LBBB pre op clinic

[Aether2000]

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Listening to the cardiologist question the patient for 30 sec about walking up stairs and their fitness, it was easy to see how misled the cardiologist might be, concluding the patient has >4 METS. A patient who was bed bound for the past 2 months was asked by the cardiologist if they could walk up a flight of stairs and the patient responded yes. The cardiologist pronounced the patient fit for surgery. However when I questioned the patient more extensively, he last walked up a flight of stairs 5 years ago, for the past 6 months could barely ambulate across the room, and for the past 2 months was bed-bound.

FUNCTIONAL CAPACITY
1 MET Eat, dress, use the toilet by yourself. Walk indoors around the house slowly.
1.8 METS Writing, desk work, typing
2.3 METS Walking 1.7mph level ground, strolling, slow walk
2.9 METS Walking 2.5 mph level ground, moderate pace walking, bowling
3.0 METS Stationary cycling 50watts, very light effort
3.3 METS Walking 3.0 mph
3.5 METS Home exercise, light or moderate effort
3.6 METS Walking 3.4 mph, light house work (dishes, dusting)
4.0 METS Bicycling less than 10 mph for leisure, to work, or for pleasure, light yard work or house work (sweeping), climb one flight of stairs
4.1 METS Walking 4.0 mph (brisk walk)
5.0 METS climbing more than 1 flight of stairs, lift >20lbs, walk>4 blocks
5.5 METS Stationary cycling 100 watts light effort
6.0 METS Heavy yard/housework, mowing, walking 5mph

 

[Aether2000]

RISK CALCULATION
So what does cardiac risk mean to a cardiologist evaluating patients for surgery? Frequently the surgical component of the risk is unknown to the cardiologist since they do not participate in surgeries and are unaware of the surgical stresses placed on the patient via differing surgical procedures. There are charts of relative surgical stressors on the body used by some cardiologists and in some risk calculators, but cardiologists do not have the in depth knowledge about the surgeon’s skills or complication rate of individual surgeons in considering these charts. So risks in the view of the cardiologist most often are based solely on the chance of a perioperative myocardial infarction and cardiac related death. While these outcome measures are important, they do not necessarily reflect the intraoperative risk of severe blood pressure changes, clinically significant dysrhythmias, heart failure (right or left), or ischemia.

The most common risk tools for cardiologists are the revised cardiac risk index (RCRI) also called the Lee index, the NSQIP (American College of Surgeons National Surgical Quality Improvement Program) online calculator, and the myocardial infarction or cardiac arrest calculator (MICA). The RCRI is the oldest and most validated of these calculators and therefore the most often used. Older models such as the Goldman cardiac risk index, Detsky modified risk index, and the Eagle criteria have largely been abandoned due to better models being available. These models (RCRI, NSQIP, MICA) provide a percent risk of MI or death. Cardiologists use these percentages to define further testing. For low risk patients (<1%) no further testing is performed. Patients with higher risk are subjected to additional testing at some point before or after surgery, not to alter the outcome of surgery (or management of anesthesia) but to lower long term risk. Herein lies the dichotomy that leads higher risk patients to warrant testing, but the testing may not be done until after the surgery. This creates a vacuum of information for the anesthesiologist who may find the testing to be very valuable before surgery to answer questions about risks due to diastolic or systolic heart failure, valvular disease impact, ischemia, and dysrhythmia management intraoperatively.

One element of the risk indexes include surgery-specific risks (RCRI, NSQIP) with the risk of MI or death being stratified at more than 5% (high risk procedures), 1-5% (intermediate risk procedures), and <1% (low risk procedures). Emergency surgery is associated with a significant increase in risk with cardiac complications being 2-5 times higher than for elective procedures. Other risk measures include history of ischemic heart disease, heart failure, cerebrovascular disease, and insulin dependent diabetes (all RCRI). Preop serum creatinine elevation >2 for RCRI and >1.5 for NSQIP is also a risk factor. Increasing age, ASA class, and preoperative functional status are part of the NSQIP risk stratification. Atrial fibrillation is a greater risk factor than a diagnosis of coronary artery disease. Obesity increases risks for adverse cardiovascular events at the time of non cardiac surgery but is not a predictor of end-organ damage.

