2024 ACC/AHA Guidelines for Noncardiac Surgery Released

[lolnotacop]

Figured it was worth discussing the updated guidelines. I'm involved with the perioperative clinic at my current job and we were already implementing most of this into our care pathway. Things that stuck out to me include:

1. Inclusion of pulm HTN in estimation of perioperative risk
2. Inclusion of frailty in estimation of perioperative risk
3. Utilizing DASI for functional capacity (instead of just METS)
4. Suggesting noninvasive treatment or palliation instead of surgery
5. Preoperative biomarker risk assessment in certain circumstances
6. They finally commented on discontinuing ACEi/ARBs perioperatively in those with heart failure

What are your thoughts?

6.

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[caligas]

Can I still use Gupta, I like that one.

 

[lolnotacop]

Can I still use Gupta, I like that one.

You can, but the AHA/ACC guidelines specifically address that utilization of risk calculators carry very different predictive results and thus would alter the care pathway. Screenshot above.

see here for more: Impact of the Choice of Risk Model for Identifying Low-risk Patients Using the 2014 American College of Cardiology/American Heart Association Perioperative Guidelines

 

[dchz]

Could you upload a lower resolution pic? Thanks!

 

[Iso4ane]

60-90 some pages?

 

[lolnotacop]

Could you upload a lower resolution pic? Thanks!

You can thank the illustrious Circulation for not allowing linking or high res screenshot to their figure ¯\_(ツ)_/¯

 

[aneftp]

About time they include ptn. Scares the crap out of me when I see pul pressures in the 70s and and unfortunately it’s not measured often and addressed in risk stratification because it was never measured.

Anyone with sleep apnea diagnosis or high probability especially non compliant with cpap should get their pulmomary pressures measured or estimated before high intermediate or high risk surgery.

 

[medicine2wallstreet]

About time they include ptn. Scares the crap out of me when I see pul pressures in the 70s and and unfortunately it’s not measured often and addressed in risk stratification because it was never measured.

Anyone with sleep apnea diagnosis or high probability especially non compliant with cpap should get their pulmomary pressures measured or estimated before high intermediate or high risk surgery.

This is an shocking take. You're essentially saying you want anyone with sleep apnea to get a TTE before surgery at best and at worst a right heart cath. That is insane.

 

[aneftp]

This is a shocking take. You're essentially saying you want anyone with sleep apnea to get a TTE before surgery at best and at worst a right heart cath. That is insane.

It’s not shocking take. It depends on the procedure. It’s depends on the patient. Also urgency of the procedure. Unfortunately that’s where a good preop clinic does come into play. And places aren’t willing to spend the time and resources to do it.

There is so much undiagnosed pul htn.

Had a patient just about die on me last Friday night with elective robotic paraesophagel hernia repair that turned to open at small community hospital. You know those type of patents. Bmi 48. Dm, cad , etc etc

Cards said intermediate risk for intermediate risk procedure.

Unstable throughout procedure. On pressures

Left intubated. Cath 4 days later. RSVP was 79. It’s was like oops. We missed that one.

He’s. A high risk risk not intermediate risk. And the question is whether he’s surgery candidate. That’s for preop testing to figure out and whether to do him at small community hospitals setting or if they want to proceed. Have it done at tertiary center.

 

[pgg]

There's a world of difference between a PA systolic pressure of 70 in a patient whose systemic SBP is 180 and one whose SBP is 100.

I often don't know quite what to make of a TTE report that reports an estimated RVSP in isolation.

Anyway. You're not going to get echoes on all these patients. You're just not.

 

[Howard888]

This is a shocking take. You're essentially saying you want anyone with sleep apnea to get a TTE before surgery at best and at worst a right heart cath. That is insane.

I agree this is absolutely insane not to mention the costs to the health care system. Good luck telling your surgeons you want that. I would tell the surgeons it’s crazy too

 

[Arch Guillotti]

About time they include ptn. Scares the crap out of me when I see pul pressures in the 70s and and unfortunately it’s not measured often and addressed in risk stratification because it was never measured.

Anyone with sleep apnea diagnosis or high probability especially non compliant with cpap should get their pulmomary pressures measured or estimated before high intermediate or high risk surgery.

This is nonsense.

 

[Beeftenderloin]

There's a world of difference between a PA systolic pressure of 70 in a patient whose systemic SBP is 180 and one whose SBP is 100.

I often don't know quite what to make of a TTE report that reports an estimated RVSP in isolation.

Anyway. You're not going to get echoes on all these patients. You're just not.

This all day. It’s always gotta be relative to the systemic pressure. Far more utile to talk about ratios. PAPs are 2/3 systemic, etc.

I’m definitely on the side of more liberal ordering of screening echos in patients with multiple CV risk factors, particularly before major surgery. Maybe not everyone with OSA, but TTEing anyone with mod-severe range AHI, non-compliant w/ CPAP sounds reasonable and would probably catch a lot of pHTN.

