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Updates in Perioperative Medicine

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Updates in Perioperative Medicine REVIEWS Updates in Perioperative Medicine Suparna Dutta, MD, MPH1*, Steven L. Cohn, MD2, Kurt J. Pfeifer, MD3, Barbara A. Slawski, MD, MS3, Gerald W. Smetana, MD4, Amir K. Jaffer, MD, MBA1 1Department of Medicine, Rush Medical College, Chicago, Illinois; 2University of Miami Miller School of Medicine, Miami, Florida; 3Froedtert Memorial Lutheran Hospital Clinical Cancer Center and Medical College of Wisconsin, Milwaukee, Wisconsin; 4Division of General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts. BACKGROUND: As our surgical population becomes may reduce risk of postoperative cardiovascular complica- older and more medically complex, knowledge of the tions, new pulmonary risk indices are available that accu- most recent perioperative literature is necessary to opti- rately estimate postoperative pulmonary complications, mize perioperative care. We aim to summarize and cri- postoperative atrial fibrillation is associated with increased tique literature published over the past year with the long-term stroke risk, risk scores such as the CHADS2 (Con- highest potential to impact the clinical practice of periop- gestive heart failure, Hypertension, Age 75 years, Diabetes erative medicine. Mellitus, previous stroke or transient ischemic attack) are METHODS: We reviewed articles published between Janu- superior to the Revised Cardiac Risk Index in predicting ary 2014 and April 2015, identified via MEDLINE search. The adverse postoperative outcomes for patients with nonvalvu- final 10 articles selected were determined by consensus lar atrial fibrillation, and utilization of bridging anticoagulation among all authors, with criteria for inclusion including scien- comes with a much higher risk of bleeding compared to tific rigor and relevance to perioperative medicine practice. patients who are not bridged. RESULTS: Key findings include: long term b-blockade CONCLUSIONS: The body of literature reviewed provides should be continued prior to surgery, routine screening with important information for clinicians caring for surgical postoperative troponin is not recommended, initiation/con- patients across multiple fronts, including preoperative risk tinuation of aspirin or clonidine in the perioperative period is assessment, medication management, and postoperative not beneficial and may increase adverse outcomes, preoper- medical care. Journal of Hospital Medicine 2016;11:231– ative diagnosis and treatment of obstructive sleep apnea 236. VC 2015 Society of Hospital Medicine Given the rapid expansion of the field of perioperative evaluation and management of patients undergoing non- medicine, clinicians need to remain apprised of the cur- cardiac surgery: a report of the American College of rent evidence to ensure optimization of patient care. In Cardiology/American Heart Association Task Force on this update, we review 10 key articles from the periopera- practice guidelines. Circulation. 2014;130:e278–e333. tive literature, with the goal of summarizing the most clinically important evidence over the past year. This Background summary of recent literature in perioperative medicine is The American College of Cardiology/American Heart derived from the Update in Perioperative Medicine Association (ACC/AHA) perioperative guideline pro- sessions presented at the 10th Annual Perioperative Medi- vides recommendations for the evaluation and manage- cine Summit and the Society of General Internal Medicine ment of cardiovascular disease in patients undergoing 38th Annual Meeting. A systematic search strategy was noncardiac surgery. used to identify pertinent articles, and the following were Findings selected by the authors based on their relevance to the clinical practice of perioperative medicine. The new guideline combines the evaluation of surgery- and patient-specific risk in the algorithm for preoperative cardiovascular evaluation into a single step and recom- PERIOPERATIVE CARDIOVASCULAR CARE mends the use of 1 of 3 tools: the Revised Cardiac Risk Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 Index (RCRI),1 National Surgical Quality Improvement ACC/AHA guideline on perioperative cardiovascular Program (NSQIP) Surgical Risk Calculator,2 or the NSQIP-derived myocardial infarction and cardiac arrest calculator.3 Estimation of risk is also simplified by stratifi- *Address for correspondence and reprint requests: Suparna Dutta, cation into only 2 groups: low risk (risk of major adverse MD, Rush Medical College, 1717 W. Congress Pkwy, 1029 Kellogg, Chicago, IL 60612; Telephone: 312–942-4200; Fax: 312–342-3568; cardiac event <1%) and elevated risk (1% risk). Coro- E-mail: [email protected] nary evaluation can be