anes121508

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Haven’t posted in a while and this topic likely discussed in the past but thought this would be a good case for discussion.

85. male. Is a physician. Dm , hld has colon ca without mets. Laparoscopic sigmoid resection. Ct scan shows calcium aorta and coronaries amd has history of nstemi and a normal tte 5 years ago. No other workup. New Stress test done with 3.8 Met on stress test and hr of 115 and no symptoms. Echo has anterior and septal wall motion abnormalities.

patient wants no heart cath and wants surgery.

Thoughts and questions and debate about the preop management?

let’s say you do the case, what helps according to data? What doesn’t? What’s the plan?
 

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Haven’t posted in a while and this topic likely discussed in the past but thought this would be a good case for discussion.

85. male. Is a physician. Dm , hld has colon ca without mets. Laparoscopic sigmoid resection. Ct scan shows calcium aorta and coronaries amd has history of nstemi and a normal tte 5 years ago. No other workup. New Stress test done with 3.8 Met on stress test and hr of 115 and no symptoms. Echo has anterior and septal wall motion abnormalities.

patient wants no heart cath and wants surgery.

Thoughts and questions and debate about the preop management?

let’s say you do the case, what helps according to data? What doesn’t? What’s the plan?

In my book, new RWMA on stress test warrants further testing especially since they were not reported on previous TTE. If pt declines LHC, a coronary CTA would be a good alternative.
 
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coffeebythelake

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Haven’t posted in a while and this topic likely discussed in the past but thought this would be a good case for discussion.

85. male. Is a physician. Dm , hld has colon ca without mets. Laparoscopic sigmoid resection. Ct scan shows calcium aorta and coronaries amd has history of nstemi and a normal tte 5 years ago. No other workup. New Stress test done with 3.8 Met on stress test and hr of 115 and no symptoms. Echo has anterior and septal wall motion abnormalities.

patient wants no heart cath and wants surgery.

Thoughts and questions and debate about the preop management?

let’s say you do the case, what helps according to data? What doesn’t? What’s the plan?

What kind of physician.. do they know pwrioperqtive medicine?? Heart history, less than 4 mets, WMA definitely concerning. I would at a minimum have patient see cardiology to be optimized. Might not be an intervention if patient adamantly opposes cath, but at least make sure maximal medical management. Document pt refusal of anythjng cardiologist recommends. Have a long discussion with patient about cardiac risks. if something happens to patient you know people will back you up.
 
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In my book, new RWMA on stress test warrants further testing especially since they were not reported on previous TTE. If pt declines LHC, a coronary CTA would be a good alternative. @anes121508

The OPs post is not super clear to me. Did he actually get a dobutamine stress echo or did he get an EKG stress test and a separate resting TTE that had static RWMAs on it?
 

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May we presume this was a stress echo? Are the RWMA at peak stress, or are these noted on pre-stress/resting echo?
What was the test stopped for? Max predicted HR? 3.8 METs is the functional equivalent of opening a well-taped piece of mail.

It’s always challenging to delay a cancer case; if a HR of 115 induces RWMA, he’s pretty high risk.

I would of course get Cardiology involved. If he doesn’t want to wait the time for BMS and DAPT, would offer POBA. He’s 85 and has cancer and has (presumably) devoted a portion of his professional life to weighing risks and benefits. I don’t fight this all that hard, in the setting of truly informed consent and requisite documentation of such. Begin beta blocker ASAP before scheduling surgery, continue periop. ERAS, including block/epidural (as able). Probably an art line.
 
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This is a case where there are probably multiple reasonable ways to proceed, as long as everyone involved understands the risk-benefit ratio of the plan chosen.
  • The cardiologist (who this patient does have to at least go see in the office) has to understand that we're talking about a cancer operation, not a knee replacement, it can't wait forever. If they do a cath and want to treat a coronary lesion, they should either just do a balloon angioplasty (14 day wait) or BMS (30 day wait).
  • The surgeon has to realize that this patient really could have a problem, so this isn't a "teaching case". Also they should send him to a postop floor with staff that will actually pay attention to him. If patients are usually "encouraged to be independent" on the usual postop floor, send him somewhere he'll get some attention and TLC.
  • The anesthesiologist has to realize that the cardiologist might not want to do a cath, or the patient might refuse, and that's ok. Aggressive medical management (high intensity statin, beta blockade, etc.) might be it for this guy. Treat him like he might really have a problem. Do an art line. Do something to manage his postop pain well (tachycardia and HTN from pain postop is bad for this guy).
  • The patient needs to realize that all of the above people want to take care of him the best way we can, so let us. We know you have cancer, we're not going to stop you from having your surgery. However, it is a distinct possibility that despite our efforts you'll have a MACE anyway.
Even in patients undergoing vascular surgery (high risk) preoperative revascularization has not been shown to improve postop outcomes. Since OP asked for data, the references section in this editorial cites some interesting and germane papers (ex. the CARP trial, and DECREASE‐V trial).
 
