Preoperative Assessment of the Cardiac Patient Undergoing ...

Preoperative Assessment of the
Cardiac Patient Patient Undergoing
Undergoing
Non Non-Cardiac Cardiac Surgery: State of the Art
University of Michigan
Cardiovascular Center
Kim Kim A. Eagle, MD
Albion Walter Hewlett Professor
Director

Kim A. A Eagle Eagle, MD, MD FACC
FACC
Director
University of Michigan
Cardiovascular Center
Grants Grants: : NIH, Hewlett Foundation,
Mardigian Foundation, Varbedian Fund,
GORE
Cons Consultant: ltant NIH NHLBI

Lecture Outline
• Estimating Patient Risk
• Causes of Perioperative Cardiac Events
• Role of Non Invasive Testing
• Medical Therapy
• Role of Revascularization
• Approach to Preoperative Screening
• Perioperative Management
• Final Comments

Estimation of the Patient’s Risk
Clinical Markers
Functional Status
Surgery - Specific Risk
Proceed with Surgery Further Evaluation/Mgmt
Evaluation/Mgmt.
Eagle KA, et al. JACC Guidelines 2002;39:542-53.

"Always Always make make things as
as
simple i l as possible......but ibl b t
never more so."
-Albert Albert Einstein

Independent Clinical Markers of
Elevated Perioperative Perioperative Risk
Risk
MMarker k RRelative l ti Risk Ri k CConfidence fid Limit Li it
Known CAD 2.4 1.3 - 4.2
Prior Heart Failure 1.9 1.1 - 3.5
Diabetes 3.0 1.3 - 7.1
RRenal l IInsufficiency ffi i 30 3.0 14 1.4 - 68 6.8
Lee, et al. Arch Int Med 1999;159:2185-92.

Death
. MI or
Periop.
10%
Clinical Risk Status and
5%
0%
V Vascular l Surgery S
03% 0.3%
Low Risk
(0 markers)
(n=1476)
2.2%
Intermediate Risk
(1-2 markers)
Clinical Risk Status
85% 8.5%
High Risk
(≥ 3 markers)
Poldermans et al. JACC 2006;48:964-969.

Risk
Higher
Lower
Functional Status
• Difficulty y with ADL
• Can’t walk four blocks or
up two flight of stairs
• Inactive but no limitation
• Active: Easily does
vigorous tasks
• Performs regular
vigorous exercise
Eagle KA, et al. JACC Guidelines 2002;39:542-53.

Mortality Data: Anaerobic Threshold
Ab Above and d Below B l 11ml/min/kg
11 l/ i /k
Anaerobic CCardio-
Threshold Vascular Percentage
ml/min/kg l/ i /k NNo. DDeaths th MMortality t lit
11 132 1 0.8
Totals 187 11 p

Functional Status
- Self Reported -
EndPoint* Poor + Good p-value
Complication ++ 20.4% 10.4%

Surgery g y - Specific Specific p Risk
Higher
• Aortic
• Non-Carotid Peripheral
Vascular
• Major Thoracic
•Major Abdominal
• Carotid
• Head/Neck
• Orthopedic
Lower • Eye Eye, Skin
Risk j
Eagle KA, et al. JACC Guidelines 2002;39:542-53.

“High Risk” Non Cardiac Surgery
Known CAD CAD-Medical CAD CAD-Medical Medical Rx – Pre Beta
Beta
Blocker Era
Type of Surgery # Patients MI Death MI/Death
Abd Abdominal i l 355 09% 0.9% 31% 3.1% 40% 4.0%
Vascular 106 8.5% 2.8% 11.3%
Thoracic 52 1.9% 5.8% 7.7%
Head and Neck 69 4.4% 2.9% 7.3%
“High High Risk Risk” 582 2.7% 3.3% 6.0%
Eagle K, et al. Circulation 1997;96:1882-87.

Adjusteed
Mortallity
(%)
12
8
4
0
Operative Mortality
Carotid Endarterectomy
1.7
1.6
1.6
1.5
1.5
Lower-extremity bypass
5.1
4.8
4.6
4.8
Elective repair of abdominal
aortic aneurysm
6.5
5.2
4.6
41
4.7
4.1 39 3.9
Birkmeyer et al. N Engl J Med 2002;346:1128-37.

“Low Risk” Non Cardiac Surgery
Known CAD CAD-Medical Medical Rx – Pre
BetaBlocker Era
Type of Surgery # Patients MI Death MI/Death
Urologic 225 0.9% 0.9% 1.8%
Orthopedic 159 0.6% 0.6% 1.2%
“Low Risk” 484 0.8% 0.8% 1.6%
Eagle K, et al. Circulation 1997;96:1882-87.