considered for patients with ele- Additional Supporting Information may be found in the online version of vated cardiac risk and poor functional capacity, but is this article. advised only if the results would alter perioperative man- Received: June 23, 2015; Revised: August 20, 2015; Accepted: August agement. For example, a patient with very high risk who 24, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2487 has evidence of ischemia on stress testing may choose to Published online in Wiley Online Library (Wileyonlinelibrary.com). forego surgery. Preoperative coronary revascularization is An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 3 | March 2016 231 Dutta et al | Updates in Perioperative Medicine only indicated for patients meeting criteria in the nonsur- with a reduction in nonfatal myocardial infarction gical setting. (MI) (relative risk [RR]: 0.69; 95% confidence inter- For patients with previous percutaneous coronary val [CI]: 0.58-0.82; P < 0.001) but an increase in bra- intervention, the ACC/AHA has not changed its rec- dycardia (RR: 2.61; 95% CI: 2.18-3.12), hypotension ommendations to optimally delay surgery for at least (RR: 1.47; 95% CI: 1.34-1.6), and nonfatal strokes 30 days after bare-metal stenting and at least 1 year (RR: 1.76; 95% CI: 1.07-2.91; P 5 0.02). The POISE after drug-eluting stent (DES) placement. However, in trial was the only one demonstrating a statistically sig- patients with a DES placed 6 to 12 months previously, nificant increase in stroke. surgery can be performed if the risks of surgical delay The major discrepancy between the DECREASE tri- outweigh the risks of DES thrombosis. After any type als and the other RCTs was related to mortality—a of coronary stenting, dual antiplatelet therapy should reduction in both cardiovascular and all-cause death be continued uninterrupted through the first 4 to 6 in DECREASE but an increased risk of all-cause death weeks and even later whenever feasible. If not possi- in the other trials. ble, aspirin therapy should be maintained through sur- gery unless bleeding risk is too high. Cautions The guideline recommends perioperative continua- Because of its size, the POISE trial heavily influences the tion of b-blockers in patients taking them chronically. results, particularly for mortality and stroke. Including Preoperative initiation of b-blocker therapy may be the DECREASE trials reduces the otherwise increased considered for patients with myocardial ischemia on risk for death to a null effect. Exclusion of the POISE stress testing or 3 RCRI factors and should be and DECREASE trials leaves few data to make conclu- started far enough in advance to allow determination sions about safety and efficacy of perioperative b- of patient’s tolerance prior to surgery. blockade. Several cohort studies have found metoprolol to be associated with worse outcomes than with ateno- Cautions lol or bisoprolol (which were preferred by the European Many recommendations are based on data from non- Society of Cardiology guidelines).8 randomized trials or expert opinion, and the data in areas such as perioperative b-blockade continue to evolve. Implications Perioperative b-blockade started within 1 day of non- Implications cardiac surgery was associated with fewer nonfatal The ACC/AHA guideline continues to be a critically MIs but at the cost of an increase in hypotension, bra- valuable resource for hospitalists providing periopera- dycardia, and a possible increase in stroke and death. tive care to noncardiac surgery patients. Long-term b-blockade should be continued periopera- tively, whereas the decision to initiate a b-blocker Wijeysundera DN, Duncan D, Nkonde-Price C, et al. should be individualized. If starting a b-blocker peri- Perioperative beta blockade in noncardiac surgery: a sys- operatively, it should be done 2 days before surgery. tematic review for the 2014 ACC/AHA guideline on per- ioperative cardiovascular evaluation and management of Botto F, Alonso-Coello P, Chan MT, et al.; on patients undergoing noncardiac surgery: a report of the behalf of The Vascular events In noncardiac Surgery American College of Cardiology/American Heart Associ- patIents cOhort evaluatioN (VISION) Investigators. ation Task Force on practice guidelines. Myocardial injury after noncardiac surgery: a large, J Am Coll Cardiol. 2014;64(22):2406–2425. international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30- Background day outcomes. Anesthesiology. 2014;120(3):564–578. Various clinical trials have reported conflicting results regarding the efficacy and safety of perioperative b- Background blockers resulting in guideline committees changing their Many patients sustain myocardial injury in the perioper- recommendations. Because of questions raised regarding ative
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