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October 2016

CCS 2016 Guideline: Perioperative Cardiac Risk Assessment and Management for Patients Undergoing Non-Cardiac Surgery. October 2016. Disclosures. All CCS guideline and position statement panel conflicts of interest can be found on the CCS website ( www.ccs.ca ).

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October 2016

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  1. CCS 2016 Guideline: Perioperative Cardiac Risk Assessment and Management for Patients Undergoing Non-Cardiac Surgery October 2016

  2. Disclosures • All CCS guideline and position statement panel conflicts of interest can be found on the CCS website (www.ccs.ca).

  3. 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 Scope of Problem Speaker: JoelParlow

  4. CCS and Canadian experts felt new guidelines needed for perioperative assessment and management in noncardiac surgery Scope of Problem Speaker: JoelParlow

  5. Co-chairs: PJ Devereaux (Cardiology) Joel Parlow (Anesthesiology) Primary Panel: Emmanuelle Duceppe (GIM) Paul MacDonald (Cardiology) Kristen Lyons (Cardiology) Michael McMullen (Anesthesiology) Sadeesh Srinathan (Thoracic Surgery) Michelle Graham (Cardiology) VikasTandon (Cardiology) Kim Styles (Cardiology) Amal Bessissow (GIM) Dan Sessler (Anesthesiology) Greg Bryson (Anesthesiology) Primary Panel Speaker: JoelParlow

  6. Multidisciplinary- 22 members 8 general internists 4 cardiologists 6 anesthesiologists 1 general surgeon 1 vascular surgeon 1 orthopedic surgeon 1 academic nurse Reviewed and provided feedback on draft guidelines Secondary Panel Speaker: JoelParlow

  7. CCS Guidelines Committee CCS Council Editor of Canadian Journal of Cardiology Final Review / Approval Speaker: JoelParlow

  8. Four themes: Preoperative cardiac risk assessment Perioperative cardiac risk modification Monitoring for perioperative cardiac events Management of perioperative cardiac complications Significant change from previous guidelines… Shift of emphasis from preoperative noninvasive cardiac testing to increased use of biomarkers and postoperative monitoring of patients at risk and management of cardiac complication Scope of Guidelines Speaker: JoelParlow

  9. Population: adult patients undergoing major noncardiacsurgery defined as requiring at least overnight stay in hospital Only cardiovascular outcomes considered Focus on highest quality evidence in the literature Scope of Guidelines Speaker: JoelParlow

  10. Primary panel members each took lead of topics Thorough discussion and voting of each topic by panel Literature search, GRADE quality assessment Excluded studies by Dr. Poldermans Meta-analyses included if results consistent Voting Recommendation required 2/3 majority of non-conflicted primary panel members 2/3 felt evidence too weak: no recommendation Good clinical practice statement required 2/3 majority to believe recommendation indicated based only on values and preferences All votes documented in appendix Guideline Process Speaker: JoelParlow

  11. Academic/intellectual or financial conflicts of interest declared Conflicted members could participate in discussion but not voting Table listing conflicts of interest of panel members for every topic Conflicts Speaker: JoelParlow

  12. Preoperative cardiac risk assessment Speaker: JoelParlow

  13. ≥45 years of age, or 18-44 years of age with known significant cardiovascular disease coronary artery disease, cerebral vascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or severe obstructive intra-cardiac abnormality e.g., aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy Which patients should undergo cardiac risk assessment before noncardiac surgery? Speaker: PJ Devereaux

  14. Emergency surgery an acute life or limb threatening condition Urgent surgery e.g., surgery for an acute bowel obstruction, hip fracture Semi-urgent surgery e.g., surgery for cancer that has potential to metastasize Elective surgery Categories of Surgery Speaker: PJ Devereaux

  15. For patients requiring emergency surgery, we recommend against delaying surgery for preoperative cardiac risk assessment Good Practice Statement Speaker: PJ Devereaux

  16. For patients requiring urgent or semi-urgentsx, we recommend undertaking preoperative cardiac risk assessment only if patient’s hxor P/E suggests potential undiagnosed severe obstructive intra-cardiac abnormality, severe pulmonary hypertension, or unstable cardiovascular condition Good Practice Statement Speaker: PJ Devereaux

  17. For patients undergoing electivenoncardiac surgery who are ≥45 years of age or 18-44 years of age with known significant cardiovascular disease, we recommend preoperative cardiac risk assessment Good Practice Statement Speaker: PJ Devereaux