Cardiovascular Risk: Non Cardiac
S Surgery Surgery NSQIP Data: D t 2002 2002-2005 2002 2002-2005 2002 2005
Procedure (n) ( ) Mortalityy Morbidityy Combined
Endovascular
AAA
(600) 1.67% 12.83% 14.50%
Carotid
Endarterectomy
(1717) 0.58% 8.44% 7.02%
Parathyroid
Surgery
(1651) 0.42% 2.29% 2.71%
Inguinal Hernia (4321) 0.14% 1.47% 1.61%
Thyroidectomy (3041) 0.06% 1.51% 1.57%
Breast (3855) 00.00% 00% 11.22% 22% 11.22% 22%
Lumpectomy

Mortality After Bariatric Surgery
Morttality
5
4
3
2
1
0
2.0%
(n=16,155) ( (n=16,155) 16 155)
28% 2.8%
4.5% %
30 DDay 90 DDay 11-Year Y
JAMA 2005;294:1903-08.

Predictors of Death at 30 Days:
Bariatric Bariatric Surgery
Women (1.5%) Men (3.7%)
< 65 years (1 (1.7%) 7%) > 65 years (4 (4.8%) 8%)
Independent Predictors of Death:
>65yrs – 5 fold ↑
Low Volume Operator p – 1.6 fold ↑

Independent p Predictors of Risk
Clinical Markers
CAD (RR 2.4)
HF (RR 1.9)
DM (RR ( 3.0) )
Poor Functional Status (RR 1.8)
Surgery - High Risk (RR 22.8) 8)
Renal Insuf. (RR 3.0)

Questions:
Who Needs Further
NonInvasive N NNonInvasive I i Testing? T ti ?
1. Will test results lead to change in care?
2. Has the patient been tested recently?
3. Is the concern related to CAD or is LV
DDysfunction f ti a concern? ?
44. Can the patient do an exercise test?

Active Cardiac Conditions for Which the
Patient Should Undergo Undergo Evaluation Evaluation and
Treatment Before Noncardiac Surgery
(Class I, Level of Evidence: B)
• Unstable coronary syndromes
• Decompensated HF (NYHA functional
class IV; worsening or new-onset HF)
• Si Significant ifi t arrhythmias h th i
• Severe valvular disease
J Am Coll Cardiol. 2007;50;159-241.

NonCardiac Testing Prior to Vascular
S Surgery M Meta t Analysis A l i
No. of No. of No. of Sensitivity, Specificity,
Test studies patients events % (95% CI) % (95% CI)
Radionuclide
ventriculography g p y
Ambulatory
8 532 54 50 (32-69) ( ) 91 (87-96) ( )
electrocardiography
Exercise
8 893 52 52 (21-84) 70 (57-83)
electrocardiography
Myocardial perfusion
7 685 25 74 (60-88) 69 (60-78)
scintigraphy
Dobutamine stress
23 3119 207 83 (77-89) 49 (41-57)
echocardiography
Dipyridamole stress
8 1877 82 85 (74-97) 70 (62-79)
echocardiography 4 850 33 74 (53-94) 86 (80-93)
Devereaux, P.J. et al. CMAJ 2005;173:627-634.

Preoperative Thallium Study Performance
N PPV NPV
Boucher ‘85 48 19% 100%
Cutler ‘87 116 20% 100%
Fletcher ‘88 67 20% 100%
Sachs ‘88 46 14% 100%
Eagle ‘89 200 16% 98%
McEnroe ‘90 95 9% 96%
Younis ‘90 90 111 15% 100%
Mangano ‘91 60 5% 95%
Strawn ‘91 68 6% 100%
Watters ‘91 26 20% 100%
Hendel ‘92 327 14 99%
Lette ‘92 355 17% 99%
Madsen ‘92 65 11% 100%
Brown ‘93 231 13% 99%
Kresowik ‘93 170 4% 98%
Baron ‘94 94 457 4% 96%
Bry ‘94 237 11% 100%
Koutelou ‘95 106 6% 100%
Marshall ‘95 117 16% 97%
Van Damme ‘97 142 N/A N/A
Huang ‘98 106 13% 100%
Cohen ‘03 153 4% 100%
TOTAL 3303 12% 99%