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anes121508

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In my book, new RWMA on stress test warrants further testing especially since they were not reported on previous TTE. If pt declines LHC, a coronary CTA would be a good alternative.

Good point. that was offered and he also declined. Begs The question why he did the stress test though.
 

anes121508

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What kind of physician.. do they know pwrioperqtive medicine?? Heart history, less than 4 mets, WMA definitely concerning. I would at a minimum have patient see cardiology to be optimized. Might not be an intervention if patient adamantly opposes cath, but at least make sure maximal medical management. Document pt refusal of anythjng cardiologist recommends. Have a long discussion with patient about cardiac risks. if something happens to patient you know people will back you up.

Pt and son are internists.

he declined cardiology referral twice now
 

anes121508

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The OPs post is not super clear to me. Did he actually get a dobutamine stress echo or did he get an EKG stress test and a separate resting TTE that had static RWMAs on it?

he has a stress echo (treadmill)

static tte was not done since 2015
 

anes121508

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May we presume this was a stress echo? Are the RWMA at peak stress, or are these noted on pre-stress/resting echo?
What was the test stopped for? Max predicted HR? 3.8 METs is the functional equivalent of opening a well-taped piece of mail.

It’s always challenging to delay a cancer case; if a HR of 115 induces RWMA, he’s pretty high risk.

I would of course get Cardiology involved. If he doesn’t want to wait the time for BMS and DAPT, would offer POBA. He’s 85 and has cancer and has (presumably) devoted a portion of his professional life to weighing risks and benefits. I don’t fight this all that hard, in the setting of truly informed consent and requisite documentation of such. Begin beta blocker ASAP before scheduling surgery, continue periop. ERAS, including block/epidural (as able). Probably an art line.

your point about stress test is accurate, He achieved 115 and 3.8 Mets then they found wall motion problems.

In terms of preop beta blocker case is scheduled in 36 hrs. He is not in any statin beta blocker or asa. Would you start any dos or day before surgery? (That’s as soon as you can in this case).
 

anes121508

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This is a case where there are probably multiple reasonable ways to proceed, as long as everyone involved understands the risk-benefit ratio of the plan chosen.
  • The cardiologist (who this patient does have to at least go see in the office) has to understand that we're talking about a cancer operation, not a knee replacement, it can't wait forever. If they do a cath and want to treat a coronary lesion, they should either just do a balloon angioplasty (14 day wait) or BMS (30 day wait).
  • The surgeon has to realize that this patient really could have a problem, so this isn't a "teaching case". Also they should send him to a postop floor with staff that will actually pay attention to him. If patients are usually "encouraged to be independent" on the usual postop floor, send him somewhere he'll get some attention and TLC.
  • The anesthesiologist has to realize that the cardiologist might not want to do a cath, or the patient might refuse, and that's ok. Aggressive medical management (high intensity statin, beta blockade, etc.) might be it for this guy. Treat him like he might really have a problem. Do an art line. Do something to manage his postop pain well (tachycardia and HTN from pain postop is bad for this guy).
  • The patient needs to realize that all of the above people want to take care of him the best way we can, so let us. We know you have cancer, we're not going to stop you from having your surgery. However, it is a distinct possibility that despite our efforts you'll have a MACE anyway.
Even in patients undergoing vascular surgery (high risk) preoperative revascularization has not been shown to improve postop outcomes. Since OP asked for data, the references section in this editorial cites some interesting and germane papers (ex. the CARP trial, and DECREASE‐V trial).

Agree.
All are good points and were discussed.


you mentioned the aggressive medical management. 2 days before case. Would you add any of those meds and what does the data say?

in preoperative studies did they include left main disease?
 

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Agree.
All are good points and were discussed.


you mentioned the aggressive medical management. 2 days before case. Would you add any of those meds and what does the data say?

in preoperative studies did they include left main disease?

Beta blockers and POISE trial.
 
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you mentioned the aggressive medical management. 2 days before case. Would you add any of those meds and what does the data say?

If he's not on appropriate medical therapy for his CAD, he's not having surgery in 2 days. He will go to the cardiologist, and will take indicated medical therapy prior to this time sensitive operation if he wants to be anesthetized by me. He is always welcome to seek care elsewhere if he prefers substandard treatment.

According to the AHA guidelines for secondary prevention for patients with CAD (here):
-he should be on aspirin, class 1 indication, level of evidence A
-he should be on a statin, class 1 indication, level of evidence A
-he probably should be on a beta blocker. If his NSTEMI was w/i 3 years that's also a class 1 indication, level of evidence A. If >3 yrs ago, its a class IIa indication, level of evidence B.
 
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Main planning would be to make sure I’m not in the hospital the day this goes down.
 
