Needs Stress Test?

[BLADEMDA]

78 year white male presents for a Right total knee replacement.

PMH:

moderate PVD (he can walk about 100 feet on a flat surface, but can not climb a flight of stairs)
DJD/Osteoarthritis
HTN
DM
Stage 2 CKD
Tobacco- 1 ppd x 30 years. He quit 9 years ago

PSH:

Lap Chole 2003
Left Inguinal Hernia 1979

Meds: Losartan, Metformin, Celebrex

VSS 143/87, HR 79

EKG: NSR, LBBB

Labs: Hgb 12.6, Plt 189,000 Cr 1.80 Electrolytes WNL

What's your plan?

Does he need a preop pharmacological stress test? Why or why not?

(No history of CHF, TIA/CVA or ischemic heart disease)

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[Arch Guillotti]

No.

Probably something will go wrong though.

 

[BLADEMDA]

No.

Probably something will go wrong though.

I was hoping for a rationale behind the decision based on published evidence. Also, if this was your Father, brother, Uncle, etc would you want him to have that stress test?

 

[sleepallday]

would like to know his BMI and why is he unable to climb stairs? Is it due to his knees or sob

 

[BLADEMDA]

would like to know his BMI and why is he unable to climb stairs? Is it due to his knees or sob

Sorry. BMI is 28. Patient can't climb stairs due to his PVD and DJD (he is vague as to which is worse). He does not get SOB with walking or attempting to climb stairs.

 

[BLADEMDA]

In my practice I see these types of patients on a routine basis. About 1/3 of them have work-ups (complete), 1/3 have a note from a medical doctor (no tests, but "cleared") and 1/3 have nothing on the chart at all. Here it is in 2018 and Medicare is spending billions of dollars on total joint replacements without guidelines in place.

At other hospitals I see about 2/3 have work-ups (whether indicated or not) and 1/3 have basically nothing on the chart. This is not isolated to just 1 hospital or region.

At the local "Mecca" near me 100% get work-ups even if NO INDICATIONS at all.

 

[BLADEMDA]

I have researched this extensively and there are ACC/AHA guidelines in place. I can assure those you in MOCA the ABA wants you to know this topic COLD. That includes new stent guidelines for elective surgery and the topic of Preop clearance.

 

[Turtlez]

RCRI 0 so low risk, no further testing indicated no?

 

[dhb]

No.

Probably something will go wrong though.

It's the typical case of a patient in poor overall condition but under control. You could make the argument for more testing because of the LBBB but what for? A stent that is worthless in this setting?
The patient is at higher risk for a cardiac event in the post-op period, any pre-op testing is just to CYA.

 

[vector2]

He has no active cardiac conditions, and he doesn't have DM on insulin, CVA, CAD, CKD 4, or CHF. It's impossible to make the argument that he needs further testing if going strictly by ACC/AHA. He does have a bunch of minor suggestive risk factors, and I do have some worry given the incidence of concomitant CAD in pts with PVD and the LBBB, but if he has good glycemic control, stable CKD, confirmed smoking abstinence, HTN no worse than stage I, and no angina or shortness of breath, I'd proceed with a spinal if he's not on antiplatelets.

 

[dchz]

RCRI 0 so low risk, no further testing indicated

FTFY

 

[Psai]

Rcri 0, nsqip low. No testing required.

Edit:...got beat. My internet sucks.

 

[Laryngophed]

Less than 4 METS, unable to stress heart on his own, GUPTA score is >2%, elective case where cardiovascular intervention could change management (i.e. he gets a stent and gets to sit out 30-180 days for the knee). By the book, yes, he gets a stress.

 

[dchz]

He has no active cardiac conditions, and he doesn't have DM on insulin, CVA, CAD, CKD 4, or CHF. It's impossible to make the argument that he needs further testing if going strictly by ACC/AHA. He does have a bunch of minor suggestive risk factors, and I do have some worry given the incidence of concomitant CAD in pts with PVD and the LBBB, but if he has good glycemic control, stable CKD, confirmed smoking abstinence, HTN no worse than stage I, and no angina or shortness of breath, I'd proceed with a spinal if he's not on antiplatelets.

how the hell do you confirm that?