Preoperative Dobutamine
E Echocardiogram h di Performance
P f
N PPV NPV
Lane ‘91 91 38 16% 100%
Lalka ‘92 60 23% 93%
Eichelberger ‘93 75 7% 100%
Langan g ‘93 74 17% 100%
Poldermans ‘93 131 14% 100%
Davila-Roman ‘93
88 10% 100%
Poldermans ‘95
302 24% 100%
Shafritz ‘97 97
42 NA 97%
Plotkin ‘98
80 33% 100%
Ballal ‘99
233 0% 96%
Bossone ‘99
46 25% 100%
Das ’00 530 15% 100%
Boersma ’01 1097 14% 98%
Morgan ’02 78 0% 100%
Torres ’02 02 105 18% 98%
Labib ’04 429 9% 98%
TOTAL 466 20% 99%

Which Stress Test?
No Yes Test
Can the patient exercise? x ETT
Am I concerned about valve disease? x Echo
Am I quantifying q y g muscle at risk? x Nuclear
Am I concerned about false positive? x Echo
Am I concerned about LV? x Echo/Nuke
Role of CT and MR not yet clear

Clinical Assessment
Only
1081 patients Bayes
Theorem
Low
High
3%(10/344) Moderate 18%(33/187)
(1-7%) 8%(42/550) (12-24%)
Dypridomole
Thallium
(6-10%)
(p

What Causes Perioperative
Cardiovascular C CCardiovascular di l Events? E t ?
• Catecholamine surges
• Prothrombotic milieau
• Blood Loss
• Volume Shifts
• Coronary Plaque destabilization
• Fixed Coronary Disease +
+ Stress testing predicts only one of the six!

Fatal Perioperative MI
Coronary C CCoronary P Pathology th l (n=42) ( 42)
Coronary Stenosis Pathology
(

Medical Therapy to Reduce
P Perioperative i ti Events E t
• Beta Adrenergic Blockers
• Statins
• Aspirin

Peri Peri-operative operative p Management g
Eveent-Free
Survival S (% %)
Beta-blocker Rx (Atenolol) 1,2
200 pts with or at risk for CAD
Atenolol Discharge
100
90
80
Atenolol
70
60
50
Placebo Peri-op Ischemia
No Hosp D/MI
40
30
20
10
0
P

Decrease Study y Design g
Elective Aortic Surgery
Clinical Markers of Risk
Demonstrable Ischemia
on
Dobutamine Echo
B-Blocker Blocker + Placebo
+ Titrated over days/weeks
NEJM 1994; 341:1749.

Perrcentage
of o Patientts
40
30
20
10
Peri Peri-operative operative p Management g
Beta Beta-blocker blocker Rx (Bisoprolol) 1
High g risk vasc surgery g y
Bisoprolol 7-89 7 89 days pre-op pre op (mean 37)
St Standard d d care
P

Do B B-Blockers Blockers Protect Protect Extremely Extremely High
High
Ri Risk k P Patients ti t Having H i Vascular V l Surgery? S ?
Preopera Preopera ative MI or De eath %
3
2
1
0 - 2 Clinical Markers > 3 Clinical Markers on Clinical Eval.
2.3%
20/855
10
0.8%
2/263 2.3%
2/86
5
< 4 Echo Segments
of new WMA
40
10.6%
12/121 36%
4/11
20
> 5 Echo Segments
of new WMA
0 0 0
B-Blocker No BB B-Blocker No BB B-Blocker No BB
33%
5/15
Boersma, Poldermans, et al. JAMA 2001.

B-Blockers Blockers to to Lower Lower Vascular Vascular Surgical
Surgical
Ri Risk: k Influence I fl of f Pre Pre-op Pre Pre-op P op H Heart t R Rate t
Periop P MI M or Death
6%
5%
4%
3%
2%
1%
0%
1.3%
Heart Rate
< 65 BPM
p=0.003
5.2%
Heart Rate
> 65 BPM
Poldermans et al. JACC;48:964-969.

“I always like to use a
new drug before its
effectiveness wears off”
- William Osler

Effect of Perioperative BB-Blockade
Blockade
in Non-cardiac Non cardiac surgery among Medicare beneficiaries
Among
Ideal
MMedicare di
Patients
Treated
with
BBeta t Blockers Bl k
(n=75,190)
Not treated
with
BBeta t Blockers Bl k
(n=260,238)
Mortality 22.73% 73% 22.91% 91%
Lindenaeur PK, Pekow P, Wang K, et al., Perioperative Beta Blocker Therapy and Mortality following
major Non-cardiac Surgery. NEJM 2005;353:349-61.

