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4 Copyright 2010 Cardiovascular Update Editorial Board. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd. under continuing medical educational grant from AstraZeneca Ltd. and Novartis Korea. AP-CVUP-10-02

5 Continuing Medical Education

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7 TOPIC 1. 8 TOPIC TOPIC TOPIC TOPIC TOPIC 6. 46

8 SECTION TOPIC 1. Clinical predictors of increased perioperative cardiovascular risk Major risk factors Unstable coronary syndromes Decompensated heart failure Significant arrhythmia Severe valvular disease Intermediate risk factors History of ischemic heart disease History of compensated or prior heart failure History of cerebrovascular disease Diabetes mellitus Renal insufficiency Minor risk factors Advanced age (>70 years) Electrocardiographic abnormalities (e.g. bundle branch block, left ventricular hypertrophy etc.) Rhythm other than sinus (e.g. atrial fibrillation) Inadequate functional capacity Uncontrolled systemic hypertension 8 Cardiovascular Update

9 . Estimated energy requirements for various activities 1 MET Sleeping Watching television Writing, desk working Walking, less than 3.2 km/h, level ground, strolling 4 METs Housekeeping Walking up a hill Walking on level ground at 6.4 km/h Running a short distance Golf, bowling, dancing >10 METs Swimming Football Basketball Cardiovascular Update 9

10 SECTION TOPIC 1. Preoperative evaluation in hypertensive patients History taking Review of current antihypertensive medications Comorbidity of hypertension (e.g. CAD, CHF, Renal impairment, Cerebrovascular diseases, etc.) Physical examinations Blood pressure and heart rate Funduscopic examination Cardiovascular examination Pulmonary examination Assessment of volume status Laboratory tests ECG Chest X-ray Electrolytes Renal function test Uncontrolled systemic hypertension CAD; Coronary artery disease, CHF; Congestive heart failure, ECG; Electrocardiography. 10 Cardiovascular Update

11 . Preoperative management of congestive heart failure Cardiovascular Update 11

12 SECTION TOPIC 1. Clinical characteristics associated with surgical early morbidity and mortality in pulmonary hypertension Clinical characteristics of NYHA class at least II early morbidity History of pulmonary embolism Obstructive sleep apnea High-risk surgery Anesthesia duration at least 3 hours Intraoperative use of epinephrine or dopamine Clinical characteristics of Right axis deviation on electrocardiogram early mortality Right ventricular hypertrophy RVSP/SBP ratio>0.6 Intraoperative use of epinephrine or dopamine RVSP; Right ventricular systolic pressure, SBP; Systolic blood pressure. 12 Cardiovascular Update

13 . Cardiac events risk, based on a kind of non-cardiac surgery High risk Aortic and major vascular surgery (reported cardiac risk >5%) Peripheral vascular surgery Emergent operation (especially, in old ages) Prolonged operation Intermediate risk Thoracic or intraperitoneal surgery (reported cardiac risk 1-5%) Carotid endarterectomy Orthopedic surgery Head and neck surgery Prostate surgery Low risk Endoscopic interventions (reported cardiac risk <1%) Cataract surgery Breast surgery Transurethral operations Tissue biopsy Cardiovascular Update 13

14 SECTION TOPIC 1. Cardiac evaluation and care algorithm for non-cardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk for patients 50 years of age or gender 14 Cardiovascular Update

15 1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 2007;50:e Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100: Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297: Detsky AS, Abrams HS, Forbath N, et al. Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index. Arch Intern Med 1986;146: Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64: Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:e Fleisher LA, Pasternack LR, Herbert R, et al. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004;139: Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest. 1999;116: Cardiovascular Update 15