 

[Laryngophed]

how the hell do you confirm that?

Urine cotinine.

 

[BLADEMDA]

Gupta MICA NSQIP database risk model — The NSQIP database was used to determine risk factors associated with intraoperative/postoperative MI or cardiac arrest [31]. Among over 200,000 patients who underwent surgery in 2007, 0.65 percent developed perioperative MI or cardiac arrest. On multivariate logistic regression analysis, five factors were identified as predictors of MI or cardiac arrest:

●Type of surgery

●Dependent functional status

●Abnormal creatinine

●American Society of Anesthesiologists’ class (table 5)

●Increased age



A risk model was developed using these five factors and subsequently validated on a 2008 data set (n = 257,385). The risk model had a relatively high predictive accuracy (C statistic of 0.874) and outperformed the RCRI (C statistic of 0.747). An easy-to-use calculator was developed from this model.

 

[BLADEMDA]

This risk calculator provides an estimate of perioperative cardiac risk for individual patients based on a model derived from a large sample (>400 000) of patients. This is intended to supplement the clinician's own judgment and should not be taken as absolute. Certain limitations exist such as absence of information on preoperative stress test, echocardiography, arrhythmia, and aortic valve disease. Unfortunately, known/remote coronary artery disease (except prior PCI and cardiac surgery) was also not controlled for in the multivariate analysis. In spite of the absence of these variables, the predictive ability of the calculator as measured by c-statistic was 0.88 (88%), much higher than previous models such as Revised Cardiac Risk Index.

The details of the methodology are provided in the published paper:

Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Pipinos II, Johanning JM, Lynch TG, Forse RA, Mohiuddin SM, Mooss AN.
Development and validation of a risk calculator for prediction of cardiac risk after surgery.
Circulation. 2011 Jul 26;124(4):381-7. Epub 2011 Jul 5

 

[dchz]

●American Society of Anesthesiologists’ class (table 5)

so if i called this pt a ASA class of "-3" (that's negative 3) does that mean i don't have to test?

i never understood the use of a very subjective measure in the gupta, therefore i dismissed it as a serious contender.

Edit: furthermore the ASA classification isn't a linear scale, the difference between ASA 1 and ASA 2 is significantly different than that between ASA 3 and ASA 4.

 

[BLADEMDA]

Less than 4 METS, unable to stress heart on his own, GUPTA score is >2%, elective case where cardiovascular intervention could change management (i.e. he gets a stent and gets to sit out 30-180 days for the knee). By the book, yes, he gets a stress.

So, based on RCRI we proceed with the case; but, based on the GUPTA model he needs a stress test. I can see why the Medical/Cardiology work-ups are all over the map on these types of patients.

 

[BLADEMDA]

so if i called this pt a ASA class of "-3" (that's negative 3) does that mean i don't have to test?

i never understood the use of a very subjective measure in the gupta, therefore i dismissed it as a serious contender.

This is what I see every single day. Real world. I do the case under SAB if at all possible. FWIW, I think he needs a stress test but the RCRI says "no". I've never cancelled a case when the data wasn't clear to me that the patient needs a work-up. I do the case. I'd say my major morbidity/mortality with these types of patients is around 0.3%. So, does 0.3% warrant a stress test? Remember, in a high volume practice losing 0.3% perioperatively won't seem like a small number.

The patient in this thread is a SOLID "3" and definitely not a 3 minus.

 

[T-burglar]

No signs or symptoms of unstable angina or other critical heart condition. Tka is a bull**** procedure that doesn’t stress the patient at all and doesn’t require a CABG/AVR or PCI/TAVR to increase the chance of surviving it

 

[dchz]

This is what I see every single day. Real world. I do the case under SAB if at all possible. FWIW, I think he needs a stress test but the RCRI says "no". I've never cancelled a case when the data wasn't clear to me that the patient needs a work-up. I do the case. I'd say my major morbidity/mortality with these types of patients is around 0.3%. So, does 0.3% warrant a stress test? Remember, in a high volume practice losing 0.3% perioperatively won't seem like a small number.

who says you have to cancel the case to stress his heart?