Targeting Perioperative
B B-Blockers Bl Blockers k to t the th “Right” “Ri ht” Patients P ti t
Revised Cardiac Risk Death Rate Odds Ratio #Needed: Treat #Needed: Harm
Clinical Subgroup
Score - 0
Score - 1
1.4% 1.36 - 208
All 2.2% 1.09 - 504
Diabetes 1.7% 1.28 - 209
Isch Isch. Hrt Hrt. Disease 20% 2.0% 112 1.12 - 408
Cerebro. Vasc. Dis. 9.0% 1.03 - 410
Renal Insuff. 7.2% 1.01 - 1505
High Risk Surgery 20% 2.0% 094 0.94 864
Score - 2 3.9% 0.88 227
Score - 3 5.8% 0.71 62
Score - 4 7.4% 0.58 33
Lindenaur PK, et al. NEJM 2005; 353:349-61.

“Evidence does not support
the use of β-blocker therapy
for the prevention of
perioperative p p clinical
outcomes in patients having
non-cardiac surgery.”
-The The Lancet

“One of the first
duties of the
physician is to
educate the
masses not ttto
take medicine.”
medicine.
Sir William Osler
(1849 – 1919)

*Average heart rate
72 bpm - BB vs.
78 bpm - Placebo
Diabetic Postoperative
Morbidity M MMorbidity bidit and d Mortality M t lit Trial T i l
921 Patients
Diabetic/No known CAD
B Blocker* Randomization Placebo*
Atenolol 50mg evening prior to surgery
Atenolol 100mg Q A.M.
Non Cardiac Surgery
Non Cardiac Surgery
( (>50% 50% Abd. Abd or Orthopedic) O th di )
( (>50% 50% Abd. Abd or Orthopedic)
O th di )
Combined In hospital endpoint, Mortality,
MI, , Unstable angina, g , Heart failure
21% (All cause death - 16% for both groups)
20%

Peri erioperative perative Ischemic Is chemic Evaluation valuation
30 Day Event
Non Fatal MI
CV Death, MI, ♥ Arrest
Stroke
Bradycardia
Toprol XL
100mg 22-4
H Hrs P PPreop
Preop→
30 Days
POISE POISE Trial T i l
8351 Patients +
RRandomized d i d
Placebo acebo
+ >45yrs of age
Had or at risk for
Atherosclerosis
Atherosclerosis-82% 82%
Had CAD or PVD
Toprol Placebo P-value
3.6%
5.1%

POISE Trial: Metoprolol vs. Placebo in
Patients Undergoing Noncardiac Surgery
Peercent
8 P=0.04 P=0.03
6
4
2
0
5.8
6.9
CV Death, MI, or Cardiac
Arrest HR 0.83
3.1
23 2.3
Total Mortality HR 1.33
Metoprolol
Placebo
Devereaux PJ, et al. Lancet 2008;371:1839-47.

Independent Postoperative
Predictors of Death
Death
Predictor HR 95% CI
Stroke 12.74 7.77-20.88
Hypotension 4.32 3.22-5.80
Symptomatic MI 3.51 2.02-6.11
Asymptomatic MI 280 2.80 187419 1.87-4.19
Bradycardia 1.99 1.35-2.92
Bleeding 1.54 1.09-2.16

Negative Consequences of
Sudden Discontinuation Discontinuation of of Beta Beta-
Blockers after Hip Surgery
Van Klei et al. Anesthesiology 2009;111:717-24.

Recommendations for Beta-Blocker
Class I
MMedical di l Therapy Th
1. Beta blockers should be continued in patients
undergoing surgery who are receiving beta blockers
to treat angina, symptomatic arrhythmias,
hypertension, or other ACC/AHA Class I guideline
iindications. di ti (L (Level l of f EEvidence: id C)
2. Beta blockers should be given to patients undergoing
vascular surgery who are at high cardiac risk owing
to the finding of ischemia on preoperative testing.
(L (Level l of f EEvidence: id B)
Fleisher L, et al. J Am Coll Cardiol 2007:50:1707-1732.

Recommendations for Beta Beta-Blocker
Beta Beta-Blocker Blocker
CLASS IIa
M Medical di l Therapy Th
1. Beta blockers are probably recommended for patients
undergoing vascular surgery in whom preoperative
assessment identifies CHD. CHD (B)
2. Beta blockers are probably recommended for patients
in whom preoperative assessment for vascular
surgery identifies high cardiac risk, as defined by the
presence of more than one clinical risk factor. (B)
3. Beta blockers are probably recommended for patients
in whom preoperative assessment identifies CHD or
high cardiac risk, as defined by the presence of more
than one clinical risk factor, who are undergoing
intermediate-risk or vascular surgery. (B)

High g Dose β-Blockers Blockers given g
indiscriminately the evening
before or morning of surgery
may cause as many events as
they prevent!