The RCRI was first published in 1999 and is used worldwide. It is predictive of major cardiac complications (cardiac death, MI, cardiac arrest, postoperative cardiogenic pulmonary edema and complete heart block) in all types of elective major surgeries with the exception of abdominal aortic aneurysm surgery, lower extremity bypass surgery, and endovascular surgery. Because some cardiologists (or their midlevels) do not know the limitations of the RCRI, they calculate the risk inappropriately using the RCRI in these surgeries. A vascular surgery cardiac risk calculator (VSGNE) has been developed for vascular procedures and should be used instead. The RCRI also underestimates the risk of complete heart block or heart failure, issues that are important intraoperatively to the anesthesiologist. The RCRI is located at Revised Cardiac Risk Index for Pre-Operative Risk - MDCalc

The Gupta (MICA) risk calculator is located online at Gupta Perioperative Cardiac Risk | Calculate by QxMD . This calculator uses 5 variables that are input online: type of surgery, dependent functional status, abnormal creatinine, ASA class, and increased age. It is an easy to use calculator that outperforms the RCRI for MI or cardiac arrest, either intraoperatively or postoperatively.

The NSQIP is more cumbersome to use requiring input of 20 patient factors plus the surgical procedure. It has excellent correlation to mortality, morbidity, and 6 other outcome factors. It is located at ACS Risk Calculator - Home Page

 

[daneeka]

Sure, the RCRI's not perfect. I just don't think getting an echo for the sole purpose of tailoring an anaesthetic is a good enough reason to delay surgery. What will I do differently? Avoid hypoxia and hypotension?

I'm being facetious, but realistically there's rarely a management decision hinging on that test result beyond "I'd just like to know their LV function".

 

[Aether2000]

My echos do not delay surgery. Our US is immediately available at the bedside.

 

[Hoya11]

Yes, I think that stenting with the aim of avoiding perioperative cardiac events is not helpful.

We've known since the CARP trial (https://www.nejm.org/doi/full/10.1056/nejmoa041905) that, at least outside of LM disease, AS and LVEF < 20%, revascularisation doesn't reduce perioperative risk.

This and other studies has lead the ACC/AHA to recommend that people should not be revascularised before surgery, unless they would be revascularised if they walked into their primary care doctor clinic. In those 2014 guidelines, CABG is recommended for LM, TVD and 2 vessel disease with proximal LAD involvement. PCI has a weaker recommendation for all of these; it has never shown a mortality benefit outside of ACS.

I'd argue (as would these guidelines/most cardiologists) that patients with severe coronary disease will have < 4 METS. Of course there's room for using clinical intuition here but I think that most people overestimate how much benefit their patients will get from a stent.

But that's not what we are talking about.

We aren't talking about stenting just to help get through the perioperative period.

We are talking about stenting this person to get through life.

We have a person with chest pain, new LBB on EKG, should this person have a positive stress, or even without it, should they not have a cath? And when the cath shows a lesion should they not have a stent?

Its not that we are putting stents in to make surgery go better, we are identifying people who should have had a stent before the operation/during/after the operation who have been missed by cardiology/PCP.

Often, people will show up for surgery, but not to PCP/cardiologist

And when someone undergoes anesthesia/surgery with an occluded coronary and then codes on the table with huge ST elevations (or even depressions), is that not "ACS" ?

I'm unsure why there is an argument about this person needing further cardiac workup including possible stenting if indicated by the cardiologist. Seems very clear to me and a bit scary those arguing against it.

 

[daneeka]

Oh come on. A "new" LBBB which developed some time between now and the last 10 years. Presumably the average person with a LBBB wasn't born with it.

This isn't some guy turning up to ED with central chest pain and an LBBB of uncertain chronicity. Atypical chest pain. Normal exercise tolerence. Sure, he can get his stress test. But don't be upset if the cardiologist won't do it before surgery.

And when the cath shows a lesion should they not have a stent?.

Maybe, maybe not. PCI does not reduce mortality unless the guy is currently having a STEMI. The intervention just isn't that good.

Look, I get where you're coming from and it's not black and white. But there's a reason we aren't primary care doctors: we can't stand not having all the facts all the time. Sometimes a bit of restraint goes a long way.

