Needs Stress Test?

[deleted171991]

I don't have anything to add, except that this is another thread that showcases @BLADEMDA's priceless contributions to the forum.

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[dannyboy1]

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.

A guy like this with a positive stress test needs to see a cardiologist regardless of plans for upcoming surgery. How do you know that there is only non obstructive CAD?
With regards to cost to the “system”. I care about the system as much as it cares about me.....

 

[deleted171991]

A guy like this with a positive stress test needs to see a cardiologist regardless of plans for upcoming surgery. How do you know that there is only non obstructive CAD?
With regards to cost to the “system”. I care about the system as much as it cares about me.....

The system cares enough to fire you, not make you partner, or not renew your group's contract, if you keep doing this... systematically.

 

[anbuitachi]

so he goes to cath and gets a des stent. i guess case postponed for 6 months at least?

 

[dannyboy1]

The system cares enough to fire you, not make you partner, or not renew your group's contract, if you keep doing this... systematically.

As I said before. If this patient slipped through the cracks and was in the hospital I would do the case. It’s low risk enough that it is not worth the fight with ortho. That being said if I were to encounter this patient in PAT’s he would definitely be sent to the cardiologist. Also I work for an AMC so am not so concerned about partnership and the group....

 

[dannyboy1]

Should start a spin off: do you postpone this case if you are an employee, and does your management change if you are fee for service

 

[deleted171991]

Should start a spin off: do you postpone this case if you are an employee, and does your management change if you are fee for service

When I worked in PP, very few cases got cancelled, because the group wanted to keep the surgeons and the hospital happy, almost at all cost (they would just get a cardiologist to put in a rubber stamp eval within an hour, then we still did the robotic surgery on the 96 year-old ASA 4).

When I worked in academia, the "professional" floor-runners were incentivized directly by the hospital, and we couldn't cancel anything without running the case by them. Not that different, although it was more by the book. Still nothing like back when I was a resident.

 

[nimbus]

so he goes to cath and gets a des stent. i guess case postponed for 6 months at least?

Yep. And the 30 day mortality for a stent is 1-2%. 30 day mortality for a total knee in all comers is around 0.2-0.3%. This patient’s risk is probably higher. However, if he dies after a stent, it’s not on us but he’s still dead.

 

[coffeebythelake]

Yep. And the 30 day mortality for a stent is 1-2%. 30 day mortality for a total knee in all comers is around 0.2-0.3%. This patient’s risk is probably higher. However, if he dies after a stent, it’s not on us but he’s still dead.

Perhaps but the pt will likely go for the DES at some point. So does he want to do it before his knee or after?

 

[deleted171991]

Perhaps but the pt will likely go for the DES at some point. So does he want to do it before his knee or after?

How about never? Remember the studies about PCI not doing crap for survival.

 

[Psai]

Perhaps but the pt will likely go for the DES at some point. So does he want to do it before his knee or after?

Stents don't even help symptomatic people and there is an ever increasing body of literature being ignored by cardiologists about them. Now they're supposed to somehow save this old asymptomatic patient?

 

[caligas]

Stents don't even help symptomatic people and there is an ever increasing body of literature being ignored by cardiologists about them. Now they're supposed to somehow save this old asymptomatic patient?

Well, let’s not confuse good medicine with covering ones ass. The concern is that he has a bad outcome and you get sued because “you should have got a cards consult.”

 

[BobLoblaw78]

I would have very low threshold for stress test (chemical). He is on the verge, which is why it makes for good discussion. I think the guidelines are great for guidance, but not the final say in the matter. If he had any neuropathy at all, I would stress test since he could be having angina and not know. I agree that if it was caught the morning of, I would do the case without stress test. Of course, I would tell the patient that he is equivocal for stress test and if he would prefer the testing, we could get that prior to surgery but that risks come from stress test as well (including treatment).

I personally would want a stress test for myself if I were this patient as much as I would want the TKA.

Spinal is nice and I believe better than general, but evidence is debatable. And you have to prepare the patient as if he may need general anyway.