How Do I Use Beta Blockers?
• Metoprolol 25mg BID titrating up to
achieve HR ≤ 60
• Prefer to begin several weeks
preoperatively
• Still use in patients with only
relative contraindications

• 100 vascular
surgery patients
• 20mg atorvastatin
or placebo l b ffor 445
days
• Vascular surgery
an average of 30
ddays after ft
RCT of Statins
Evvent-free
Survival S (%) (
100
80
60
40
20
0
Days after Surgery
At Atorvastatin t ti
Placebo
P = 0.018
0 30 60 90 120 150 180
randomization Atorvastatin 50 44 43 41 40 40 40
Placebo
50 38 36 35 34 33 33
Durazzo et al. J Vasc Surg 2004;39:967.

In-hospital Mortality after Non-Cardiac
S Surgery: Lipid Li id lowering l i therapy th
4% 3.05%
2%
0%
2.13%
Lipid p Rx No Lipid Rx
(OR 0.71;
95% CI
0.67-0.75)
Lindenauer PK, et al. JAMA 2004;291:2092-99.

Allocated to Fluvastatin (n= 250)
R Received i d allocated ll t d i intervention t ti
(n= 247)
Lost Lost to to follow follow-up up up at at 30 30 days days (n (n=0) 0)
Temporarily discontinued (n=61)
Permanently discontinued (n=16)
Assessed for Eligibility
(n=1669)
Enrollment
Randomization
All Allocation ti
Follow Follow-up up
Excluded (n=1172)
Not meeting inclusion criteria (n=356)
St Statin ti users ( (n=798) 798)
Other reasons (n=18)
Allocated to Placebo (n= 247)
Received allocated intervention
(n= 246)
Lost Lost to to follow follow-up up at 30 days (n (n= 0)
Temporarily discontinued (n=54)
Permanently discontinued (n=18)
N = 250 Analysis
N = 247
Dutch Echographic Cardiac Risk Evaluation Applying Stress Echo III

Carddiac
death
or nonnfatal
MII
(%)
15
12
9
6
3
0
N Engl J Med. 2009;361:984.
DECREASE III
P = 0.039
Placebo
Fluvastatin
0 5 10 15 20 25 30
Days after surgery

DECREASE IV
Eligible
45,000
6,460
1,421
Included
Low or High Risk
Beta-Blocker and/or
Statin Therapy
Informed Consent,
Previous Participation
Excluded
38,540
(86%) ( %)
55,039 039
(78%)
355
(25%)
1,066
(2.4%)

Outcome: Primary End Point
Log-rank p-value 0.003 Log-rank p-value 0.17 Log-rank p-value 0.003
8% 8% 8%
6% 6% 6%
4% 4% 4%
2%
2%
0% 0%
0%
0 15 30 0 15 30 0 15 30
Bisoprolol vs.
Fluvatatin vs.
Combination vs.
Bisoprolol-Control Fluvastatin-Control
Double Control
2%
Days after surgery
Dunkelgrum M, et al. Ann Surg 2009;249:921-926.

Recommendations for Statin Therapy
Class I
1. For patients currently taking statins and scheduled
for noncardiac surgery surgery, statins should be continued continued.
(Level of Evidence: B)
Class IIa
1. For patients undergoing vascular surgery with or
without clinical risk factors, statin use is reasonable.
(Level of Evidence: B)
Fleisher L, et al. J Am Coll Cardiol 2007:50:1707-1732.

Aspirin in CVD
Antithrombotic Trialists BMJ 2002;324:71–86.

Wh What t About Ab t Prior P i Coronary C
Revascularization?
Does It Lower Risk?

Influence of Prior CABG to Lower
Risk Ri Risk k of f Periop, P i MI/Death MI/D th
Pre Pre-operative operative CABG Surgery: CASS Registry
% Patients P
5
4
3
2
1
1.7
p=0.03 p=0.002
3.3
0.8
2.7
n=1961
Hi High h Ri Risk k
CABG
Med Rx
0
Deaths MI
• Greatest risk reduction with MVD, MVD more severe angina
• ECSG, CASS: CABG vs Med Rx in pts with CAD and PVD
Eagle KA, et al. Circulation 1997;96:1882-87.

Influence of Prior CABG vs. PTCA
on Ri Risk k in i NonCardiac N C di S Surgery
First Non-Cardiac CABG PTCA p-value
Surgery n=250 n=251
Cardiac Events 4(1.6%) 4(1.6%) 1.00
DDeath/MI th/MI 2/2 2/2 11.00/1.00 00/1 00
First High risk n=120 n=109
Surgery
Cardiac Events 2(1.7%) 2(1.8%) 1.00
All Non-Cardiac n=538 n=511
Procedures
Cardiac Events 7(1.3%) 8(1.5%) 0.80
DDeath/MI th/MI 5/2 6/2 00.77/1.00 77/1 00
Hassan SA, et al. Am J Med 2001;110:260-66.