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Pt and son are internists.

he declined cardiology referral twice now

Patient seems unreasonable. I get it’s cancer. Having a conversation w a cardiologist doesn’t mean they’ll slip in a DES when patient looks the other way.

Some great posts up there by @bigdan and @UnbentLaryngoscope.
 
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Good point. that was offered and he also declined. Begs The question why he did the stress test though.

It’s a pet peeve of mine when people make these sorts of condescending counterproductive comments. What if the stress test was negative? Would be nice reassurance, no? Risk stratification has value for making an informed decision. I would like the information as a competent anesthesiologist whether or not he goes through with the cath as recommended. Patients have the right to make informed decisions. They don’t have to agree with everything you recommend.

We as physicians constantly whine about how patients and families want too much end of life care and then throw a fit when the rare one actually wants to take ownership of their decision making and informed consent.
 
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I see a lot of elderly patients in my practice. Some have "failed stress tests" with significant ischemia noted on the record. Typically, they are asymptomatic with many other co-morbidities. If they are asymptomatic the cardiologist will note "discussed with patient. risk/benefits. Will proceed with medical management at this time." Rather than Cath them I see this type of management 30% of the time. Of course, medical management may mean good BP control, statin, baby aspirin, B Blocker, etc. I leave that up to the "expert" dealing with that patient.

My job is to make sure the patient is "optimized" for the procedure and the risks have been explained to the patient/family. I then proceed with the case.
I will NOT do the case without "clearance" on these types of patients because the expert in the field is not an anesthesiologist but rather a cardiologist. I defer to their judgement most of the time provided it is reasonable.

I have seen patients go into renal failure after cardiac catheterization. This can be a life-altering complication for an elderly person. Like other posters have mentioned there is no evidence every patient needs a cath and/or a stent who fails his/her stress test. I am not saying we should avoid our obligation to do the best for each patient but we owe it to them to look at the entire situation and not just one isolated test.

Finally, if the patient refuses to have proper testing prior to a surgery the reason better be darn good or I'm going to cancel the case. Proper consent requires risk stratification and testing does help assess the risk. Typically, for elective surgery (not urgent) I am not going to proceed on a high risk patient without the proper work-up.
 
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Example:

86 year old female shows up for a total hip replacement. BMI is 39. HTN. DM-type 2. Sleep Apnea. High Cholesterol. DJD. She can not do 4 mets due to her bad hip (so she says). Upon further questioning she states dyspnea upon walking to the mail box. She gets "indigestion" from time to time at home but it seems to go away on its own.

I inform her she needs a work-up prior to surgery and cancel the case. She gets angry at me and says the hip is killing her and she doesn't care about the risk to her heart. " I am 86 years old. I live alone with a little dog. All I want to do is walk my dog each morning and night. I don't care if I die having the surgery."

Guess what? I still cancel the case because she doesn't get to make the final decision for elective surgery. She returned 6 months later to the O.R. following DES placement by her cardiologist.
 
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"A more important question is how often providers believe that elective noncardiac surgeries should be preceded by a coronary revascularization procedure when the overwhelming evidence suggests that the intervention will not modify perioperative risk but will delay and possibly prevent the needed operation. If outcome therapy is deemed important, perhaps fewer PCIs prior to high‐risk noncardiac surgery can be viewed as the goal. "

Our current guidelines still recommend cardiac testing for patients who are either symptomatic (not been worked up yet) or can not perform 4+ mets. I would tell you that 20% of the elderly patients I see are "asymptomatic" but can't do 4+ mets due to a bad back, bad knee or bad hip. They have other risk factors for CAD but again are asymptomatic.

At my shop most allow these patients to proceed for surgery without further work-up even though they can't do 4+ mets. Is this the correct approach? Would it hold up in a court of law? Is the ASA out of touch with the Cardiology literature? Or, do most of you agree these patients all need further work-ups like stress tests?
 
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My mind has changed on this recently after seeing more good surgeons in practice. Not trying to be contrarian here. But if the physician in OP was me in 50 years, I'd be on the same page as him. I feel the ca risk is way more threatening than the MACE risk. I would gladly take possibility of curable Ca at the chance of slight MACE. ~1% MACE for 100% cure on cancer? sign me up! (exaggeration to prove a point).

Here is what I would do if I was the physician in the OP:
I know the exact surgeon I'd go to have my surgery done, I've seen the surgeon do this surgery in under 30 mins on the robot with total operating time under 1 hour. approx 50cc blood loss, robot surgery incisions.
I'd find the best guy with thoracic epidurals, peprhaps fly in @abolt18, run it before the surgery and watch my HR never go above 80. If they want to, they can put in a TEE to watch the walls of my heart move just fine. I'll get a cath after I recover.

I'd sign a full legal waiver as well. I believe, if executed correctly, the legal risk overshadows the true MACE risk. This is ridiculously hard to execute though. Better start making friends with the excellent surgeons and anesthesiologists around town.

But as the anesthesiologist providing the anesthesia? better maximize risk mitigation.
 