Smack him on the face until his HR is > 100 then put a TTE probe on to see if there is any regional wall motion abnormality.

Make sure you tell him about your unconventional "stress test" in the consent. That way he can't sue.

 

[BLADEMDA]

No signs or symptoms of unstable angina or other critical heart condition. Tka is a bull**** procedure that doesn’t stress the patient at all and doesn’t require a CABG/AVR or PCI/TAVR to increase the chance of surviving it

False. I have personally seen several deaths perioperatively during and after this procedure. All of them met RCRI criteria/score. Whether or not you believe PCI changes the odds I sleep better at night knowing these patient got the best possible care before dying perioperatively.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60540-7/abstract

 

[BLADEMDA]

No signs or symptoms of unstable angina or other critical heart condition. Tka is a bull**** procedure that doesn’t stress the patient at all and doesn’t require a CABG/AVR or PCI/TAVR to increase the chance of surviving it

If the patient was a friend of mine or relative I'd tell him without hesitation to get a stress test. Life is precious. His total knee can wait.

 

[BLADEMDA]

The "official" answer is the patient does not meet the criteria under the RCRI to warrant a stress test. Proceed with the case. Yet, the BEST hospital in my area would absolutely do a stress test on this patient. Hence, there are different levels of care based on what institution you go to and what type of insurance you have.

 

[BLADEMDA]

Mortality After Total Knee Arthroplasty: A Systematic Review of Incidence, Temporal Trends, and Risk Factors
Berstock, James R., MBChB, FRCS, MD, PGCert1,a; Beswick, Andrew D., BSc1; López-López, José A., BSc, MSc, PhD2; Whitehouse, Michael R., BSc, MBChB, MSc, PhD, FRCS, PGCert, FHEA1; Blom, Ashley W., MBChB, MD, PhD, FRCS1

JBJS: June 20, 2018 - Volume 100 - Issue 12 - p 1064–1070
doi: 10.2106/JBJS.17.00249
Evidence-Based Orthopaedics

Background: The capacity for total knee arthroplasty to improve pain, quality of life, and functional outcomes is widely recognized. Postoperative mortality is rare but of paramount importance, and needs to be accurately quantified and conveyed to patients in order to support decision-making prior to surgery. The purpose of this study was to determine a contemporary estimate of the risk of mortality following total knee arthroplasty, including the identification of temporal trends, common causes, and modifiable and nonmodifiable risk factors.

Methods: We performed a systematic review with searches of MEDLINE, AMED, CAB Abstracts, and Embase. Studies in any language published from 2006 to 2016 reporting 30 or 90-day mortality following total knee arthroplasty were included, supplemented by contact with authors. Meta-analysis and meta-regression were performed for quantitative data.

Results: Thirty-seven studies with mortality data from 15 different countries following over 1.75 million total knee arthroplasties formed the basis of this review. The pooled Poisson-normal random-effects meta-analysis estimates of 30 and 90-day mortality were 0.20% (95% confidence interval [CI], 0.17% to 0.24%) and 0.39% (95% CI, 0.32% to 0.49%). Both estimates have fallen over the 10-year study period (p < 0.001). Meta-regression using the median year of surgery as a moderator showed that 30 and 90-day mortality following total knee arthroplasty fell to 0.10% (95% CI, 0.07% to 0.14%) and 0.19% (95% CI, 0.15% to 0.23%), respectively, in 2015. The leading cause of death was cardiovascular disease.

Conclusions: There is an ongoing worldwide temporal decline in mortality following total knee arthroplasty. Improved patient selection and perioperative care and a healthy-population effect may account for this observation. Efforts to further reduce mortality should be targeted primarily at reducing cardiovascular events following total knee arthroplasty.