What About Immediate
Coronary Revascularization
To Lower Risk?

Surgery After (bare metal) Stent Implantation –
Methodist Hospital Houston
Stent
SSurgery 1-14d 1 14d Surgery 15-39d 15 39d
(n=25) (n=15)
Results Pt
(%)
• 8 deaths
•6 due to MI
•2 due to bleeding
• 11 bleeds
• 3/5 pts t operated t d on
ticlid died (1 bleed – 2
MI+ bleed)
6 of 7 pts died
(86%)
MI
Death
40 P=0.015
20
0
28.0
32.0
0.0 0.0
1-14 days >14 days
Kaluza et al, JACC 2000

Death/MI after Non Cardiac Surgery
i in Patients P ti t with ith Recent R t Bare B Metal M t l Stent St t
5%
4%
3%
2%
1%
0%
4.8%
(8/168)
0%
(0/39)
PCI ≤ 6 weeks PCI ≥ 7 weeks
Before Surgery Before Surgery
J Am Coll Cardiol 2003;42:234-40.

Bare Metal Coronary Stenting
Prior to Noncardiac Surgery †
Bare Metal Coronary Stenting
Prior to Noncardiac Surgery †
Prior to Noncardiac Surgery †
Prior to Noncardiac Surgery †
Event ≤30 Days ++ Event ≤30 Days 31 90 Days >90 Days OR P value
++ 31-90 Days >90 Days OR P-value
MACE + 10.5% 3.8% 2.8% (3.6, 1.6) 0.003
(47/899; 5.2%)
Bleedingg 6.9% 4.6% 3.6% (1.3, ( 0.7) ) 0.46
(43/899; 4.8%)
† Nuttall GA,et al. Anesthesiology 2008;109:588-595.
+ MACE – 31 deaths, 12 Q-MI, 6 non-Q MI, 9 Stent thrombosis, 12 repeat revascularization.
++ Time from BMS to noncardiac surgery.

DES and Non-cardiac Surgery: Erasmus Data
4/30
1/162
1999-2005
Surgery g y within 2 yrs y
from PCI (n=192)
n=13
n=17
n=99
n=93
5 ffatal t l MIs MI in i 192 pts t
2.6% (95% CI 0.9-6%)
(stent thrombosis in 4)
J Am Coll Cardiol 2007;49:122-5.

Day Stennt
Thrombbosis
(%) )
30
10
8
6
4
2
Stent Thrombosis After
NonCardiac NonCardiac Surgery
p = 0.014
0
000 0.00 025 0.25 050 0.50 075 0.75 100 1.00 125 1.25 150 1.50 175 1.75 200 2.00 225 2.25 250 2.50 275 2.75
Time from PCI with DES (yrs)
Anwaruddin S, et al. JACC Intv 2009;2:542-9.

CARP: Coronary Revascularization
P Prophylaxis h l i before b f Major M j Vascular V l Surgery S
Vascular
Patients
Screening
Process
Coronary
Angiography
Study St Study d Patients
(n=510; 8.7%)
(n=5859)
(n=4669; 79.7%)
(n=380; 11.6%)
Surgical Indications for the Trial
• Abdominal Aortic Aneurysm (n=1935)
• Claudication (n=1528)
• Rest Pain (n=981)
• Tissue Loss (n=1415)
Clinical Exclusions from the Trial
• Insufficient cardiac risk (n=1654)
• Urgent/Emergent surgery (n=1025)
• Prior CABG/PCI and no ischemia (n=626)
• Co-morbid condition (n=731)
• Refusal or non-eligible (n=633)
Anatomical Exclusions from the Trial
• Non-obstructive coronary arteries ( (n=363) )
• Not amenable to revascularization (n=215)
• Left Main Stenosis > 50% (n=54)
• LV Ejection Fraction < 20% (n=11)
• Refusal (n=29)
McFalls EO, et al. N Engl J Med 2004;351:2785-804.