I’m sure a lot of people balked when the recommendation for yearly chest CTs for anyone 50-80 with a significant smoking history came out. That’s standard of care now because it catches problems early so they can be intervened on before they get bad and actually saves money in the long run. Why can’t this be the case with TTE?

 

[aneftp]

I

This is nonsense.

it won’t be non sense in 10 years. I will be long gone from anesthesia practices.

I’m as cowboy as they go in terms of doing cases and not cancelling cases.

 

[rowsdower88]

"PH is a concerning complication of OSA and thought to occur in roughly 20% of individuals with OSA, but the range is anywhere from 17% to 70% in the literature." - Pretty wide range if your only criteria for ordering it is the diagnosis of OSA. Probably higher if you restrict it to severe OSA as suggested. But then you're still probably catching a lot of people with mild-moderate pHTN that you wouldn't really care about.

"Individuals who are obese are also subject to having obesity hypoventilation syndrome (OHS). OHS patients have a prevalence 59% greater of PH in OSA than having OSA alone, which is likely attributed to increased hypercapnic effects." - If you restrict the criteria to OHS you're probably going to catch more of the people you want to.

Obstructive Sleep Apnea and Pulmonary Hypertension: A Review of Literature - PMC

Obstructive sleep apnea (OSA) is a disease process involving recurrent pharyngeal collapse during sleep, resulting in apneic episodes. Clinically, symptoms can include snoring, sudden awakening with a choking-like sensation, excessive somnolence, ...

www.ncbi.nlm.nih.gov

There's probably better epidemiology out there that gets closer to answering the question. But I still think the number needed to treat is going to be pretty high because severe pHTN is much rarer than mild-moderate. Seems like the appropriate question would be "what is the prevalence of patients with severe OSA who also have undiagnosed severe pHTN?" I don't think most docs alter their anesthetic plan much for mild-moderate.

 

[caligas]

I only worry when PAP is higher than systemic

 

[Arantius]

My favorite consult to put in is palliative care consult from preop clinic for a goals of care discussion. 99% of the time the surgeons have completely failed to even look at the whole patient’s situation. It’s sad

 

[kidthor]

My favorite consult to put in is palliative care consult from preop clinic for a goals of care discussion. 99% of the time the surgeons have completely failed to even look at the whole patient’s situation. It’s sad

Do the surgeons give any pushback, or are they happy you’re involved? I’m glad whatever the case that you’ve got a way to do the right thing for the patients. The amount of unnecessary (and often harmful) surgeries we participate in has always upset me, and I think it causes a lot of moral injury for us.

 

[lolnotacop]

Do the surgeons give any pushback, or are they happy you’re involved? I’m glad whatever the case that you’ve got a way to do the right thing for the patients. The amount of unnecessary (and often harmful) surgeries we participate in has always upset me, and I think it causes a lot of moral injury for us.

Not the original person to bring this up but happens where I work. As with anything patient care related, there are the true hammers and there are those more reasonable.

 

[PpfSuxTube]

About time they include ptn. Scares the crap out of me when I see pul pressures in the 70s and and unfortunately it’s not measured often and addressed in risk stratification because it was never measured.

Anyone with sleep apnea diagnosis or high probability especially non compliant with cpap should get their pulmomary pressures measured or estimated before high intermediate or high risk surgery.

Hold up.
Ok, I'm cardiac and ICU guy at 1800 hearts per year centre. Everything bar transplant.


So we see a lot.

Phtn is just one data point. It may indicate poor outcome but it may not.
It all depends on so many factors..
How does the rest of the heart move, what are the other pressures, what's the papi, what's the case, the duration, the destination the baseline, how are the valves, fluid status?

Yeah a triple valve case on pa systolic 70 with biv failure and anuria on ticag is gonna suck, but a tka or something in an outpatient on all the heart meds? No totally different

So many variables go into the mix...

And that's why pre-op echos are actually shown to have a trend in the literature towards harm... They delay the case and they are misinterpreted by people who may not fully understand the information


One data point is interesting but not enough for any other meaningful interpretation

 

[aneftp]

Hold up.
Ok, I'm cardiac and ICU guy at 1800 hearts per year centre. Everything bar transplant.


So we see a lot.

Phtn is just one data point. It may indicate poor outcome but it may not.
It all depends on so many factors..
How does the rest of the heart move, what are the other pressures, what's the papi, what's the case, the duration, the destination the baseline, how are the valves, fluid status?

Yeah a triple valve case on pa systolic 70 with biv failure and anuria on ticag is gonna suck, but a tka or something in an outpatient on all the heart meds? No totally different

So many variables go into the mix...

And that's why pre-op echos are actually shown to have a trend in the literature towards harm... They delay the case and they are misinterpreted by people who may not fully understand the information


One data point is interesting but not enough for any other meaningful interpretation

The issue is icu care.

Small community hospitals not equipped to handle sick patients to be honest. Np at night and icu doc on virtual icu.