 

[Hoya11]

Oh come on. A "new" LBBB which developed some time between now and the last 10 years. Presumably the average person with a LBBB wasn't born with it.

This isn't some guy turning up to ED with central chest pain and an LBBB of uncertain chronicity. Atypical chest pain. Normal exercise tolerence. Sure, he can get his stress test. But don't be upset if the cardiologist won't do it before surgery.


Maybe, maybe not. PCI does not reduce mortality unless the guy is currently having a STEMI. The intervention just isn't that good.

Look, I get where you're coming from and it's not black and white. But there's a reason we aren't primary care doctors: we can't stand not having all the facts all the time. Sometimes a bit of restraint goes a long way.

somehow you are making the strange approach of algosdoc justified

 

[Mman]

Maybe, maybe not. PCI does not reduce mortality unless the guy is currently having a STEMI. The intervention just isn't that good.

Look, I get where you're coming from and it's not black and white. But there's a reason we aren't primary care doctors: we can't stand not having all the facts all the time. Sometimes a bit of restraint goes a long way.

I am 100% in agreement that stents are next to meaningless for periop mortality, but I'm more curious if they need a CABG. We have multiple patients every single year that get referred to cardiology from preop testing that end up getting a CABG before whatever other surgery they were going to have. Many of them may not have had an EKG in while or regularly see a PCP and the combination of risk factors and symptoms comes up and they deserve a workup and then end up having severe coronary disease.

 

[chocomorsel]

These echo's are getting out of control lol. Not too long ago a newer grad anesthesiologist in our group cancelled a case bc she saw a recent echo on the patient which showed aortic SCLEROSIS not seen before on the previous echo. Otherwise completely normal echo. Pt is healthy and says he runs 3 miles a day. She cancelled for further workup. The pt himself was literally laughing at her

Wow. Did she attempt to get a second opinion from a more senior colleague? Did you attempt to talk to her or did you laugh at her too?
That’s what I do when I am conflicted. Of course I have never been conflicted about aortic sclerosis.

 

[deleted87051]

These echo's are getting out of control lol. Not too long ago a newer grad anesthesiologist in our group cancelled a case bc she saw a recent echo on the patient which showed aortic SCLEROSIS not seen before on the previous echo. Otherwise completely normal echo. Pt is healthy and says he runs 3 miles a day. She cancelled for further workup. The pt himself was literally laughing at her

This is strange on so many levels. Did she not know what aortic sclerosis is? Did she have a tee time she didn’t want to miss? Sounds like she was looking for an excuse to cancel the case. What happened next? I hope you guys don’t make her a partner.

And why did a healthy guy who runs 3 miles a day get an echo?

 

[Noyac]

IMHO cardiology consults for pre-operative evaluation and "clearance" are a complete waste of time and money. Not infrequently, even with strong indicators of active ischemia or pump failure, there is no nuclear stress test or Echo planned until AFTER the surgical procedure. I do my own echos now at the bedside in the pre-op area and use expansive questioning regarding exercise tolerance.

So you so your own echo but you are not stressing the pt since he would be lying in bed essentially resting. I would put very little faith in this exam.
If I was sending this pt to cards I would phrase it like this, “ please evaluate this pts cardiac status prior to surgery due to new LBBB with intermittent CP at rest.”

 

[Noyac]

I would think that it would. You sent him to an expert and followed his recommendations. That would play a whole lot better in front of a jury especially because his lawyer is sure to bring up the pre op EKG abnormality ....

And you would be wrong.

Does anyone have an example of a pt having an intraop MI and the surgeon and anesthesiologist are left off the suit butnhte cardiologist gets blamed? I have never heard of anything like this. Don’t fool yourselves, you want the cardiologist input and info from testing so that you can maximize your approach to avoid ischemia. But you will still be blamed if he has an MI. Not the cardiologist.

 

[Mman]

And you would be wrong.

Does anyone have an example of a pt having an intraop MI and the surgeon and anesthesiologist are left off the suit butnhte cardiologist gets blamed? I have never heard of anything like this. Don’t fool yourselves, you want the cardiologist input and info from testing so that you can maximize your approach to avoid ischemia. But you will still be blamed if he has an MI. Not the cardiologist.

