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Cardiologists?!

This review examines the frequency and pathology of perioperative myocardial infarction (MI) and the role of cardiologists in managing high-risk surgical patients. It discusses the evidence surrounding preoperative assessments, the outcomes of major studies like POISE, and the implications of findings on morbidity and mortality rates. Questions surrounding the effectiveness of cardiology interventions and preoperative revascularization strategies are addressed. Ultimately, the study highlights the need for a better understanding of perioperative MI and standardized protocols for cardiology involvement.

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Cardiologists?!

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  1. Cardiologists?! Google UCL Robert Stephens Dr Rob CM Stephens

  2. Contents • Introduction • Periop MI – frequency, pathology • Morbidity • Do cardiologists make a difference?

  3. Introduction The Cashpoint Private Practice Harley Street Doshville Dear Anaesthetist Many thanks for referring Mr George Smart  I think anaesthesia would be safe so long as you avoid hypotension or hypoxia’. I’d have thought a spinal would be OK. Yours Sincerely Dr Graham Jones MRCP

  4. Introduction: What’s the problem? • Paucity of evidence CPEx • Paucity of large RCT’s Preoperative assessment • Evidence of lack of effect • Perioperative MI pathology not understood • Cardiology investigations / interventions • Positive tests: poor positive predictive value • No generally agreed protocol Ix Mx • Studies quote MI/Cardiac not all cause mortality

  5. Introduction: Endpoints important! • POISE Lancet 2008 • 8351 patients • with/at risk of, atherosclerotic disease • non-cardiac surgery • B Block 24 hrs preoperatively – 30 days postop • Metoprolol vs Placebo • MI 4·2% vs 5·7% 0·84 p=0·002 Deaths 3·1% vs 2·3% 1·33 p=0·03 Stroke 1·0% vs 0·5% 2·17 p=0·005 BP 15.0% vs. 9.7% p < 0.0001 Bradycardia 6.6% vs. 2.4% p < 0.0001

  6. Perioperative MI • Frequency • Goldman 1.9% 1001 • Lee rCRI 2% 2893 • CASS 2.7% 582 • CARP 7% 240 troponin • Decrease V ~32% 101 troponin

  7. Pathology MI • Non Perioperative • 64%–100% coronary artery plaque fissuring +/or • 65%–95% acute luminal thrombus • Dawood 1996 Cohen 1999 Landesberg 2003 Ellis 1996 Biccard 2010 • Perioperative (day 1-3 vs later?) • 10-15% exhibited plaque fissuring • Only ~1/3 had an intracoronary thrombus • Preop severity angiogram related to periop MI • Site coronary artery stenosis ≠ infarct territory • Multiple factors

  8. Periop Complications • Consistent with inadequate organ oxygenation • POM Survey @ day 5 ; n=438 ✜ 1.6% • 31% Gastrointestinal • 15% Renal • 10% Respiratory • 7% Infectious • 5% Cardiovascular • 5% Haematological • 1% Wound • Attempts to increase perfusion ‘optimisation’  reduce complications / mortality Bennett-Guerrero 1999

  9. CASS Coronary Artery Surgery Study • 24,959 Pts undergoing Coronary Angiogram 1970’s • Pts randomised to CABG vs Medical • Retrospectively examined • ~3500 Patients non-cardiac operations in Yr 1 • Hi risk Thoracic, Abdominal Max Fax • vs low risk Eagle 1997

  10. But CABG associated deaths excluded ! CASS Eagle 1997

  11. CARPCoronary-Artery Revascularization Prophylaxis • 5859 Vascular patients screened • Clinical score + Stress testing • 510 had angiogram • 49% 2 rCRI factors, 13% 3 rCRI factors • 225 revascularisation • ✜3.1% MI 11.6% • 237 conservative • ✜3.4% MI 14.3% rCRI High-risk surgery Ischemic heart disease (MI/ExTT+ve/Q / Nitrates / Pain) Congestive Heart Failure Cerebrovascular diseaseInsulin Preop serum creatinine >177mmol Mcfalls 2004 Lee 1999

  12. DECREASE- V Pilot • Those with extensive Ischemic Ht Disease • 1888 Vascular Pts Screened • 430 ≥3 rCRI factors =  • ECHO/ Nuclear imaging • 101 = extensive ischemia on imaging; • 50% had angina; 43% had LEVF< 35% • randomised- • Medical • Angiogram/Revascularised – 67% 3 vessel, 8% LMS • B blocked- vascular surgery Poldermans 2007

  13. DECREASE- V Pilot Medical Revascularised n=52 n=49 MI30 34.7% 30.8% MI365 36.7% 36.5% Death365 26.5% 23.1% Poldermans 2007

  14. Caveats: ?should discuss AHA/ACC unstable angina acute ST-elevation myocardial infarction (MI) ?stable angina and left main stem disease, triple vessel disease (particularly if the left ventricular ejection fraction is < 50%) Mostly- coincidental findings suggesting asymptomatic coronary artery disease are probably best left alone.

  15. Summary • Periop MI does occur, pathology not understood • Studies Imperfect, vascular patients Evidence that preoperative revascularisation not helpful • AHA/ACC suggest non invasive testing

  16. References Bennett-Guerrero et al Anesth Analg 1999;89:514 –9 Mcfalls et al N Engl J Med 2004;351:2795-804. Poldermans et al JACC Vol. 49, No. 17, 2007 Schouten et al Heart 2006;92:1866–1872 Snowden et al Ann Surg 251(3):535-41 (2010) Dawood et al Int J Cardiol 1996 57 37-44 Cohen et al Cardiovasc Path 1999 8 133-9 Landesberg et al J Am Coll Cardiol 2003;42:1547–1554 Ellis et al J Cardiol1996 77 1126-8 Biccard et al Anaesthesia2010 65 733-41 Lee et al Circulation 1999;100;1043-1049

  17. IHD • Prevalence • Depends on population eg vascular • Depends on risk factors • Problem? Periop MI • Problem • CPET any good at detecting? • Timing: elective/emergency • Can we do anything about it? • Caveats

  18. IHD • Prevalence • Depends on population eg vascular • Depends on risk factors • Problem? Periop MI • CPET any good at detecting? • Timing: elective/emergency • Can we do anything about it? • Caveats

  19. Heart Failure • Postop morbidity/mortality..is flow related • CPEx good at measuring function • VO2 peak used lots scenarios

  20. Valves

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