16 SECTION TOPIC 1 9. Poldermans D, Bax JJ, Schouten O, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control J Am Coll Cardiol. 2006;48: Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289: Lee HJ, Youn HJ, Chon JY et al. Anesthesia for Cesarian section in a parturient with peripartum cardiomyopathy. Korean J Anesthesiol 2000;39: Pearson GD, Veille JC, Rahimtoola S, et al. Peripartum cardiomyopathy. JAMA 2000;283: Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol. 2006;47: Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol. 2006;48:e Jaffer AK, Ahmed M, Brotman DJ, et al. Lowmolecular-weightheparins as periprocedural anticoagulation for patients on long-term warfarin therapy: a standardized bridging therapy protocol. J Thromb Thrombolysis. 2005;20: Charles Fox, Philip L. Kalarickal, Michael J. Yarborough, et. al. Perioperative management including new pharmacological vistas for patients with pulmonary hypertension for noncardiac surgery. Curr Opin Anaesthesiol 2008;21: Ramakrishna G, Sprung J, Ravi BS, et al. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol 2005; 45: Brenda MacKnight, Elizabeth A. Martinez, Brett A. Simon. Anesthetic Management of Patients with Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2008;12: Devereaux PJ, Goldman L, Yusuf S, et al. Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ. 2005;173: Smith SC Jr., Feldman TE, Hirshfeld JW Jr., et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol. 2006;47:e Wiesbauer F, Schlager O, Domanovits H, et al. Perioperative beta-blockers for preventing surgeryrelated mortality and morbidity: a systematic review and meta-analysis. Anesth Analg. 2007;104: Pastore JO, Yurchak PM, Janis KM, et al. The risk of advanced heart block in surgical patients with right bundle branch block and left axis deviation. Circulation. 1978;57: Cardiovascular Update

17 Cardiovascular Update 17

18 SECTION TOPIC 2 18 Cardiovascular Update

19 Cardiovascular Update 19

20 SECTION TOPIC 2 20 Cardiovascular Update

21 Cardiovascular Update 21

22 SECTION TOPIC 2 22 Cardiovascular Update

23 1. Fleisher LA, Beckman JA, Brown KA et al. ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation and Care for Noncardiac surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007; 50: e159- e Nishimura RA, Carabello BA, Faxon DP et al. ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis: A Report of the American College of Cardiology/ American Heart Asssociation Task Force on Practice Guidelines. Circulation 2008; 118: Goldman L, Caldera DL, Nussbaum et al. Multi factorial index of cardiac risk in noncardiac surgical procedures. N Eng J Med 1977; 297: Goldman L. Cardiac risk in noncardiac surgey: An update. Anesth Analg 1995; 80: Cardiovascular Update 23

24 SECTION TOPIC 3 24 Cardiovascular Update

25 Cardiovascular Update 25

26 SECTION TOPIC3 26 Cardiovascular Update

27 Low thromboembolic risk / low bleeding risk Low thromboembolic risk / low bleeding risk High thromboembolic risk INR: international normalized ratio, LMWH: low molecular weight heparin, UFH: unfractionated heparin Cardiovascular Update 27

28 SECTION TOPIC 3 1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007; 50: e Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J Nov;30(22): Epub 2009 Aug Grines CL, Bonow RO, Casey DE Jr., et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115: De Caterina R, Husted S, Wallentin L, Anticoagulants in heart disease: current status and perspectives. Eur Heart J 2007; 28: Pengo V, Cucchini U, Denas G, Erba N, Guazzaloca G, La Rosa L, De Micheli V, Testa S, Frontoni R, Prisco D, Nante G, Iliceto S; for the Italian Federation of Centers for the Diagnosis of Thrombosis and Management of Antithrombotic T. Standardized lowmolecular-weight heparin bridging regimen in outpatients on oral anticoagulants undergoing invasive procedure or surgery. an inception cohort management study. Circulation 2009; 119: Douketis JD, Berger PB, Dunn AS, Jaffer AK, et al; American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:2S99-S Dunn AS, Spyropoulos A, Turpie AG. Bridging therapy in patients on long-term oral anticoagulants who require surgery: the Prospective Peri-operative Enoxaparin Cohort Trial (PROSPECT). J Thromb Haemost 2007; 5: Oosterga M, Voors AA, Pinto YM, et al. Effects of quinapril on clinical outcome after coronary artery bypass grafting (The QUO VADIS Study). QUinapril on Vascular Ace and Determinants of Ischemia. Am J Cardiol 2001;87: Cardiovascular Update