 

[BLADEMDA]

Total hip replacement causes a short-term increase in the risk of mortality. It is important to quantify this and to identify modifiable risk factors so that the risk of post-operative mortality can be minimised. We performed a systematic review and critical evaluation of the current literature on the topic. We identified 32 studies published over the last 10 years which provide either 30-day or 90-day mortality data. We estimate the pooled incidence of mortality during the first 30 and 90 days following hip replacement to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81), respectively. We found strong evidence of a temporal trend towards reducing mortality rates despite increasingly co-morbid patients. The risk factors for early mortality most commonly identified are increasing age, male gender and co-morbid conditions, particularly cardiovascular disease. Cardiovascular complications appear to have overtaken fatal pulmonary emboli as the leading cause of death after hip replacement. Cite this article: Bone Joint Res 2014;3:175-82.
(PDF) Mortality after total hip replacement surgery A SYSTEMATIC REVIEW. Available from: https://www.researchgate.net/public...l_hip_replacement_surgery_A_SYSTEMATIC_REVIEW [accessed Jul 01 2018].

 

[narcusprince]

This is a best practice issue ideally. Bump this guy to the last case if possible call cardiology to come by and see the patient in the preop hold bay. Also is the lbbb new or old. If new definitely needs a workup have cards come by for assessment. If old lbbb no functional status change since onset proceed. Not a case to send home DOS with a new joint. Also consider not using amicar or txa for the case. If he bleeds a little more he may be lower risk for coronary thrombosis. Ideally the preop process should alert an anesthesia provider prior to dos to review(all patients with new onset lbbb need anesthesiologist consult).

 

[narcusprince]

This is a best practice issue ideally. Bump this guy to the last case if possible call cardiology to come by and see the patient in the preop hold bay. Also is the lbbb new or old. If new definitely needs a workup have cards come by for assessment. If old lbbb no functional status change since onset proceed. Not a case to send home DOS with a new joint. Also consider not using amicar or txa for the case. Maybe discuss with surgeons to start Lovenox postop given poor activity and dvt risk. If he bleeds a little more he may be lower risk for coronary thrombosis. Ideally the preop process should alert an anesthesia provider prior to dos to review(all patients with new onset lbbb need anesthesiologist consult).

 

[nimbus]

CABG and PCI are not risk free. They may kill the patient before he gets a chance to return for the TKR. Assume he has CAD (which he does), proceed with the knee, and avoid hypotension and tachycardia.

 

[dannyboy1]

CABG and PCI are not risk free. They may kill the patient before he gets a chance to return for the TKR. Assume he has CAD (which he does), proceed with the knee, and avoid hypotension and tachycardia.

Ok. He is a vasculopath with poor exercise tolerance, htn, dm, and a a former smoker with EKG anomalies. Does not sound like an opening statement that you want a plaintiffs attorney to make. At the very least cover your a$$ and get a cardiac clearance.

 

[Hoya11]

78 year white male presents for a Right total knee replacement.

PMH:

moderate PVD (he can walk about 100 feet on a flat surface, but can not climb a flight of stairs)
DJD/Osteoarthritis
HTN
DM
Stage 2 CKD
Tobacco- 1 ppd x 30 years. He quit 9 years ago

PSH:

Lap Chole 2003
Left Inguinal Hernia 1979

Meds: Losartan, Metformin, Celebrex

VSS 143/87, HR 79

EKG: NSR, LBBB

Labs: Hgb 12.6, Plt 189,000 Cr 1.80 Electrolytes WNL

What's your plan?

Does he need a preop pharmacological stress test? Why or why not?

(No history of CHF, TIA/CVA or ischemic heart disease)

I would get a stress test or make sure he had one within the last 5 years if I have the time, if that means cancelling surgery i wouldnt cancel tho

 

[dchz]

get a cardiac clearance.

"low risk for low risk surgery, perioperative MACE of < 1%. follow up with cardiologist after surgery."

