angina, HTN, arrhythmia Probable indications (Class 2a): • Vascular or intermediate-to-high risk surgery patients with coronary disease, or more than 1 other risk predictor * Uncertainty (Class 2b): • Patients undergoing vascular or intermediate risk surgery without coronary disease but with 1 other predictor * * CAD, CHF, DM, CKD, CVA/TIA

POISE: Treatment Protocol Patients: 8351 pts with s/f major noncardiac surgery • CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery • Not already taking β -blocker 2-4 h OR 0-6 h 12 h 2nd dose 3rd & daily dose 1st dose Metoprolol XL Metoprolol XL Metoprolol XL 100 mg 200 mg 100 mg Outcome : 30-day cardiac mortality, nonfatal arrest or MI Devereaux PJ. Lancet. 2008; 371:1839-1847

POISE: Results Metoprolol XL: Reduced cardiac events (mostly nonfatal MI) but Increased risk of stroke & total mortality Devereaux PJ. Lancet. 2008; 371:1839-1847

DECREASE-IV Patients: 1066 pts with estimated 1-6% risk of postoperative cardiac complications, undergoing elective non-CV surgery Treatment: 1. Bisoprolol 2.5 mg daily started at randomization; -- dose titrated in hospital by 1.25 - 2.5 mg daily; -- maximum 10 mg daily; -- target heart rate = 50-70 with SBP >100 2. Fluvastatin XL 80 mg daily 3. Bisoprolol + Fluvastatin 4. Double placebo • Drugs started median 34 days prior to surgery Outcome: 30-day cardiovascular mortality or nonfatal MI Dunkelgrun, M et al. Ann Surgery, 2009; 249: 921-926.

DECREASE-IV Results Cardiac Death or Nonfatal MI Bisoprolol-treated * P = .002 patients had fewer complications Trend towards benefit with statins * * No safety issues Dunkelgrun, M et al. Ann Surgery, 2009; 249: 921-926.

Investigation of possible breaches of academic integrity Findings regarding DECREASE IV: • Data poorly documented • Inclusion criteria violated • Outcomes not assessed per protocol Conclusions: • Cannot vouch for reliability of findings or validity of conclusions from this trial

β -blockers: So Now What? Meta-analysis of secure β -blocker trials • Reduces perioperative MI (mostly asymptomatic) • Increase in mortality & strokes Practice & Guideline Changes? • Uncertain benefit vs. risk, even in high risk patients • Avoid fixed dose (non- titrated) perioperative β -blockade • No good reason to start β -blocker without other indication Bouri, S et al. Heart 2013;0:1–9. doi:10.1136/heartjnl-2013-304262

Managing Perioperative Anticoagulation Your orthopedic colleague asks your advice on how to manage anticoagulation in two patients who had hip fractures. • One has atrial fibrillation due to HTN. • The other has a mechanical AVR. • Neither has any other relevant comorbidity 1. Heparin bridge for AVR only 2. Heparin bridge for AF only 3. Heparin bridge for both 4. Heparin bridge for neither

Thromboembolic Risks with Atrial Fibrillation CHADS-2 Score: 1 point for CHF, HTN, Age>75, DM Annual Stroke Risk 2 points for Stroke/TIA Score 0 - 2: < 5% stroke risk / yr Score 3 - 4: 5-10% Score 5 - 6: > 10% Ansell J. Chest. 2004;126:204S-233S.

Thromboembolic Risks with Mechanical Valves Annual Incidence Cannegieter, et al. Circulation , 1994