29 Unstable coronary syndrome: unstable angina, recent myocardial infarction Decompensated heart failure: NYHA functional class 4 or new onset of heart failure Significant arrhythmia: high grade or Mobitz 2 atrioventricular block, third degree atrioventricular block, symptomatic ventricular arrhythmia, supraventricular arrhythmia with uncontrolled heart rate, symptomatic bradycardia, newly recognized ventricular tachycardia Severe valvular disease: severe aortic stenosis, symptomatic mitral stenosis Cardiovascular Update 29

30 SECTION TOPIC 4. Clinical predictors of increased perioperative cardiovascular risk Major Unstable coronary syndromes (e.g. unstable or severe angina, recent MI) Decompensated heart failure Significant arrhythmias Severe valvular disease Intermediate History of heart disease History of compensated or prior heart failure History of cerebrovascular disease Diabetes mellitus Renal insufficiency Minor Advanced age (greater than 70 years) Abnormal ECG (e.g. LV hypertrophy, left bundle branch block, ST_T abnormalities) Rhythm other than sinus Uncontrolled systemic hypertension *ECG; echocardiogram, Mi; myocardial infarction 30 Cardiovascular Update

31 . Cardiac risk stratification for noncardiac surgical procedures High Aortic and other major vascular surgery Peripheral vascular surgery Intermediate Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery Cardiovascular Update 31

32 SECTION TOPIC 4 32 Cardiovascular Update

33 Cardiovascular Update 33

34 SECTION TOPIC 4 34 Cardiovascular Update

35 Cardiovascular Update 35

36 SECTION TOPIC 4 36 Cardiovascular Update

37 Cardiovascular Update 37

38 SECTION TOPIC 4 1. Young Cheol Woo, Dong Choon Ha. Analysis of preoperative echocardiography in 381 geriatric patients. Korean Journal of Anesthesiology 2000;39: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE.et al: ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: Executive summary. J Am Coll Cardiol 2007;50: Adesanya AO, de Lemons JA, Greilich NB, Whitten CW: Management of posteoperative myocardial infarction in noncardiac surgical patients. Chest 2006;130: London MJ. Cardiovascular problems in noncardiac surgery. Current Opinion in Critical Care 2009;15: Froehlich JB, Fleishe LA. Noncardiac surgery in the patient with heart disease. Med Clin N Am 2009;93: Ashton MC, Petersen JN, Wray PN et al. The incidence of postoperative myocardial infarction in men undergoing non-cardiac surgery. Ann Intern, Med 1993;118: Christ M, Sharkova Y, Geldner G, Maisch B. Preoperative an perioperative care for patient with suspected or established aortic stenosis facing noncardiac surgery. Chest 2009;128: Cannesson M, Collange V, Lehot J-J. Anesthesia in adult patients with congenital heart disease. Current opinion in anesthesiology 2009;22: Cannesson M, Earing MG, Collange V, Kersten JR. Anesthesia for noncardiac surgery in adults with congenital heart disease. Anesthesiology 2009;111: Bignami E, Landoni G, Biondi-Zoccai GGL, Boroli F, Messina M, Dedola E, et al. Epidural analgesia improves outcome in cardiac surgery. A meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth Cardiovascular Update

39 Cardiovascular Update 39

40 SECTION TOPIC 5 40 Cardiovascular Update

41 Cardiovascular Update 41

42 SECTION TOPIC 5 42 Cardiovascular Update

43 Cardiovascular Update 43

44 SECTION TOPIC 5 I ( ) B ( ) I ( ) B ( ),, I ( ) C ( ) IIa ( ) B ( ) IIa ( ) C ( ) IIb ( ) B ( ) (titration) III ( ) A ( ) III ( ) B ( ) 44 Cardiovascular Update

