Episode 91: Perioperative evaluation for non-cardiac surgery with Tom Metkus

In this episode, episode 91, I welcome Dr. Tom Metkus back to the show to discuss how we risk-stratify patients for non-cardiac surgery.

References:

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000104

http://www.onlinejacc.org/content/64/22/e77

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/ESC-ESA-Guidelines-on-non-cardiac-surgery-cardiovascular-assessment-and-managemhttp://

www.onlinejacc.org/content/accj/69/14/1861.full.pdf

9 Replies to “Episode 91: Perioperative evaluation for non-cardiac surgery with Tom Metkus”

  1. Thanks for the wonderful discussion on a very important topic. Can you comment on the occasional scenario in which a patient is completely asymptomatic with METS > 4 but underwent pre-op stress testing for whatever reason and it showed a positive result? For example, a moderate area of ischemia in the apical and inferior region on nuclear perfusion imaging. When this patient comes in for a non-emergent surgery without further ischemic workup, what would you do? Would you proceed because the stress test was not necessary in the first place or delay surgery until more information is available from a diagnostic coronary angiogram?

    1. Hi Huayong, that’s a tough question because it depends a lot on why they got the stress test. In reality, for a totally elective case, I think most people would wait. Not because the patient is likely to do poorly, but because if something bad did happen, it would be hard to justify having ignored the positive stress test. The exception might be if the patient, with or without their cardiologist, decided they didn’t want to pursue further cardiac workup or intervention.

      A related question is the patient who got a stress test but doesn’t have the results.

      Dr. Metkus’ response:
      Probably a lot of clinical nuance and clinical judgement needed here, doubt there is a one size fits all answer- for example, why did they have a stress test? Symptoms? Abnormal ECG? Physical finding? other concern? how positivity was the stress test? Is there known CAD? Etc.

  2. We delayed the surgery and obtained cardiology consult for a diagnostic angiogram like many people would in this situation. Patient also has dilated LV with mildly reduced EF. No signs or symptoms of heart failure or chest pain. Surgery is non-emergent but can’t be delayed for too long. Balancing the risk vs benefit of delaying the surgery for ischemic workup is difficult. Even if significant CAD is present, is there data that supports revascularization for stable CAD before Surgery improves outcome?

    1. The guidelines and data from the CARP trial would suggest that no, there isn’t any benefit to revascularization in that scenario with the possible exception of a subset of patients such as those with significant left main disease. Either way there are pros and cons and the discussion should include the patient, the surgeon, the anesthesiologist and the patient’s cardiologist.

  3. Hi Jed and Tom,

    I love the podcast and thanks for covering this important topic!

    Some of Dr. Metkus’ comments (re stress testing) seem to reflect the 2007 guidelines more so than the 2014 guidelines. For example, the step to consider whether the surgery is low-risk (with assessment of functional capacity and then RCRI risk factors if not low-risk and <4METS) has been replaced with assessment of "combined clinical/surgical risk" (<1% vs higher) followed by assessment of functional status if not low risk. https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Anticoag-10-14/DAPT/1%20Levine%202016%20DAPT%20Guidelines.pdf?la=en.

    As a side note, a discussion of risk calculator(s) would be helpful – e.g. RCRI risk assessment may over-estimate risk for lower risk/outpatient procedures compared to the NSQIP calculator.

    Regarding duration of DAPT for drug-eluting stents, Dr. Metkus mentions 6-12 months while the 2016 ACC/AHA update recommends 3-6 months (6 months preferred, 3 months can be considered weighing risks and benefits). https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Anticoag-10-14/DAPT/1%20Levine%202016%20DAPT%20Guidelines.pdf?la=en

    Since it can be hard to stay on top of the guidelines I thought I'd add this–realizing guidelines are a starting point and may not be perfect for each patient. Please do correct me if I've misunderstood….

    Keep up the great work
    -Francis

    1. Thanks so much Francis, and nice to hear from you! I will run this by Tom to see if he has anything to add but I think what you’ve added makes a lot of sense and I appreciate it! I hope all is well!

      Best,
      Jed

  4. Two questions:
    (1) Is it appropriate, on the RCRI, to count as a “yes” any diabetic who probably should be on insulin based on a markedly elevated A1c (e.g., 10+)?
    (2) For those patients who fall into the ‘soft’ emergent or urgent category and have several comorbid conditions increasing the chance of heart disease, is it appropriate to ask for a resting bedside TTE to check for low EF or stenotic valve disease, since these affect anesthetic management for anything other than minimally stressful surgeries?

    1. Hi Kevin,

      I can’t speak for the authors of the RCRI but I certainly think that someone who should be on insulin but isn’t could count as a diabetic. As for your second question, we would definitely consider a bedside TTE if there is time in a patient like the one you describe. And if you don’t have time, it’s always a good idea to treat the patient as if they are high risk, even if you don’t know for sure.

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