Baseline Clinical Variables: CARP
Clinical Variables Revascularization No Revascularization P-value
(N=258) (N=252)
Hi History t
Age (years) 65±11.1 67.2±10.4 0.099
Angina (%) 39.9 37.7 0.606
PPrior i MI (%) 43 43.0 0 40 40.9 9 00.623 623
Prior CHF (%) 12.0 7.5 0.089
Diabetes (%)
Laboratory
37.6 40.0 0.840
LDL (mg/dL)
Cardiac Status
105±37 107±42 0.596
LV Ejection Fraction 54±12 55±12 00.363 363
3-vessel CAD (%)
Indications for Surgery
35.4 31.4 0.685
Abdominal aneurysm (%) 34 34.4 4 32 32.1 1 00.613 613
Claudication (%) 38.8 35.3 0.613
Rest pain (%) 11.6 13.9 0.613

CARP: Main Results
Revasc. No Revasc. P-value value
(N=225) (N=237)
Surgical Management
Abdominal Surgery (%) 39.9 42.1 0.890
Urgent or Emergent (%) 5.8 5.9 0.900
General G GGeneral l anesthesia th i (%) 81.1 81 81.1 1 84.3 84 84.3 3 0 0.499 499
Perioperative Medications
Beta Beta-adrenergic adrenergic adrenergic blockers (%) 83.9 83 83.9 9 86.4 86 86.4 4 0 0.448 448
Aspirin (%) 76.1 70.0 0.163
Statins (%) 53.5 54.0 0.925
Postoperative Events
Death (%) 3.1 3.4 0.873
MI (enzymes ( y and ECG) ) ( (%) ) 7.6 6.8 0.737
Loss of Limb 0.5 0.9 0.114
McFalls EO, et al. N Eng J Med 2004;351:2785-804.

CARP: Long-Term Long Term Survival Survival in in the
the
Probability
of Survival
1.0
0.8
0.6
04 0.4
0.2
0.0
T Two Randomized R d i d Groups G
Assigned to No Coronary Artery Revasularization
Assigned to Coronary Artery Revasularization
0 1 2 3 4 5 6
Survival Time (Years)
McFalls EO, et al. N Engl J Med 2004;351:2795-804.

Long Term Survival in CARP (2 (2-5 (2 (2-5 5 Yrs)
Yrs)
Survival S Post-Vasculaar
Surgery
1
09 0.9
0.8
0.7
0.6
0.5
04 0.4
0.3
0.2
0.1
0
2-Vessel 3-Vessel Left Main Prior CABG
(N=204) (N=130) (N=48) (N=225)
Medical
Treatment
Preoperative
Revascularization
Garcia S, et al. Am J Cardiol 2008;102:809-15.

Survival S Poost-Vasculaar
Surgery
1.0
0.8
0.6
04 0.4
0.2
CARP: Left Main Survival
P=0.007
(+) Preoperative Revascularization
(-) Preoperative Revascularization
0
0 1 2 3
4
Time Following Vascular Surgery (Years)
Garcia S, et al. Am J Cardiol 2008;102:809-15.

But should we we revascularize revascularize the
the
coronaries of stable patients
with “many” many clinical markers markers (≥3)
and major major ischemia ischemia on D D-Echo?
Echo?

DECREASE DECREASE – V V Pilot Pilot Study
Study
PreOp
PreOp p Coronary Coronary y Revascularization
Pre Pre-Major Pre Pre-Major Major Vascular Vascular Surgery
Surgery
1 – yr composite
MI or Death
Cath
1880 1880 Pts Pts Screened
101 Pts
Randomized
3 or more clinical markers
(+)
Major j ischemia on DSE
(±5 5 segments or ≥ 3 walls)
52 Pts Pts 49 Pts
Pts
PCI – 32 Pts Medical Rx
CABG – 17 Pts Only
24 (49%) 22 (44%)
No Cath
JACC 2007;49:1763-9.

Cardiac Risk of Vascular Surgery
DES - 30
Aft After R Recent t DES
49 49 High High Risk Risk Patients
Patients
Coronary
PCI - 32 CABG - 17
Revascularization
Non Cardiac
Surgery
BMS -2 Q – Wave MI - 11
STE – 7/11 pts; 5 of 7
in Stented Coronary
Despite Dual Antiplatelet Rx.
Poldermans. JACC; 2007.

Revascularization Before
N NNon Non-Cardiac Non Non-Cardiac C Cardiac di Surgery S
DECREASE-V Pilot Study
Incidence of All-Cause Death or Myocardial Infarction During Follow-Up
Revascularization
Medical therapy
Revascularization
Medical therapy
JACC 2007; 49:1763.

Timing
of
Surgery
Perioperative Guidelines
Acute MI, high-risk high risk ACS, or high high-risk risk cardiac anatomy
Bleeding risk
of surgery
Not Low
Low
Stent and continued
dual dual-antiplatelet
antiplatelet
therapy
(COR IIb/LOE C)
14 to 29 days 30 to 365 days Greater than 365 days
B Balloon ll
angioplasty
BBare Bare-metal metal t l
stent
DDrug Drug-eluting eluting l ti
stent
(COR IIb/LOE C) (COR IIa/LOE C) (COR IIb/LOE C)
TTreatment t t for f patients ti t requiring i i percutaneous t coronary intervention i t ti who h need d subsequent b t
surgery. ACS indicates acute coronary syndrome; COR, class of recommendation; LOE,
level of evidence; and MI, myocardial infarction.
Fleisher L, et al. JACC 2007;50:1707-32.