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My mind has changed on this recently after seeing more good surgeons in practice. Not trying to be contrarian here. But if the physician in OP was me in 50 years, I'd be on the same page as him. I feel the ca risk is way more threatening than the MACE risk. I would gladly take possibility of curable Ca at the chance of slight MACE. ~1% MACE for 100% cure on cancer? sign me up! (exaggeration to prove a point).

Here is what I would do if I was the physician in the OP:
I know the exact surgeon I'd go to have my surgery done, I've seen the surgeon do this surgery in under 30 mins on the robot with total operating time under 1 hour. approx 50cc blood loss, robot surgery incisions.
I'd find the best guy with thoracic epidurals, peprhaps fly in @abolt18, run it before the surgery and watch my HR never go above 80. If they want to, they can put in a TEE to watch the walls of my heart move just fine. I'll get a cath after I recover.

I'd sign a full legal waiver as well. I believe, if executed correctly, the legal risk overshadows the true MACE risk. This is ridiculously hard to execute though. Better start making friends with the excellent surgeons and anesthesiologists around town.

But as the anesthesiologist providing the anesthesia? better maximize risk mitigation.
LOL thanks for the mention, though I'm confident others would be far more qualified/capable. Besides, I'd be happy to drive, make a road trip out of it.
 

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It’s a pet peeve of mine when people make these sorts of condescending counterproductive comments. What if the stress test was negative? Would be nice reassurance, no? Risk stratification has value for making an informed decision. I would like the information as a competent anesthesiologist whether or not he goes through with the cath as recommended. Patients have the right to make informed decisions. They don’t have to agree with everything you recommend.

We as physicians constantly whine about how patients and families want too much end of life care and then throw a fit when the rare one actually wants to take ownership of their decision making and informed consent.

Nice reassurance? So I'll just blast the guy with prop because of a negative stress? Testing for pretty much anything in medicine should only be done if it ALTERS care based on results. If the guy is refusing cath/stent/cabg, who gives a damn about a stress test? Why do it? I'll treat the guy like he's got 25 vessel disease with an aortic valve area of .0001 and tell him he's high risk for refusing definitive treatment and we're going to take every precaution to get him through it if he's adamant about no treatment for his cardiac issues. Documenting every word preop of course.

I fully agree with patients making their own decisions (with some level of understanding consequences) and it's nice to not have family pushing for 99 year old severe pulm htn, stage 12 cancer, gtube fed, demented grandma with a broken hip pushing for "everything." So while I don't agree with this guy's viewpoint medically to forego further workup and treatment, I also respect his choices.
 
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I think it's worth mentioning that not all MACE is created equal; it's one thing to have a small apical reversible defect at 10 METS. It's quite another to have a large anterior wall defect with the equivalent level of exertion needed to saunter up a flight of stairs.
 
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Nice reassurance? So I'll just blast the guy with prop because of a negative stress? Testing for pretty much anything in medicine should only be done if it ALTERS care based on results. If the guy is refusing cath/stent/cabg, who gives a damn about a stress test? Why do it? I'll treat the guy like he's got 25 vessel disease with an aortic valve area of .0001 and tell him he's high risk for refusing definitive treatment and we're going to take every precaution to get him through it if he's adamant about no treatment for his cardiac issues. Documenting every word preop of course.

I fully agree with patients making their own decisions (with some level of understanding consequences) and it's nice to not have family pushing for 99 year old severe pulm htn, stage 12 cancer, gtube fed, demented grandma with a broken hip pushing for "everything." So while I don't agree with this guy's viewpoint medically to forego further workup and treatment, I also respect his choices.

Absolutely nothing wrong with proceeding with noninvasive testing like a stress test for more information and risk stratification. And yes, i am a fan of noninvasive testing and it indeed changes my approach to anesthetics. I’m not going to delay every other case for an echo but i will never complain about having one.
 

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I’m surprised that people would delay this case for “cardiology clearance”. This isn’t an elective THA, this is an early stage cancer operation. @BLADEMDA if you read them word for word, our guidelines suggest further testing in these patients ONLY IF IT WILL CHANGE MANAGEMENT. I see this as the question which the CARP trial addresses: would intervening on a positive stress test improve outcomes? The best evidence that we have seems to suggest that it doesn’t (despite the gut feeling that it should). So, especially for a cancer operation, I don’t think further cardiac work up would change my management at all: put in an art line, careful hemodynamics during the case, consent patient for higher risk of MACE and document as such. Patient is making an informed (and very reasonable) decision, I respect that autonomy.

I would feel very comfortable defending this decision making in court if it came to that... As a consultant I am interpreting the data and following our somewhat vague guidelines in a manner which is consistent with our best evidence, using my clinical judgement of risks vs benefits.