  18. Ethical requirement to accurately apprise patients about benefits and risks of surgery Survey of 104 general internists (Taher 2002) marked variability in definitions of low, moderate, and high perioperative cardiac risk Systematic review of surgical and non-surgical RCTs (Trevena 2006) patients have more accurate perception of risk presented as numbers rather than subjective words (low, moderate, or high-risk), probabilities, or effect measures (e.g., RRR) Risk Communication Speaker: PJ Devereaux

  19. We recommend communicating to patients their perioperative cardiac risk Good Practice Statement Speaker: PJ Devereaux

  20. We recommend explicit communication of perioperative cardiac risk based on expected event rate among 100 patients or range of risk consistent with 95% confidence interval of risk estimate Strong recommendation, moderate-quality evidence Recommendation Speaker: PJ Devereaux

  21. Clinical risk indices Revised Cardiac Risk Index (RCRI) National Surgical Quality Improvement Program (NSQIP) risk scores Method of preop cardiac risk assessment Speaker: Amal Bessissow

  22. RCRI systematic review - 792,740 pts, 24 studies (Ford 2010) RCRI had moderate discrimination to predict major perioperative cardiac complications RCRI has undergone extensive external validation NSQIP risk scores NSQIP MICA (Gupta 2011), ACS NSQIP (Bilimoria 2013) based on large datasets suggest superior discrimination than RCRI likelyunderestimaterisks no systematic monitoring of events no external validation Clinical Risk Indices Speaker: Amal Bessissow

  23. Revised Cardiac Risk Index * based on high-quality external validation studies Speaker: Amal Bessissow

  24. When evaluating cardiac risk, we suggest clinicians use RCRI over other available clinical risk prediction scores Conditional recommendation, low-quality evidence Recommendation Speaker: Amal Bessissow

  25. Reilly et al. (1999) prospective cohort 600 pts undergoing major noncardiac sx self-reported functional capacity did not predict CV events aOR, 1.81 ; 95% CI, 0.94-3.46 Wiklund et al. (2000) prospective cohort, 5939 pts having major noncardiac sx METs not independently predictive of major cardiac events data suggest observer bias in estimation of pts METS Given limitations of evidence primary panel decided not to make recommendation on how to use patient self-reported functional capacity to estimate perioperative cardiac risk Self-reported functional capacity Speaker: Amal Bessissow

  26. Individual patient data meta-analysis (Rodseth 2014) 2179 patients – 18 studies Preop NT-proBNP/BNP independently associated with death or nonfatal MI at 30 days aOR 3.40 (95% CI, 2.57-4.47) p<0.001 Threshold value associated with lowest p value for death and MI NTproBNP≥300 ng/l BNP ≥92 mg/l NT-proBNP/BNP Speaker: Emmanuelle Duceppe

  27. NT-proBNP/BNP Risk of death or MI at 30 days after noncardiac surgery, based on patient’s preoperative NT-proBNP or BNP • 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% Speaker: Emmanuelle Duceppe

  28. 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 Recommendation Speaker: Emmanuelle Duceppe

  29. Considering cost – NT-proBNP/BNP testing restricted to patient groups with baseline clinical risk estimate >5% RCRI score 1 has >5% risk of MI, cardiac arrest, or death 30 days after surgery VISION Study data – 30 day risk of CV death or MI patients ≥65 years of age, 45-64 years of age with known CV disease have >5% risk patients without these characteristics have 2.0% risk Compared to cardiac imaging and non-invasive cardiac stress testing NT-proBNP/BNP inexpensive and avoids need for return visits Values and Preferences Speaker: Emmanuelle Duceppe

  30. Hospitals without NT-proBNP/BNP available at core lab can obtain point-of-care instrument to measure NT-proBNPin preopclinic Practical Tip Speaker: Emmanuelle Duceppe

  31. 3 studies including 2832 pts inconsistent association between TTE findings and perioperative ischemic events Park 2011 1923 pts prospective cohort TTE within 2 weeks before sx Several TTE measurements predictors of major CV events all TTE parameters inferior to NT-proBNP for predicting major CV events (p<0.001) Resting Echocardiography Speaker: Kim Styles

  32. We recommend against performing preoperative resting echocardiography to enhance perioperative cardiac risk estimation Strong recommendation low-quality evidence Recommendation Speaker: Kim Styles

  33. If patient requires urgent/semi-urgent or elective surgery and clinical exam suggests undiagnosed severe obstructive intra-cardiac abnormality or severe pulmonary HTN, obtain urgent echocardiography before surgery to inform anesthesiologist, surgeon, and medical team of type and degree of disease If clinical assessment suggests patient may have undiagnosed cardiomyopathy then echocardiogram should be obtained to facilitate optimization of long-term cardiac health, physicians should consider urgency of surgery when deciding whether to obtain echocardiogram before or after surgery Practical Tips Speaker: Kim Styles