 

[anbuitachi]

How about never? Remember the studies about PCI not doing crap for survival.

Yea exactly. So i guess what is the best for the patient? Proceed w procedure? Or postpone, get stress test, if negative, proceed with procedure.. if positive.. start some meds.. proceed with procedure

 

[deleted171991]

Yea exactly. So i guess what is the best for the patient? Proceed w procedure? Or postpone, get stress test, if negative, proceed with procedure.. if positive.. start some meds.. proceed with procedure

First do no harm... to yourself. CYA.

 

[Twiggidy]

First do no harm... to yourself. CYA.

Im learning this day by day.

 

[T-burglar]

You could argue successfully that this patient never needed a work up even if he had an MI and dies still sitting up right after you give him a spinal

Low risk procedure, no concerning signs or symptoms, only risk factors. Anyone walking around over a certain age could have silent ischemia. We base our recommendations on likelihood of change in management. The likelihood this guy gets a cath let alone intervention is very low. Presumably the LBBB was scrutinized for signs of scar, and found to be plain block without evidence of scar? Anesthetists mostly think all LBBB are the same, which is far from true. A new left bundle is one of the least common presentations of IHD, especially with no symptoms or concerning QRS morphology.

It’s a TKA, I’d be more worried about the guy throwing a PE from manipulating his immobilized legs and loostening the DVT nobody knew was there.

 

[Noyac]

I did not read every post so forgive me if this has been mentioned already.
If this were at my facility I assume this is how it would go. If I saw him in the pre-op clinic I would get a stress test just so none of my partners balk at the case on the DOS and because it can easily be warranted. In actuality most would not cancel him though.
If he was my pt and had not had a stress test I would proceed as would most of my partners. Unless the surgeon was a total turd. I have worked with surgeons that would absolutely knock this guy off. It matters who is doing the case.

 

[dannyboy1]

Well, let’s not confuse good medicine with covering ones ass. The concern is that he has a bad outcome and you get sued because “you should have got a cards consult.”

This. Also why is everyone on this board trying to tell the cardiologist how to do their job? They don’t tell me how to intubate I won’t tell them when and how to stent....

 

[Twiggidy]

Now that I've actually read the stem this is a pretty cut and dry answer. It's a totally elective TKR. Send this man to a cardiologist for his blessing. If the cardiologist says everything is okay, then do the can and put an A-line in the guy (i know some may not even do that). Otherwise, the cardiologist won't clear him and then the guy will get a cath, maybe a stent, and then hopefully he'll be more optimized. I think given the risk factors (age, comorbidities, ability to walk stairs (which is either due to knee or heart so hard to tell, ie another good reason for a pharm stress test)) it's not the end of the world if this guy collects a cards clearance before coming to your OR.

 

[dhb]

Well, let’s not confuse good medicine with covering ones ass. The concern is that he has a bad outcome and you get sued because “you should have got a cards consult.”

You are a troll and a well know CRNA

 

[caligas]

You are a troll and a well know CRNA

You can call me a troll all day but I draw the line at CRNA

 

[BLADEMDA]

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?

I do spinals routinely on high risk patients off of plavix for just 5 days. I order the P2Y12 test and if WNL I proceed with SAB. I fully respect those who choose to do a GA but that's how I roll these days because I've lost a few patients in my career from perioperative MIs.

Usefulness of the VerifyNow P2Y12 assay to evaluate the antiplatelet effects of ticagrelor and clopidogrel therapies. - PubMed - NCBI

https://watermark.silverchair.com/a...wrGhrINrJQWdY1XxAqedGfRRt1iqSznG54GyvxjLSZOZ8

plavix and platelet inhibition assay, neuraxial recs

 

[BLADEMDA]

You could argue successfully that this patient never needed a work up even if he had an MI and dies still sitting up right after you give him a spinal

Low risk procedure, no concerning signs or symptoms, only risk factors. Anyone walking around over a certain age could have silent ischemia. We base our recommendations on likelihood of change in management. The likelihood this guy gets a cath let alone intervention is very low. Presumably the LBBB was scrutinized for signs of scar, and found to be plain block without evidence of scar? Anesthetists mostly think all LBBB are the same, which is far from true. A new left bundle is one of the least common presentations of IHD, especially with no symptoms or concerning QRS morphology.