There you go.

 

[dannyboy1]

"low risk for low risk surgery, perioperative MACE of < 1%. follow up with cardiologist after surgery."

There you go.

If it’s from a cardiologist that’s fine by me. I know that the academic types look down on this but I have seen this save someone in an m and m. And this would definitely go a long way toward limiting your liability in a court of law...

 

[Laryngophed]

I cherrypicked the Gupta score because it would allow me to argue for the stress eval. I didn’t NSQIP this patient, but I would suspect the cardiac morbidity would ride the line of 1%.

Agreed with Blade, in an ideal world this patient gets an evaluation by the S3 jockeys. But in the real world, I think anyone last day 180 of CA1 year has anesthetized this patient with no firsthar workup.

 

[narcusprince]

I cherrypicked the Gupta score because it would allow me to argue for the stress eval. I didn’t NSQIP this patient, but I would suspect the cardiac morbidity would ride the line of 1%.

Agreed with Blade, in an ideal world this patient gets an evaluation by the S3 jockeys. But in the real world, I think anyone last day 180 of CA1 year has anesthetized this patient with no firsthar workup.

S3??

 

[Laryngophed]

S3??

The heart sound. Would you have preferred JVP jockey?

 

[BLADEMDA]

This is the type of case we see all the time. As I get older and the decades roll by I'm always thinking should I have done more for the patient? It's a good discussion either way and the Gupta score on this guy would indicate a stress test vs RCRI which shows "proceed with the case."

Fortunately, with a SAB I think overall mortality is less than 0.30%. That's low but it isn't zero.

 

[AdmiralChz]

Urine cotinine.

Several hospitals actually test new hires (after informing them prior) to ensure no active tobacco use. Seems more than a little Big Brother to me.

 

[dhb]

This is the type of case we see all the time. As I get older and the decades roll by I'm always thinking should I have done more for the patient? It's a good discussion either way and the Gupta score on this guy would indicate a stress test vs RCRI which shows "proceed with the case."

Fortunately, with a SAB I think overall mortality is less than 0.30%. That's low but it isn't zero.

What good would a stent do to the patient? If you tell me a stent is indicated in an asymptomatic patient then you should never post a study again.

If you want to diffuse responsibility i understand but don't tell me you are doing the patient any good by sending him to the heart plumber.

 

[BLADEMDA]

What good would a stent do to the patient? If you tell me a stent is indicated in an asymptomatic patient then you should never post a study again.

If you want to diffuse responsibility i understand but don't tell me you are doing the patient any good by sending him to the heart plumber.

We live in different countries with different expectations. Plus, the population here is far older and sicker than yours while still expecting to get every elective procedure their heart desires. I seriously doubt the legal atmosphere in your area is anything close to mine either. For example, an 89 year old dies after a total hip replacement on POD3 and his 88 year old wife sues the entire surgical team. Her lawyer claims a "new" LBB on EKG and other "risk" factors indicating the patient was not "healthy enough" to undergo the procedure.

It's not just diffusing responsibility it is about managing expectations on a 75+ year old population many of whom are solid ASA 3.

Do you realize that even a frivolous lawsuit in the USA is very time consuming and painful? Every Physician will need to list the lawsuit on his/her application for privileges for the remainder of his/her career.

 

[caligas]

Aside from the issue of doing the best thing for the patient, anyone feel there is any real liability reduction in telling the patient and family that 1) you have some risk of a heart attack. 2) postponing is the safest approach, but if you and the surgeon choose to proceed now I will do my best to get you through it safely.

 

[sleepallday]

5 years ago, I would say no further testing needed and do the case. But now that I'm a little wiser, I'll ask cardiology for a stress test. I lose nothing by postponing the surgery. At my hospital, I could get the stress test done the same day and do the case a few hours later.