I've seen plenty of intra and postop MIs that did not become lawsuits.

 

[MoMoGesiologist]

We could eliminate intra and postop MIs if people would just stop checking troponins!

 

[deleted87051]

And you would be wrong.

Does anyone have an example of a pt having an intraop MI and the surgeon and anesthesiologist are left off the suit butnhte cardiologist gets blamed? I have never heard of anything like this. Don’t fool yourselves, you want the cardiologist input and info from testing so that you can maximize your approach to avoid ischemia. But you will still be blamed if he has an MI. Not the cardiologist.

I can’t think of a single example that did become a lawsuit.

 

[coffeebythelake]

We could eliminate intra and postop MIs if people would just stop checking troponins!

And stop looking at the EKG leads

 

[coffeebythelake]

The question is: do u suppose u would be more likely to be sued if patient has diagnosed CAD and develops an MI perioperatively, vs no known CAD (plenty of risk factors and concerning sx but never formally diagnosed) and then develops an MI perioperatively. I would argue that the latter is worse? Certainly the spiel and informed assessment of cardiac risk would be easier to make with the former

 

[Mman]

I can’t think of a single example that did become a lawsuit.

I'm too lazy to dig up the closed claims database for things we get sued for but I know it is not high on the list.

 

[dannyboy1]

And you would be wrong.

Does anyone have an example of a pt having an intraop MI and the surgeon and anesthesiologist are left off the suit butnhte cardiologist gets blamed? I have never heard of anything like this. Don’t fool yourselves, you want the cardiologist input and info from testing so that you can maximize your approach to avoid ischemia. But you will still be blamed if he has an MI. Not the cardiologist.

It may prevent a suit if the patient had cardiac clearance. It’s all how it would look to a jury... the first thing anyone asks in M and M when this happens is was there clearance...

 

[Mman]

It may prevent a suit if the patient had cardiac clearance. It’s all how it would look to a jury... the first thing anyone asks in M and M when this happens is was there clearance...

just a terminology thing, but I sincerely hope an anesthesiologist isn't asking "if there was clearance". I send patients to cardiologists for preoperative evaluation and maybe testing, not clearance.

 

[dannyboy1]

just a terminology thing, but I sincerely hope an anesthesiologist isn't asking "if there was clearance". I send patients to cardiologists for preoperative evaluation and maybe testing, not clearance.

Usually from the surgeons. That being said everyone in the department understands that it is a lot more difficult to cancel for cardiac issues when there is a “clearance” in the chart.

 

[deleted171991]

You dont trust a pre-op nuclear stress test as a sensitive indicator of ischemia?

Negative stress tests are poor predictors. The EM literature and blogs are full of MI cases with recent normal stress tests. Just food for thought for everybody. The reason being that a stress test evaluates flow, not the stability of a plaque. That applies to cardiac cath, too, unless coupled with ultrasound of the plaque. The plaque could burst and thrombose one day after the patient does 8 METs.

Cardiac workup/risk stratification is, unfortunately, more of a CYA than we think.

 

[Mman]

Negative stress tests are poor predictors. The EM literature and blogs are full of MI cases with recent normal stress tests. Just food for thought for everybody. The reason being that a stress test evaluates flow, not the stability of a plaque. That applies to cardiac cath, too, unless coupled with ultrasound of the plaque. The plaque could burst and thrombose one day after the patient does 8 METs.

Cardiac workup/risk stratification is, unfortunately, more of a CYA than we think.

I would agree except I think it's equally valid to call it a standard of care issue than just a CYA issue. I mean the tests aren't perfect. Until we get something better it's hard to argue there is no utility to using them.

 

[deleted171991]

I would agree except I think it's equally valid to call it a standard of care issue than just a CYA issue. I mean the tests aren't perfect. Until we get something better it's hard to argue there is no utility to using them.

Standard of care is CYA by definition. It is what most other doctors would do, even if it is NOT what's scientifically correct.

Not that sending a LBBB with chest pains to see a cardiologist is not the correct thing to do.

 

[Mman]

Standard of care is CYA by definition. It is what most other doctors would do, even if it is NOT what's scientifically correct.

CYA is doing something for no other reason than to prevent a lawsuit.

 

[deleted171991]

CYA is doing something for no other reason than to prevent a lawsuit.