Now as as to whether it’s worth delaying the case I order to get him on optimal medical therapy (BB, statin, ASA, BP control)... That seems like more of a gray area. Delaying the case until he can see his PCP and get on those meds would be totally reasonable, but for me it would depend on how long we’d be delaying the surgery. Surgeon all booked up and patient could be delayed for a month plus? Personally I would hate to delay this dude’s potentially curative cancer operation, so I would probably still go ahead after having him started on all those meds for a few days (recognizing that this is a data-free decision and reflects my own risk tolerance to a greater degree)
 
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I’m surprised that people would delay this case for “cardiology clearance”. This isn’t an elective THA, this is an early stage cancer operation. @BLADEMDA if you read them word for word, our guidelines suggest further testing in these patients ONLY IF IT WILL CHANGE MANAGEMENT. I see this as the question which the CARP trial addresses: would intervening on a positive stress test improve outcomes? The best evidence that we have seems to suggest that it doesn’t (despite the gut feeling that it should). So, especially for a cancer operation, I don’t think further cardiac work up would change my management at all: put in an art line, careful hemodynamics during the case, consent patient for higher risk of MACE and document as such. Patient is making an informed (and very reasonable) decision, I respect that autonomy.

I would feel very comfortable defending this decision making in court if it came to that... As a consultant I am interpreting the data and following our somewhat vague guidelines in a manner which is consistent with our best evidence, using my clinical judgement of risks vs benefits.

Now as as to whether it’s worth delaying the case I order to get him on optimal medical therapy (BB, statin, ASA, BP control)... That seems like more of a gray area. Delaying the case until he can see his PCP and get on those meds would be totally reasonable, but for me it would depend on how long we’d be delaying the surgery. Surgeon all booked up and patient could be delayed for a month plus? Personally I would hate to delay this dude’s potentially curative cancer operation, so I would probably still go ahead after having him started on all those meds for a few days (recognizing that this is a data-free decision and reflects my own risk tolerance to a greater degree)


My posts were NOT meant as a response to the OP. That patient is more of an "urgent" case not a totally elective case like a hip replacement. Again, what would most of you do for an asymptomatic patient with many risk factors for CAD who can not do 4 mets? At my shop they proceed with the elective case. At the MECCA up the road they TEST everyone who fails to do 4 mets. I realize there is a gray area here like the athlete who hasn't been able to do much the past 6 weeks secondary to injury vs the 80 year old male with BMI of 44, HTN, COPD, 75 year pack history, DM type 2, etc who can't walk to his mail box.

Does it change outcome? Maybe for 1 particular patient but not for a large number. The question is are you willing to put your license and malpractice policy on the line to do an elective case on someone who clearly appears at high risk of CAD? Unlike many of you I have seen these patient die postop secondary to CAD. For those patients the intervention COULD have been life-saving events. Everything may seem like a statistic until it happens to you.
 
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For case originally presented, the sticking point for me is the patient not being on appropriate medical therapy. That means he's not optimized. Furthermore, cancer patients are hypercoagulable, and furthermore surgery is a pro-thrombotic and pro-inflammatory insult. None of those things are great news for someone with hemodynamically significant CAD.

He needs to go home and take his ASA/BB/statin for a week and come back for his operation. His cancer has probably been there for a year, this operation can wait a week for his coronary plaques to marinade in some statin for plaque stabilization, and for his platelets to get a little less sticky from some aspirin. If he's cranky about taking meds, he can stop taking them after surgery for all I care, he's just gotta take them a few days leading up to the operation to get past me as his roadblock. He's an internist, he's supposed to be smarter than me :rolleyes: surely he can figure all this out.
 
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BLADEMDA

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For case originally presented, the sticking point for me is the patient not being on appropriate medical therapy. That means he's not optimized. Furthermore, cancer patients are hypercoagulable, and furthermore surgery is a pro-thrombotic and pro-inflammatory insult. None of those things are great news for someone with hemodynamically significant CAD.

He needs to go home and take his ASA/BB/statin for a week and come back for his operation. His cancer has probably been there for a year, this operation can wait a week for his coronary plaques to marinade in some statin for plaque stabilization, and for his platelets to get a little less sticky from some aspirin. If he's cranky about taking meds, he can stop taking them after surgery for all I care, he's just gotta take them a few days leading up to the operation to get past me as his roadblock. He's an internist, he's supposed to be smarter than me :rolleyes: surely he can figure all this out.


For me this is simple: He gets the Cardiology note on his chart which states "optimized for surgery" prior to doing the case. I would hope that between the 3 of them (patient, son and cardiologist) one of them would grasp what optimized means in this situation.
 
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For case originally presented, the sticking point for me is the patient not being on appropriate medical therapy. That means he's not optimized. Furthermore, cancer patients are hypercoagulable, and furthermore surgery is a pro-thrombotic and pro-inflammatory insult. None of those things are great news for someone with hemodynamically significant CAD.

