Optimize perioperative risk and dominate perioperative medicine. Topics include surgical risk calculators, preoperative labs, stress testing, use of BNP and troponins, postoperative MI, cardiac and pulmonary risk stratification, and more! We’re joined by perioperative medicine expert, Avital O’Glasser MD, Associate Professor of Medicine at Oregon Health & Science University and Assistant Program Director for Scholarship and Social Media. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).
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Written and produced by: Matthew Watto MD
CME questions by: Matthew Watto MD
Hosts: Matthew Watto MD, Stuart Brigham MD
Edited by: Matthew Watto MD
Guest: Avital O’Glasser MD
“The preoperative consultation may represent the first careful cardiovascular evaluation for a patient in years, or in some instances…ever”Dr O’Glasser paraphrasing the 2007 ACC/AHA guidelines
“Think of the evaluation (assessment) as pertaining to this patient for this surgery with this surgeon at this time and maybe even at this venue…for this surgical indication.”Dr O’Glasser’s perioperative medicine mantra
The METS Trial compared subjective METS (metabolic equivalents) vs the DASI (Duke Activity Index) vs stress testing vs BNP. The DASI performed best for predicting postoperative events [Wijeysundera Lancet 2018 – PMID 30070222]. Dr O’Glasser notes that this study may drive changes to the next guidelines update (i.e. use of DASI rather than subjective measures of functional status/METS).
For the time being, Dr O’Glasser still takes a history that includes subjective estimate of functional capacity. Check out whyiexercise.com to estimate METS.
Dr O’Glasser often combines information from multiple risk calculators based on their strengths and weaknesses. Check out this paper by perioperative medicine guru, Steve Cohn MD comparing risk calculators [Cohn Am J Cardiol 2018 – PMID 29126584].
Dr O’Glasser recommends using the ACS NSQIP surgical risk calculator for more medically complex patients. It predicts length of stay, the need for rehab, and risk of non-cardiac post-op complications, and more (see example).
The RCRI is the oldest and has been externally validated for predicting major adverse cardiac events. It may overestimate the risk for low risk surgical procedures and underestimate the risk for major vascular surgeries [Cohn Annals Int Med 2016 – PMID 27919097].
Bottom line: It is reasonable to use any of the three calculators as part of your perioperative medicine evaluation.
Universal preoperative screening labs are low value care. Decide on which labs by the history and physical.
Bottom line: Most tests aren’t indicated unless you would have ordered them in the absence of surgery. -Dr O’Glassers expert recommendation
Get to know your surgical colleagues. Then, dissuade them from low value preoperative testing. –Paraphrasing Dr O’Glasser on The Curbsiders
Is their CAD well controlled? Are my patient’s cardiac risk factors optimized (e.g. diabetes, smoking, blood pressure)?
The patient with prior myocardial infarction (MI) who now has well controlled risk factors and is exercising has a much different risk profile than a patient with the same cardiac history, but poorly controlled risk factors and poor functional capacity. –Paraphrasing Dr O’Glasser on The Curbsiders
In general, preoperative stress testing is NOT recommended for asymptomatic patients [Cohn Annals Int Med 2016]. It’s warranted ONLY if needed to work up a patient’s symptoms (i.e. you would have ordered it even absent a plan to pursue surgery). -Dr O’Glasser
It should be noted that preoperative revascularization was not shown to improve mortality in patients with stable angina (The CARP trial – NEJM 2004l). Similarly, in patients with positive dobutamine stress echocardiography, revascularization did not lower the rate of postoperative MI or death at 30 days or 1 year (The DECREASE V trial – PMID: 17466225). —Cohn SL. In the Clinic: Preoperative Evaluation for Noncardiac Surgery. Annals Int Med. Dec 2016. doi:10.7326/AITC201612060
“Will further testing impact decision making OR effect perioperative care?” -2014 ACC/AHA Periop Guidelines JACC 2014
Dr O’Glasser notes preoperative revascularization hasn’t been shown to improve outcomes (e.g. prevent postoperative MI or death). BUT, stress testing may help inform risk/benefit discussions, and influence medical therapy, type of anesthesia, surgical setting, and other nuanced perioperative decisions!!!!
About 65 percent of patients with myocardial injury after noncardiac surgery (MINS) are clinically asymptomatic [Duceppe CJC 2017]. Cardiac troponin testing increases the sensitivity to detect MINS. Patients with MINS after noncardiac surgery have a poor prognosis [Duceppe CJC 2017]. MINS is an independent predictor of 30-day and 1-year mortality [Botto et al Anesthesiology 2014 PMID 24534856; MANAGE Trial page ClinicalTrials.gov].
In the MANAGE Trial, MINS was defined by elevated cardiac troponins with either 1) symptoms of ischemia 2) ischemic EKG changes 3) wall motion abnormalities on echocardiogram OR elevated troponin after surgery with no alternative explanation (e.g., pulmonary embolism, sepsis) for myocardial injury. [Devereaux Lancet 2018]
The MANAGE trial tested dabigatran versus placebo for MINS. It found a slight decrease in the composite outcome of “major vascular events” without a significant increase in major bleeding [Devereaux Lancet 2018].
The Canadian guidelines recommend checking preoperative BNP or NT-proBNP for select patients with at least a five percent risk of cardiac events within 30 days of surgery [Duceppe CJC 2017].
Check daily cardiac troponins and postoperative EKG (in the PACU) for patients with preoperative BNP above 92 or NT-proBNP above 300 [Duceppe CJC 2017].
Bottom line: MINS is common and often asymptomatic. That said, Dr O’Glasser and her friends in perioperative medicine are not currently following the Canadian guidelines and experts are still gathering data on how to treat MINS.
Dr O’Glasser recommends an echocardiogram for patients who meet criteria of 2014 ACC/AHA guidelines, “unexplained dyspnea, heart failure with a change in condition, or suspected valve disease (as well as those with known valvular disease who are overdue for imaging) –2014 ACC/AHA Periop Guidelines JACC 2014.
NOTE: The echocardiogram can estimate pulmonary and cardiac pressures, ejection fraction and identify valvular lesions. This information can inform the perioperative management, which includes preoperative, intraoperative and postoperative care. -Dr O’Glasser’s expert opinion.
Obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHVS) and pulmonary hypertension are the pulmonary conditions that get Dr O’Glasser’s attention. An elevated serum bicarbonate or low resting oxygen saturation should raise the level of concern. Uncontrolled OHVS can be a reason to cancel or postpone surgery until patient is optimized. -Dr O’Glasser’s expert opinion
Use local instead of general anesthesia; hospital instead of ambulatory surgical center; 23 hour observation instead of same day discharge; sleep in recliner instead of flat in bed; minimize post-op opioids; and ensure family member supervision night of surgery. -Dr O’Glasser’s expert opinion
Counseling patients about perioperative pain including expected pain level and plan for pain management may improve perceived pain scores and decrease the needs for narcotic pain medications [Altman JAMA Otolaryngol 2017 – PMC5824296].
Listeners will develop a systematic and evidence based approach to perioperative risk evaluation and medical optimization.
After listening to this episode listeners will…
Dr O’Glasser reports no relevant financial disclosures. The Curbsiders were sponsored by the American College of Physicians for this episode.
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