It’s a TKA, I’d be more worried about the guy throwing a PE from manipulating his immobilized legs and loostening the DVT nobody knew was there.

Honestly, I see these types of patients daily in my practice. Only about a 1/3 have a real work-up. I rarely, if ever, cancel or delay a case. I have on occasion gotten a TTE or P2Y12 test. We can debate the merits of this guy getting a cardiac stent, assuming he needs one, all day long. FYI, this patient did indeed have mild neuropathy of both his feet (some tingling in the toes).

If this was ME or my family member I'd want a stress test. DHB and FFP may disagree but that's how I see it. I realize the risk from the PCI may be much greater than the mortality from the TKR/TKA but I'd want to know. Does it change outcome? Probably not statistically at all but I'm not a statistic.

In Europe the cost effectiveness of working this guy up makes no fiscal sense. The stats are very clear on that fact. But, this isn't Europe and you can bet your arse I'm getting a stress test at my age before any major surgery. I don't really care what the statitics say. Many of my colleagues have done the same and we all know what the literature says.

I've enjoyed the discussed and really appreciate the comments from DHB and FFP. The RCRI is seared into my brain now and although I know the data I also like to add my experience to the decision making process.

(One last comment is an expert witness could easily quote the Gupta data in his deposition. I would then need to convince lawyers and lay people that seeing a Cardiologist (depsite the Gupta data) wouldn't have benefited this DEAD GUY at all. But, I really don't worry that much these days about the lawyers... I just want to do the right thing. )

 

[MoMoGesiologist]

I do spinals routinely on high risk patients off of plavix for just 5 days. I order the P2Y12 test and if WNL I proceed with SAB. I fully respect those who choose to do a GA but that's how I roll these days because I've lost a few patients in my career from perioperative MIs.

If you don't mind me asking, did these patients have any clues they would have periop MIs? Were they random events? How did it change your management on who you decide to delay and work up and intraop management? Sounds like you prefer to do blocks over GA for sick hearts.

 

[MoMoGesiologist]

How about never? Remember the studies about PCI not doing crap for survival.

Are you saying there are studies showing coronary interventions (stents, CABG) don't change risk of periop MI (aka it doesn't matter whether I get my CAD fixed before my TKA, my risk of MI will be the same regardless) or don't increase survival at all (even for patients not undergoing surgery). If getting my heart fixed before surgery doesn't change periop outcomes, why bother sending people to the cardiologist? Just treat them like a cardiac patient regardless, right?

 

[deleted171991]

Are you saying there are studies showing coronary interventions (stents, CABG) don't change risk of periop MI (aka it doesn't matter whether I get my CAD fixed before my TKA, my risk of MI will be the same regardless) or don't increase survival at all (even for patients not undergoing surgery). If getting my heart fixed before surgery doesn't change periop outcomes, why bother sending people to the cardiologist? Just treat them like a cardiac patient regardless, right?

Those guidelines are from ACC/AHA, not from independent organizations.

If there is still decent flow in a vessel (i.e. stable angina), dilating the plaque can actually worsen the risk of occlusion. Hence the DAPT after stent placement.

 

[deleted162650]

I do spinals routinely on high risk patients off of plavix for just 5 days. I order the P2Y12 test and if WNL I proceed with SAB. I fully respect those who choose to do a GA but that's how I roll these days because I've lost a few patients in my career from perioperative MIs.

Usefulness of the VerifyNow P2Y12 assay to evaluate the antiplatelet effects of ticagrelor and clopidogrel therapies. - PubMed - NCBI

https://watermark.silverchair.com/a...wrGhrINrJQWdY1XxAqedGfRRt1iqSznG54GyvxjLSZOZ8

plavix and platelet inhibition assay, neuraxial recs

What evidence do you have that SAB is any less risky than GA for reducing MI risk???