He needs to go home and take his ASA/BB/statin for a week and come back for his operation. His cancer has probably been there for a year, this operation can wait a week for his coronary plaques to marinade in some statin for plaque stabilization, and for his platelets to get a little less sticky from some aspirin. If he's cranky about taking meds, he can stop taking them after surgery for all I care, he's just gotta take them a few days leading up to the operation to get past me as his roadblock. He's an internist, he's supposed to be smarter than me :rolleyes: surely he can figure all this out.

I like this approach.

Stress tests have basically zero predictive value. There's plenty of cases of people who have a negative stress test and come back with a rip roaring MI. There are also plenty of cases of patients who have reversible defects but get through surgery no problem.
 

vector2

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For case originally presented, the sticking point for me is the patient not being on appropriate medical therapy. That means he's not optimized. Furthermore, cancer patients are hypercoagulable, and furthermore surgery is a pro-thrombotic and pro-inflammatory insult. None of those things are great news for someone with hemodynamically significant CAD.

He needs to go home and take his ASA/BB/statin for a week and come back for his operation. His cancer has probably been there for a year, this operation can wait a week for his coronary plaques to marinade in some statin for plaque stabilization, and for his platelets to get a little less sticky from some aspirin. If he's cranky about taking meds, he can stop taking them after surgery for all I care, he's just gotta take them a few days leading up to the operation to get past me as his roadblock. He's an internist, he's supposed to be smarter than me :rolleyes: surely he can figure all this out.

This x 100. Optimal medical therapy is very effective, as evidenced by the fact that it is very difficult to prove outcome differences between intervention and OMT unless the CAD symptomatic and/or is 3V or LM with hemodynamically significant stenosis and/or pt is bad diabetic.

Even with cancer, proceeding on this guy who isn’t even on ASA, BB, statin seems not particularly wise. Doubly so if his A1c is chronically bad.
 
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Twiggidy

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I would definitely get a "cardiologist clearance" for this case. Just something that said "I've seen the patient. He's the best I can get him despite him not wanting further cardiology evaluation". I would have a good discussion with the patient about his risks. If he agrees to proceed there are definitely ways to do the case and get him through safely. I would 100% place an arterial line so I can tightly control his BP and I would 100% place a CVP more so in case I need a cocktail of drips to go directly to his heart.

Another big factor in the case which I can't remember if I've read above or not is SURGEON SKILL. Is this the type of surgeon who plays around with the laparoscope or is this a surgeon who will be "in and out" before you can even finish charting. I would argue that's just as big of a factor as any anesthetic technique.
 
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vector2

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I like this approach.

Stress tests have basically zero predictive value. There's plenty of cases of people who have a negative stress test and come back with a rip roaring MI. There are also plenty of cases of patients who have reversible defects but get through surgery no problem.

I just got done covering a couple days in the MICU. We take a HD2 admit from the floor with afib RVR hx of pAF, DM, HTN supposedly non-obstructive CAD. He had been doing fine on the floor but then started getting progressive dyspneic with poor response of the RVR to dilt. We do not have his outside records but he’s not been taking his metoprolol but he has been taking his eliquis. Doesn’t appear to have a cardiologist. Does not take ASA or statin. He’s in pulmonary edema, LVEF is down to 25% when we bedside echo him. No hx of ischemic CM. May be tachycardia mediated. Diaphoretic as hell. He’s complaining of chest pain (mostly sounds like palpitations) but maintaining his bp fine. We stop the dilt, amio load, lasix 80 IV, bipap. Stat ekg and trop are stone cold negative except for afib. Yesterday’s EKG and trop were also negative. We give him ASA 81 and high dose atorva given his possible CAD history and risk factors. Starts getting symptomatic relief, chilling in bed.

A few hours later he decides to get up without calling the nurse. Syncopizes. We put him back in bed but he’s now persistently hypotensive and requiring high dose levo to maintain MAP 65. Chest pain back. Stat EKG and trop. EKG with obvious anterolateral STEMI. Goes to cathlab. Trop comes back >80. They find a mid-LAD plaque rupture, diffuse RCA and LCx.

The moral of the story is that this guy has severe 3v disease and has been undergoing a 36-48h stress test without even leaking any troponin. A large, large percentage of acute MIs are due to plaque rupture, so not having someone on medication which helps to prevent plaque rupture (and mitigates the rupture if it does happen) before an extremely inflammatory event doesn’t seem right.
 
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teacher2md

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Here’s a question for you guys: Does PCI for stable CAD improve outcomes at all?


My hunch is that we get fixated on those big 80-99% lesions and feel better after stenting them, but the 30% lesions are just as likely to rupture and cause an MI.

For this case, my thought would be to proceed without cath and try to keep HR and afterload on the low end, but I know this is tricky from a medico-legal perspective if there’s a bad outcome.

EDIT: I just saw vector2's comment-- i agree.
 