45 1. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005;173: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Mana-gement in Non-cardiac Surgery of the European Society of Cardiology(ESC) and endorsed by the European Society of Anaesthesiology (ESA). Guidelines for preoperative cardiac risk ass-essment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30: Writing Group ACCF/AHA Focused Update on Perioperative Beta Blockade. Circulation 2009;120: POISE Study Group. Effect of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial. Lancet;371: Auerbach AD, Goldman L.Blockers and reduction of cardiac events in noncardiac surgery. JAMA 2002;287: Stevens RD, Burri H, Tramer MR. Pharmacologic myocardial protection in patients undergoing noncardiac surgery: a quantitative systematic review. Anesth Analg 2003;97: Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, Banga JD, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiogra phy, and beta-blocker therapy. JAMA 20001; 285: Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005;353: Dunkelgrun M, Boersma E, Schouten O, et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann Surg 2009;249: Cardiovascular Update 45

46 SECTION TOPIC 6 Cardiac risk (Combined incidence of cardiac death and nonfatal myocardial infarction) stratification for noncardiac surgical procedures (ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery) Risk Stratification Procedure Examples Vascular (reported cardiac risk Aortic and other major vascular surgery often more than 5%) Peripheral vascular surgery Intermediate (reported cardiac Intraperitoneal and intrathoracic surgery risk generally 1-5%) Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low (reported cardiac risk Endoscopic procedures generally less than 1%) Superficial procedure Cataract surgery Breast surgery Ambulatory surgery 46 Cardiovascular Update

47 Cardiovascular Update 47

48 SECTION TOPIC 6 Suggested patient risk stratification for perioperative arterial or venous thromboembolism *CHADS2; Congestive heart failure-hypertension-age-diabetes-stroke. 48 Cardiovascular Update

49 Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable (AHA 2007 guidelines on prevention of infective endocarditis) Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous infective endocarditis Congenital heart disease (CHD)* Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) Cardiac transplantation recipients who develop cardiac valvulopathy *Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure. Cardiovascular Update 49

50 SECTION TOPIC 6 Levels of thromboembolism risk in surgical patients without prophylaxis GCS; graduated compression stocking, HFS; hip fracture surgery, IPC; intermittent pneumatic compression, LDUH; low-dose unfractionated heparin, LMWH; low-molecular-weight heparin, SCI; spinal cord injury, U; unit, VKA; vitamin K antagonist, VTE; venous thromboembolism. 50 Cardiovascular Update

51 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation. 2009;120:e169-e Grines CL et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115: Wilson W et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. A guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116: James D. Douketis, Peter B. et al. The Perioperative Management of Antithrombotic Therapy American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008;133;299S- 339S. 3. Lockhart PB, Gibson J, Pond SH, et al. Dental management considerations for the patient with an acquired coagulopathy. Part 2: Coagulopathies from drugs. Br Dent J. 2003;195: Cardiovascular Update 51

52 THE MOST ADVANCED CONTINUING MEDICAL EDUCATION SERVICE VOL 1 NO VOL 1 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 3 NO VOL 3 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 12 NO VOL 12 NO VOL 12 NO Cardiovascular Update 52

53 Cardiovascular Update

54 1. Elmfeldt D et al. Blood Press 2002;11: Bönner, Fuchs. Curr Med Res Opin 2004; 20: McMurray et al. Lancet 2003; 362: Mcmurray J et al. Am Heart J 2006; 151: Ogihara T. CASE-J study. Presented at the ISH, Oct Mogensen CE, BMJ 2000;321: Rossing K et al. Diabetes Care 2003; 26: Susan C Fagan et al. J Hypertens 2006; 24: Papademetrious V et al. JACC 2004;44: P [ ]-V2.1

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