Most events are due plaque rupture or clotting due to the pro-inflammatory/hypercoagulable state which is the result of surgical tissue injury. Any small degree of supply demand mismatch from a poorly executed GA is insignificant. Additionally, there is a good body of literature out there on anesthetic pre-conditioning which suggests that exposure to volatile anesthetic makes the myocardium more resistant to an ischemic insult.

 

[BLADEMDA]

What evidence do you have that SAB is any less risky than GA for reducing MI risk???

Most events are due plaque rupture or clotting due to the pro-inflammatory/hypercoagulable state which is the result of surgical tissue injury. Any small degree of supply demand mismatch from a poorly executed GA is insignificant. Additionally, there is a good body of literature out there on anesthetic pre-conditioning which suggests that exposure to volatile anesthetic makes the myocardium more resistant to an ischemic insult.

The peer reviewed evidence for SAB over GA for reducing MI/Ischemia is weak at best. But, IMHO, I believe it's the way to go.
https://watermark.silverchair.com/a...faY9vrIJchuqMMSDze5DT9eEJmQRlN_teMO5vFRx7bRkZ

 

[BLADEMDA]

At HSS, where we perform significantly more hip and knee replacements annually than other leading orthopedic hospitals, 98% of patients undergoing these surgeries receive regional anesthesia,” says Dr. Liguori. “Nationwide, that figure is closer to 25%.”

Regional Anesthesia and Pain Management Innovations Improve Patient Outcomes

Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty:A Retrospective, Propensity Score–matched Cohort Study | Anesthesiology | ASA Publications

 

[deleted171991]

What evidence do you have that SAB is any less risky than GA for reducing MI risk???

Most events are due plaque rupture or clotting due to the pro-inflammatory/hypercoagulable state which is the result of surgical tissue injury. Any small degree of supply demand mismatch from a poorly executed GA is insignificant. Additionally, there is a good body of literature out there on anesthetic pre-conditioning which suggests that exposure to volatile anesthetic makes the myocardium more resistant to an ischemic insult.

RA decreases the risk of thrombosis in the lower extremities.

 

[BLADEMDA]

CONCLUSIONS:
Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. - PubMed - NCBI

 

[Twiggidy]

Are you saying there are studies showing coronary interventions (stents, CABG) don't change risk of periop MI (aka it doesn't matter whether I get my CAD fixed before my TKA, my risk of MI will be the same regardless) or don't increase survival at all (even for patients not undergoing surgery). If getting my heart fixed before surgery doesn't change periop outcomes, why bother sending people to the cardiologist? Just treat them like a cardiac patient regardless, right?

When you have pushy surgeons this is what they will ask you to do anyway and in reality, even if a guy did get a stent or CABG you would probably still treat them as a "cardiac patient".

 

[Laryngophed]

When you have pushy surgeons this is what they will ask you to do anyway and in reality, even if a guy did get a stent or CABG you would probably still treat them as a "cardiac patient".

Of course you would. But this is an ELECTIVE TKA. This patient can go home, not have this surgery for six months, and still be alive because of it. (And yes, I know all of you smart doctors can paint a picture where not having the TKA is the root cause of a bad outcome.) If this was emergent, you go and do your best to care for this man. But this isn't. It's elective. Is the patient optimized? I think they ride the fence enough that if you pick and choose you can make your argument either way. Again, I think anyone who has done more than a few months of the CA years has anesthetized "this" patient without further workup. But I think a strong argument can be made that being eyeballed by a cardiologist could benefit him.

 

[dhb]

I'm getting a stress test at my age before any major surgery.

Why? Why wait for surgery? If you feel that a cardiac work up is going to be beneficial why don't you do one tomorrow?

But I think a strong argument can be made that being eyeballed by a cardiologist could benefit him.

Can somebody explain what kind of benefit you are expecting?

 

[nimbus]

At HSS, where we perform significantly more hip and knee replacements annually than other leading orthopedic hospitals, 98% of patients undergoing these surgeries receive regional anesthesia,” says Dr. Liguori. “Nationwide, that figure is closer to 25%.”