 

[dhb]

We live in different countries with different expectations. Plus, the population here is far older and sicker than yours while still expecting to get every elective procedure their heart desires. I seriously doubt the legal atmosphere in your area is anything close to mine either. For example, an 89 year old dies after a total hip replacement on POD3 and his 88 year old wife sues the entire surgical team. Her lawyer claims a "new" LBB on EKG and other "risk" factors indicating the patient was not "healthy enough" to undergo the procedure.

It's not just diffusing responsibility it is about managing expectations on a 75+ year old population many of whom are solid ASA 3.

Do you realize that even a frivolous lawsuit in the USA is very time consuming and painful? Every Physician will need to list the lawsuit on his/her application for privileges for the remainder of his/her career.

That's exactly what i said: if you need execessive testing to diffuse liability i don't really mind but don't tell me you'd advise a friend or family to go to the cath lab.

 

[dannyboy1]

Aside from the issue of doing the best thing for the patient, anyone feel there is any real liability reduction in telling the patient and family that 1) you have some risk of a heart attack. 2) postponing is the safest approach, but if you and the surgeon choose to proceed now I will do my best to get you through it safely.

Nope. We are not a ski slope or skydiving school where you can make them sign a waiver. If a procedure is not appropriate it should not be offered. Also, in court it will become a “he said, she said” RE: the risks actually discussed and understood. Far better to have a note from the cardiologist stating that the patient is good to go.

 

[dannyboy1]

Ideally this case should have been caught in PAT’s and referred immediately to cardiology. If somehow the patient slipped through and is in holding on day of surgery I would grit my teeth and do it because, as mentioned extensively above the risk of something actually happening is quite small especially with an SAB. (of course I would document 4 mets and no chest pain all over the chart).

 

[Psai]

5 years ago, I would say no further testing needed and do the case. But now that I'm a little wiser, I'll ask cardiology for a stress test. I lose nothing by postponing the surgery. At my hospital, I could get the stress test done the same day and do the case a few hours later.

But what do you do if the stress is positive? Then they cath the guy, giving his kidneys a nice dye load before surgery as well as the risks of bleeding, infection, atheromatous emboli, arterial dissection, occlusion, etc only to find nonobstructive cad.

You do the case anyway with no change in inherent patient risk factors except those you added on with unnecessary testing and a huge cost to the medical system for a likely unemployed member of society.

 

[kmurp]

In a somewhat related note: I often see patients like this for tkr who had been on plavix. The cardiologist tells them no plavix for seven days. So I see them on the morning of day seven, and I’m nervous a bit about a spinal. They are always right on the edge of the recommended time frame. Should I be worried?

 

[Psai]

In a somewhat related note: I often see patients like this for tkr who had been on plavix. The cardiologist tells them no plavix for seven days. So I see them on the morning of day seven, and I’m nervous a bit about a spinal. They are always right on the edge of the recommended time frame. Should I be worried?

Everyone metabolizes differently but let's say the half life of plaxiv is 6 hours (ignoring that it is a prodrug for now). So after a day the level of active drug is maybe 5%. If we assume that the action is irreversible and that platelets live for about a week, the number of functional platelets should be more than adequate.

This is assuming normal patient factors and nothing like sepsis, alcoholism, etc that would cause cause thrombocytopenia or coagulopathy.

 

[MoMoGesiologist]

This guy is 78yo, can't go up stairs or walk far 2/2 PVD (so you can't accurately assess his functional capacity), and has multiple RFs for CAD (HTN, DM, smoker). If his LBBB hasn't been worked up before, it should be worked up. He may have underlying CAD.

I have no doubt you can get him through surgery. Probably can get him through with beautiful train track vitals as well. However, surgery is a pro inflammatory and prothrombotic state that lasts a couple days. Why risk an MI later during his hospital stay? If it's someone you would work up regardless of surgery, you would work him up before an elective procedure. I think that would be the answer you would give for the oral boards anyways. What you do in real life, well, that's up to you.

Also, from my understanding, GA vs regional for surgeries hasn't shown a difference in periop mortality or major adverse cardiac events. Regional has less DVT/PE risk though, so that's nice.