Cardiologists?!
Dr Rob CM
Stephens
Google
UCL Robert Stephens
the centre for
Anaesthesia
Contents
 Introduction
 Periop MI – frequency, pathology
 Morbidity
 Do cardiologists make a difference?
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
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
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
Deaths
Stroke
BP
0.0001
Bradycardia
0.0001
3·1% vs 2·3%
1·0% vs 0·5%
15.0% vs. 9.7%
1·33 p=0·03
2·17 p=0·005
p<
6.6% vs. 2.4%
p=0·002
p<
Perioperative MI
 Frequency
 Goldman
 Lee rCRI
 CASS
 CARP
troponin
 Decrease V
troponin
1.9%
2%
2.7%
7%
1001
2893
582
240
~32%
101
Pathology MI
 Non Perioperative
 64%–100% coronary artery plaque fissuring +/or
 65%–95% acute luminal thrombus
• 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
 Dawood 1996 Cohen 1999 Landesberg 2003 Ellis 1996 Biccard 2010
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
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
CASS
But CABG
associated
deaths
excluded !
Eagle 1997
CARP
Coronary-Artery Revascularization Prophylaxis
 5859 Vascular patients screened
 Clinical score + Stress testing
rCRI
High-risk surgery
 510 had angiogram
Ischemic heart disease (MI/ExTT+ve/Q / Nitrates / Pain)
Congestive
Heart
Failure
 49%
2 rCRI
factors,
13%
3 rCRI factors

Cerebrovascular disease
225
revascularisation
Insulin
creatinine >177mmol
 ✜3.1% Preop
MIserum
11.6%
 237
conservative
 ✜3.4%
MI 14.3%
Mcfalls 2004 Lee 1999
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
DECREASE- V Pilot
Medical
MI30
MI365
Death365
Revascularised
n=52
n=49
34.7%
36.7%
26.5%
30.8%
36.5%
23.1%
Poldermans 2007
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.
Summary
 Periop MI does occur, pathology not understood
 Studies
Imperfect, vascular patients
Evidence that preoperative revascularisation
not helpful
 AHA/ACC suggest non invasive testing
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
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
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
Heart Failure
 Postop morbidity/mortality..is flow related
 CPEx good at measuring function
 VO2 peak used lots scenarios
Valves