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teacher2md

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Here's a recent trial where they randomized patients with stable CAD and moderate-severe ischemia on stress testing to either PCI or medical management; no difference in outcomes.

ISCHEMIA trial
 
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teacher2md

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Maybe but not necessarily. Don’t skimp on documentation.

I think the tricky part is that there are still guidelines from ACC/AHA that indicate that you should consider revascularization, and it wouldn't be hard to find an expert witness cardiologist to testify that this would have saved the patient's life (even if most recent evidence disagrees).
 
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At my shop most allow these patients to proceed for surgery without further work-up even though they can't do 4+ mets. Is this the correct approach? Would it hold up in a court of law? Is the ASA out of touch with the Cardiology literature? Or, do most of you agree these patients all need further work-ups like stress tests?

I am still early in my career, so I do this sort of thing by the book when I'm on deck to get calls from our pre-anesthesia testing clinic, and send for some type of stress test. I see it as important for risk stratification (I admit, because I have been taught to see it that way).

On the flip side, I receive patients in my line that have been through our pre-anesthesia testing clinic, cleared by my partners, that can't do 4 METS, and that they didn't refer for testing. My partners say "oh that surgeon is really fast, and there won't be much blood loss, so the patient will be ok". I do those cases because I feel like I have to, and so far I haven't had any problems.

I admit though, I worry that if something happens it wouldn't hold up in court. I also worry that this might be the type of thing where we think the patient does ok... and perhaps we're too shortsighted. If the patient has a MACE 2 weeks later, we might not hear about it, or might not feel like we own that complication. Even though the pro-inflammatory and pro-thrombotic state caused by the patient having surgery, which we enabled to occur, may have been the proximate cause. Hard to tell. I haven't been in the game that long, so I certainly don't really know.
 
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I will tell the surgeon to minimize the intraperitoneal pressure during laparoscopy. Only inflate to pressures that you need to get the surgery done quickly. i will put a TEE probe and ask my cardiac anesthesia colleague to stand by. I have had a 48 yr old patient with Positive family history (brother having had Cabg at 52 yrs old and mother had CABG At 65 yrs old. And a positIve stress test For laparoscopic ventral hernia repair. The cardiologist in upstate New York hospital cleared the patient and it was assigned to me ( Locum )anesthesiologist.

I talked to the surgeon about the risk and he was adamant that I did not have more knowledge and judgement about the cardiovascular risk as it has been cleared by the cardiologist. I spoke to the cardiologist and he was saying that the patient is medically optimized. This hospital does not have any interventional cardiac cath and stenting procedures, in case of cardiac complication We’re to happen to bail us out.

I tried to discourage the patient, citing his young age and his high positive family history, patient wAnted to get his ventral hernia fixed as he said it was hurting him and did not want any more cardiac work up.

proceeded with an a line and metoprolol for heart rate control and patient did well. Kept him in the hospital overnight as per cardiologist and discharged him. For all this the surgeon complaints to the chief of anesthesia that I delayed the case for 1.5 hours and that I am trying to find reasons not to work and run out the clock.

on my part I lashed out at the surgeon and reminded him that if things go bad after he starts the incision that his judgement will also be questioned by my defense lawyers.
 
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coffeebythelake

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I like this approach.

Stress tests have basically zero predictive value. There's plenty of cases of people who have a negative stress test and come back with a rip roaring MI. There are also plenty of cases of patients who have reversible defects but get through surgery no problem.

Stress test may not be predictive for plaque rupture STEMI, but j think it is useful when assessing risk for demand ischemia NSTEMI
 
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I think the tricky part is that there are still guidelines from ACC/AHA that indicate that you should consider revascularization, and it wouldn't be hard to find an expert witness cardiologist to testify that this would have saved the patient's life (even if most recent evidence disagrees).

The important part is that you consider revascularization. On my end, that means that I consult an expert in cardiovascular disease, that is capable of revascularizing someone... a cardiologist. Said expert can discuss the risk benefit ratio with the patient and they can come to a decision, and they can medically optimize the patient.

As you've found, for a particular patient there may not be much benefit to revascularization. It absolutely may be reasonable, and within the standard of care not to cath someone with a positive stress test. However, send the patient to a cardiologist and have them tell you that. If the patient has a problem, the cardiologist can defend themselves for the decision not to cath. The only thing I have to defend is my anesthetic management of the patient.
 
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vector2

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Stress test may not be predictive for plaque rupture STEMI, but j think it is useful when assessing risk for demand ischemia NSTEMI

But in someone for whom you were equivocal about getting a stress test but who, say, would’ve refused intervention, you wouldn't have run your anesthetic any differently right? You’re going to induce carefully, avoid tachycardia, hypo/hypertension, hypo/hypervolemia regardless. Are you going to be checking for trops POD 0 and 1 to assess for MINS?
 