 

[Iso4ane]

I think eyeball test is undervalued. There are many times patients look fine, they do they ADLs, they drove themselves to all their visits, then all of a sudden a little pHTN shows up with no other signs of heart failure and then everyone tries to pass the buck to a ‘cardiac’ anesthesiologist.

 

[lolnotacop]

"
I think eyeball test is undervalued. There are many times patients look fine, they do they ADLs, they drove themselves to all their visits, then all of a sudden a little pHTN shows up with no other signs of heart failure and then everyone tries to pass the buck to a ‘cardiac’ anesthesiologist.
"

Functional status. Idrc what your “numbers” are if you can truly go up a flight of stairs and do a backflip at the top.

 

[PpfSuxTube]

Eyeball is only fine if you have the skills to back up any possibility if you're wrong...
Today I had 2 guys with lvedp 30-40 that to look at them you would think they could run a mile... Lvef 20 to 30

Both probably only have a few years left max

 

[Iso4ane]

Eyeball is only fine if you have the skills to back up any possibility if you're wrong...
Today I had 2 guys with lvedp 30-40 that to look at them you would think they could run a mile... Lvef 20 to 30

Both probably only have a few years left max

If they can really run a mile without any symptoms, that better than a lot of people with normal EFs.

 

[PpfSuxTube]

If they can really run a mile without any symptoms, that better than a lot of people with normal EFs.

I said 'you would think'... By eyeballing then. They couldn't.

Eyeballing doesn't work only for small change operations

 

[T-burglar]

The Eyeballing thing is confirmation bias. I’ve seen saddle PEs look ok sitting up in holding and I conducted the case as if they’d arrest on induction before we got on bypass and wouldn’t you know, several of them did just that.

 

[pgg]

The Eyeballing thing is confirmation bias. I’ve seen saddle PEs look ok sitting up in holding and I conducted the case as if they’d arrest on induction before we got on bypass and wouldn’t you know, several of them did just that.

Eyeballing has good negative predictive value but terrible positive predictive value. 🙂

A patient who looks like death wall warmed over probably is very sick.

A patient who looks OK might well be teetering on the edge.

 

[Airway]

A patient who looks OK might well be teetering on the edge

Agree! Alot of well compensated liver failure patients look like this. They are one infection away from death (or fall).

 

[minwoo]

Figured it was worth discussing the updated guidelines. I'm involved with the perioperative clinic at my current job and we were already implementing most of this into our care pathway. Things that stuck out to me include:

1. Inclusion of pulm HTN in estimation of perioperative risk
2. Inclusion of frailty in estimation of perioperative risk
3. Utilizing DASI for functional capacity (instead of just METS)
4. Suggesting noninvasive treatment or palliation instead of surgery
5. Preoperative biomarker risk assessment in certain circumstances
6. They finally commented on discontinuing ACEi/ARBs perioperatively in those with heart failure

What are your thoughts?

View attachment 392696
6.

@lolnotacop I'm also in charge of our pre-op screening and we're trying to use more discretion in ordering pre-op EKGs. Did your clinic change how pre-op EKGs are ordered with this updated guideline?

According to updated guideline- it's reasonable to order a pre-op 12-lead EKG if patients have any of the above listed risk modifiers (severe pHTN, valvular dz, congenital heart dz, stroke, etc). My understanding is that in general, pre-op EKGs have very little clinical utility but are ordered because "it's nice to have a baseline".

 

[BlueRug]

Hold up.
Ok, I'm cardiac and ICU guy at 1800 hearts per year centre. Everything bar transplant.


So we see a lot.

Phtn is just one data point. It may indicate poor outcome but it may not.
It all depends on so many factors..
How does the rest of the heart move, what are the other pressures, what's the papi, what's the case, the duration, the destination the baseline, how are the valves, fluid status?

Yeah a triple valve case on pa systolic 70 with biv failure and anuria on ticag is gonna suck, but a tka or something in an outpatient on all the heart meds? No totally different

So many variables go into the mix...

And that's why pre-op echos are actually shown to have a trend in the literature towards harm... They delay the case and they are misinterpreted by people who may not fully understand the information


One data point is interesting but not enough for any other meaningful interpretation

Cannot agree more. Isolated numbers are almost meaningless.

 

[lolnotacop]

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According to updated guideline- it's reasonable to order a pre-op [emoji[emoji[emoji6]][emoji[emoji6][emoji6]]][emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]]-lead EKG if patients have any of the above listed risk modifiers (severe pHTN, valvular dz, congenital heart dz, stroke, etc). My understanding is that in general, pre-op EKGs have very little clinical utility but are ordered because "it's nice to have a baseline".

We haven’t done anything to significantly change our preoperative EKG ordering thus far. I do find that I will order NT-pro BNPs on more patients, however.

Agreed about the utility of a preoperative EKG. Unless it’s been a while since previous or there has been a change in baseline without EKG, we don’t order them.