Regional Anesthesia and Pain Management Innovations Improve Patient Outcomes

Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty:A Retrospective, Propensity Score–matched Cohort Study | Anesthesiology | ASA Publications

The reason the nationwide rate for regional anesthesia is only 25% is because there is NOT a clear advantage for regional anesthesia in this setting. If there was a clear advantage in real life, people would do regional. For example, the rate of regional anesthesia for OB C-section is probably 98% because there IS a clear advantage in that setting.

In my view, these studies comparing regional vs general anesthesia are not useful because there are so many ways to conduct each type of anesthetic and also so many ways to screw them up.

 

[nimbus]

Of course you would. But this is an ELECTIVE TKA. This patient can go home, not have this surgery for six months, and still be alive because of it. (And yes, I know all of you smart doctors can paint a picture where not having the TKA is the root cause of a bad outcome.) If this was emergent, you go and do your best to care for this man. But this isn't. It's elective. Is the patient optimized? I think they ride the fence enough that if you pick and choose you can make your argument either way. Again, I think anyone who has done more than a few months of the CA years has anesthetized "this" patient without further workup. But I think a strong argument can be made that being eyeballed by a cardiologist could benefit him.

Or they can go to a cardiologist, be referred for a cabg, and be dead or stroked out 1 week later because of it.

Why expose your patient to a high risk procedure in order to mitigate the risk of a lower risk procedure?

 

[BLADEMDA]

The reason the nationwide rate for regional anesthesia is only 25% because there is NOT a clear advantage for regional anesthesia in this setting. If there was a clear advantage in real life, people would do regional. For example, the rate of regional anesthesia for OB C-section is probably 98% because there IS a clear advantage in that setting.

In my view, these studies comparing regional vs general anesthesia are not useful because there are so many ways to conduct each type of anesthetic and also so many ways to screw them up.

We agree that data "proving" SAB over GA for TKA/TKR is weak. It isn't convincing in terms out outcome. That said, it has never let me done vs GA so that is how I roll with patients like in this thread whenever possible.

 

[vector2]

Or they can go to a cardiologist, be referred for a cabg, and be dead or stroked out 1 week later because of it.

Why expose your patient to a high risk procedure in order to mitigate the risk of a lower risk procedure?

NNT to treat for CABG is pretty good, 1/25 for death, 1/10-14 for non-fatal MI. Once the cath reveals 3VD, getting the CABG is a benefit in and of itself. Mitigating the risk of TKR just becomes a nice side benefit.

 

[dannyboy1]

Or they can go to a cardiologist, be referred for a cabg, and be dead or stroked out 1 week later because of it.

Why expose your patient to a high risk procedure in order to mitigate the risk of a lower risk procedure?

Again I ask. Why are people trying to tell cardiologists how to manage CAD? This is an ELECTIVE procedure. If the cardiologist decides that the patient needs a cath with a stent or CABG it is not because of the upcoming knee surgery, it’s because the patient has significant CAD.

 

[Psai]

Again I ask. Why are people trying to tell cardiologists how to manage CAD? This is an ELECTIVE procedure. If the cardiologist decides that the patient needs a cath with a stent or CABG it is not because of the upcoming knee surgery, it’s because the patient has significant CAD.

Because we also went to medical school and know the risks/benefits of surgery way better than someone who hasn't stepped foot in an operating room since ms3. I can bs about allhat and crap like that with the best of them.

 

[dannyboy1]

Because we also went to medical school and know the risks/benefits of surgery way better than someone who hasn't stepped foot in an operating room since ms3. I can bs about allhat and crap like that with the best of them.

The point is that the knee surgery is completely elective.
Forget about the knee surgery. What you have here is a patient with risk factors for CAD being evaluated by a cardiologist. It makes no more sense to weigh in on the cardiologists management of this patient than it does for any other of his patients.

 

[deleted171991]

My usual reply to this kind of crap is: if the cardiologist knows anesthesiology (including preop clearance) better than me, he's welcome to provide anesthesia for this "low risk surgery", and "optimized" patient. I won't.