  34. Coronary CTA VISION (Sheth 2015) Prospective cohort - 955 patients Results blinded unless left main disease identified Preop CCTA predicted CV death and nonfatal MI beyond RCRI extensive disease: aHR 3.76 (95% CI, 1.12-12.62) CCTA overestimated risk amongst patients who did not suffer primary outcome compared to RCRI, preopCCTA results in inappropriate risk classification in 81patients in 1000 patient sample based on risk categories of <5%, 5-15%, >15% Coronary CT Angiography Speaker: PJ Devereaux

  35. We recommend against performing preoperative coronary CT angiography to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence Recommendation Speaker: PJ Devereaux

  36. Limited data - 4 studies (508 patients) only 2 studies performed risk adjusted analysis Carliner 1985 – treadmill exercise 200 pts prospective cohort no significant association between ECG exercise change and death or MI Sgura 2000 – supine bicycle 149 pts prospective cohort, vascular surgery no significant association between exercise induced ST depression and death or MI Exercise Stress Testing Speaker: Vikas Tandon

  37. We recommend against performing preoperative exercise stress testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence Recommendation Speaker: Vikas Tandon

  38. Colson 2012 1725 patients undergoing major elective abdominal or thoracic surgery CPET weak independent predictor of mortality at 5 yrs 3 studies looked at CPET association with 30 day outcomes 706 patients inconsistent results across studies no study evaluated if CPET improved risk reclassification in addition to clinical evaluation Cardiopulmonary Exercise Testing Speaker: Vikas Tandon

  39. We recommend against performing preoperative cardiopulmonary exercise testing to enhance perioperative cardiac risk estimation Strong recommendation, low-quality evidence Recommendation Speaker: Vikas Tandon

  40. 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) Pharmacological stress echocardiography and radionuclide imaging Speaker: Vikas Tandon

  41. We recommend against performing preoperative pharmacological stress echocardiography Strong recommendation, low-quality evidence and Recommendations Speaker: Vikas Tandon

  42. We recommend against performing preoperative radionuclide imaging to enhance perioperative cardiac risk estimation Strong recommendation, moderate-quality evidence, respectively Recommendations Speaker: Vikas Tandon

  43. Panel believed that cost and potential delays associated with stress tests should be taken into account given absence of evidence of overall absolute net improvement in risk reclass Values and Preferences Speaker: Vikas Tandon

  44. Perioperative cardiac risk modification

  45. Smoking cessation Meta-analysis smoking cessation RCTs (Thomson 2014) CV events after surgery 4 trials – 653 patients no impact of preoperative smoking cessation on major CV events RR 0.58 (95% CI, 0.17-1.96) only 16 events Perioperative Risk Modification Speaker: Paul MacDonald

  46. Meta-analysis smoking cessation RCTs (Thomson 2014) Smoking cessation at time of surgery 12 trials – 1867 patients Brief intervention: RR 1.30 (95% CI, 1.16-1.46) Intensive intervention: RR 10.76 (95% CI, 4.55-25.46) Smoking cessation at 12 month 5 trials – 836 patients Brief intervention: RR 1.09 (95% CI, 0.68-1.76) Intensive intervention: RR 2.96 (95% CI, 1.57-5.55) Smoking Cessation Speaker: Paul MacDonald

  47. We recommend discussing and facilitating smoking cessation before noncardiacsurgery Strong recommendation low-quality evidence Recommendation Speaker: Paul MacDonald

  48. Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk Values and Preferences Speaker: Paul MacDonald

  49. Given that even brief counselling on smoking cessation during preoperative evaluation may positively impact smoking cessation, panel members felt it was important to take advantage of this opportunity to optimize long-term cardiac risk Values and Preferences Speaker: Paul MacDonald

  50. POISE 2 (2014) – RCT 10,010 noncardiacSx patients with known vascular disease or risk factors Initiation stratum (5628 pts) ASA 200 mg vs placebo preop and ASA 100 mg daily vs placebo x 30 days postop Continuation stratum (4382 pts) ASA 200 mg vs placebo preopand ASA 100 mg daily vs placebo x 7 days postop ASA had to be stopped ≥3 days preop(median 7 days) Systematic monitoring troponin postop ASA Initiation / Continuation Speaker: Paul MacDonald

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