Coronary Revascularization before
Class III
NNon-Cardiac C di Surgery S
It is not recommended that routine
prophylactic coronary revascularization
Be performed p in stable CAD before non-
cardiac surgery.
Fleisher L, et al. J Am Coll Cardiol 2007:50:1707-1732.

Who Needs Coronary y Angiography?
g g p y
• Indicators are the same as for patients p not
being seen for preop evaluation
• Unstable or poorly controlled symptoms on
medical Rx
• Stable patients with likelihood of advanced
multivessel CAD +/- LV Dysfunction facing
high stress surgery
Eagle KA, et al. JACC Guidelines 2002;30:542-63.

Who Should I Screen
Before
Non Cardiac Surgery?

Potential Approach
pp
1. Stable Clinical
Markers and/or Not
Revascularization
candidate
• Angina, q-waves, prior
MI
– Beta Blocker +
Statin + ASA
• SSystolic t li hheart t ffailure il
– Beta Blocker, ACE
inhibitor, , Aldo
inhibitor
2. Multiple p Markers, , • Stress Echo
established CAD or
HF, and high risk
surgery
• Rarely Cath if severe
ischemia in large regions
• BBest t medical di l RRx bbased d
on history & stress echo

Potential Approach
pp
3.Unstable CAD •Cath
and/or HF
• Revascularize those
eligible
4.Non-cardiac
markers
only…DM, Age,
creatinine
• B-Blocker if HTN
• Statin if lipids

Perioperative p Pain Management g
• EEpidural id l or PCA with i h more
complete relief of pain reduces
catecholamine surges
•This may y reduce perioperative
p p
ischemia or infarction

Recommendations for
Post Post-operative Post Post-operative operative Surveillance
• Patients without evidence of CAD
– Surveillance restricted to those who develop
perioperative signs of cardiovascular
dysfunction
• Patients with known or suspected CAD, and
undergoing g g high g or intermediate risk procedure:
p
– ECG’s at baseline, immediately after procedure,
and daily x 2 days
– Cardiac troponin measurements 24 hours
postoperatively and on day 4 or hospital
discharge (whichever comes first)
2002 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

Post Operative Therapy and
F Future t Considerations
C id ti
• Patients suffering recurrent postop ischemia ischemia,
ischemic CHF, or nonfatal MI have 2-3 fold risk
of MI or cardiac death over next 4 years
• Their subsequent risk stratification and treatment
should be aggressive
• Perioperative evaluation and treatment may
identify important cardiovascular problems and/or
risk factors for the first time. Appropriate longterm
goals g should be defined and relayed y to
patients primary physicians

Axioms of Periop p Assessment
• Foundation of coronary management
in patients undergoing non-cardiac
surgery g y is identical to foundation of
strategies for coronary patients in
general g
• The preoperative moment may
represent the first chance for a patient
to have an appropriate coronary
evaluation
l ti

Resource Use and Outcomes After
Implementation Implementation of of ACC/AHA ACC/AHA Preoperative
Risk Assessment Guidelines
Resource I II III P-value P-value
Utilization “Post “Late Post
“Controls” Guideline” Guideline” I vs. II I vs. III
( (n=102) 102) ( (n=94) 94) (104)
Stress Test 90 (88%) 44 (47%) 43 (41%)

Resource Use and Outcomes After
Implementation Implementation of of ACC/AHA ACC/AHA Preoperative
Risk Assessment Guidelines
Resource I II III P-value P-value
Utilization “Post “Late Post
Outcomes
“Controls” Controls Guideline” Guideline Guideline” Guideline I vs. II I vs. III
(n=102) (n=94) (104)
Death 4 (4%) 3 (3%) 0 (0%) 0.77
MI 7 (7%) 3 (3%) 5 (5%) 0.24
Death or MI 11 (11%) 4 (4%) 5 (5%) 0.08
J Vasc Surg 2002;36:758-63.

“Prediction Is Very Difficult,
Especially p y About The Future”
- Niels Bohr Bohr, Danish Physicist

Former President Bush Visit

“M “Medicine di i is i an Art A
of fU Uncertainty, t i t and d a
Science S SScience i of f Probability”
P b bilit ”
- Si Sir Willi William Osler
O l