For example, having the same patient see a cardiologist, despite not having any chest pains and having a decent exercise tolerance, just because of the "new" LBBB.

I equal "standard of care" more with CYA than with science, probably because of my CCM background. In critical care, many times, the best thing to do is not what most intensivists would. Most intensivists are not as good as they think (this one included).

 

[Noyac]

I've seen plenty of intra and postop MIs that did not become lawsuits.

Thats not the question.

 

[Mman]

Thats not the question.

you seemed to imply having an MI had something to do with a lawsuit

 

[anes121508]

This. A large proportion of patients presenting for CABG have normal resting echos and normal resting EKGs. They are not sensitive for ischemic heart disease.

Exactly. “But the patient has a normal ekg and echo”. Hear it all the time and it amazes me the lack of understanding that this a resting snapshot in time.

Additionally, the example above about high gradient through the lvot assuming it’s aortic stenosis on the basis of gradient alone is why tte probe in the hands of a non expert can be dangerous if you assume you found nothing or silly when you think u see something you don’t. A thorough understanding of what you are looking at, limitations of the data given, and all the reasons it may or may not be quite as simple is required before putting a probe on someone’s chest to look for a gradient and cance a case or better yet move forward despite a murmur and symptoms because the bedside echo done by the novice was fine.

For example:
Are you sure you were even shooting the lvot?
Are you sure your alignment was correct?
Peak or mean?
What was the shape of spectral Doppler?
Is gradient all we look at for stenosis?
What else causes elevated gradients?
What causes falsely low gradients in setting of true as?
Do we say patient has AS based on gradient aline?
What’s the valve look like?
High gradient in lvot yet valve looks totally normal and has adequate excursion?
Ect ect ect

Unless u really know what you are doing, I don’t think anyone should make major clinical decisions based on their bedside echo finding alone. Using it and Knowing limitations is probably best approach if you aren’t an expert.

 

[T-burglar]

Exactly. “But the patient has a normal ekg and echo”. Hear it all the time and it amazes me the lack of understanding that this a resting snapshot in time.

Additionally, the example above about high gradient through the lvot assuming it’s aortic stenosis on the basis of gradient alone is why tte probe in the hands of a non expert can be dangerous if you assume you found nothing or silly when you think u see something you don’t. A thorough understanding of what you are looking at, limitations of the data given, and all the reasons it may or may not be quite as simple is required before putting a probe on someone’s chest to look for a gradient and cance a case or better yet move forward despite a murmur and symptoms because the bedside echo done by the novice was fine.

For example:
Are you sure you were even shooting the lvot?
Are you sure your alignment was correct?
Peak or mean?
What was the shape of spectral Doppler?
Is gradient all we look at for stenosis?
What else causes elevated gradients?
What causes falsely low gradients in setting of true as?
Do we say patient has AS based on gradient aline?
What’s the valve look like?
High gradient in lvot yet valve looks totally normal and has adequate excursion?
Ect ect ect

Unless u really know what you are doing, I don’t think anyone should make major clinical decisions based on their bedside echo finding alone. Using it and Knowing limitations is probably best approach if you aren’t an expert.

I like this post. aortic stenosis is simultaneously the most studied valve disease with the most literature and also the most complex. It seems the more we learn about AS the more questions we have. It is the farthest thing from a simple quick bedside look diagnosis .

 

[POW16]

POC US (IMHO) should be used to answer a binary question. It's not meant to be used solely to make complex decisions. If your bedside TTE in pre-OP is suggestive of AS in a symptomatic patient, get a formal one and move on with your life.

 

[Noyac]

you seemed to imply having an MI had something to do with a lawsuit

I meant that having a cardiologist on board whether you want to call it clearance or whatever does not mean that if the pt has a perioperative Cardiac event we will not be sued.

 

[ProRealDoc]

It's fine that we can all bedside TTE someone and estimate EF and look at valves, but bear in mind, even someone with significant CAD can have a normal EF and normal valves. I agree with Southpaw. Send this guy to cards for a formal evaluation for this elective case. If it were and emergency incarcerated hernia then you have to do what you have to do

Bingo! It's naïve to assume a normal bedside TTE guarantees avoidance of an intraop MI.