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Hork Bajir

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The important part is that you consider revascularization. On my end, that means that I consult an expert in cardiovascular disease, that is capable of revascularizing someone... a cardiologist. Said expert can discuss the risk benefit ratio with the patient and they can come to a decision, and they can medically optimize the patient.

As you've found, for a particular patient there may not be much benefit to revascularization. It absolutely may be reasonable, and within the standard of care not to cath someone with a positive stress test. However, send the patient to a cardiologist and have them tell you that. If the patient has a problem, the cardiologist can defend themselves for the decision not to cath. The only thing I have to defend is my anesthetic management of the patient.

I agree with much of what you have said on this thread, but respectfully disagree with you here. I don’t think cardiologists have a great understanding of what goes on in the OR, and while there are certainly cases that I will request their expertise, I would push back on the idea that only a cardiologist can determine whether someone is “optimized” (or whether they need a cath). We are meant to be experts in perioperative medicine, we have read the literature on the benefits (or lack thereof) for preop PCI, and in a straightforward case I don’t feel that I need a cardiologist to tell me that PCI isn’t indicated. More complex cases, sure- I welcome cards input. But this case isn’t rocket science.

@BLADEMDA I also have stories of patients who had MACE after surgery. It happens. In the trials looking at revascularization vs none for non cardiac surgery, there were MACEs in BOTH GROUPS. Just because something bad happens after surgery doesn’t necessarily mean that you eff’d up by not sending to cards or cathing them - it just means that they had risk factors, and in our business it’s a numbers game. You do this for long enough in high risk patients and you see complications. That’s no excuse for ignoring the data and letting recency bias govern your practice, IMHO. You can call me young and naive if you’d like, but I’ll stand by my statement : )
 
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coffeebythelake

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But in someone for whom you were equivocal about getting a stress test but who, say, would’ve refused intervention, you wouldn't have run your anesthetic any differently right? You’re going to induce carefully, avoid tachycardia, hypo/hypertension, hypo/hypervolemia regardless. Are you going to be checking for trops POD 0 and 1 to assess for MINS?

Informed consent involves patient knowing their risks. Are you going to tell all your patients they have a major risk for MACE when that isn't the case or vice versa? If you tell someone they have 1% chance of MACE vs 15% chance that SHOULD change the conversation. I plan all my anesthetics to watch hemodynamics closely but that doesn't mean it always ends up being railroad tracks through the case. You should know that there is a difference between plan and implementation.
 

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Informed consent involves patient knowing their risks. Are you going to tell all your patients they have a major risk for MACE when that isn't the case or vice versa?

Stress testing is not definitively superior to stratification based on functional status + RCRI, so I would just quote the pt the percentage from one of those risk calculators if they wanted more specific information than “you have/don’t have some increased risk for MACE”
 

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This type of post makes me sad. I love the discussions about when to proceed and they are certainly relevant on a different patient. It makes me sad because we are just as concerned about the medico-legal aspect as we are about the patient. This is an 85! Year old physician and a physician son who don’t want a cardiac cath. I’m sure he knows his CAD could knock him off but he wants this surgery done and we are (rightly) afraid of lawyers. Lawyers have killed medicine but are rarely brought up in the discussion of how to decrease costs.
Thanks everyone for the good clinical discussions. Keep em coming.
 
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BLADEMDA

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This type of post makes me sad. I love the discussions about when to proceed and they are certainly relevant on a different patient. It makes me sad because we are just as concerned about the medico-legal aspect as we are about the patient. This is an 85! Year old physician and a physician son who don’t want a cardiac cath. I’m sure he knows his CAD could knock him off but he wants this surgery done and we are (rightly) afraid of lawyers. Lawyers have killed medicine but are rarely brought up in the discussion of how to decrease costs.
Thanks everyone for the good clinical discussions. Keep em coming.

Some of you people are just naive. Plain and simple. A review of the case by the plaintiff’s expert will destroy you. Your Analysis is flawed as seen by a jury of your peers. That’s who is going to determine your fate. So, for those who don’t get the cardiology note on high risk patients your defense won’t hold up and the case will be settled quickly. You are not viewed as equal to an expert in cardiology by the public. We all take calculated risks each and every day in our practice. I highly recommend good care along with appropriate consults with our colleagues regardless of whether it changes outcome. I guarantee the one outcome it does change is whether you get sued or not.
 
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I agree with much of what you have said on this thread, but respectfully disagree with you here. I don’t think cardiologists have a great understanding of what goes on in the OR, and while there are certainly cases that I will request their expertise, I would push back on the idea that only a cardiologist can determine whether someone is “optimized” (or whether they need a cath). We are meant to be experts in perioperative medicine, we have read the literature on the benefits (or lack thereof) for preop PCI, and in a straightforward case I don’t feel that I need a cardiologist to tell me that PCI isn’t indicated. More complex cases, sure- I welcome cards input. But this case isn’t rocket science.

@BLADEMDA I also have stories of patients who had MACE after surgery. It happens. In the trials looking at revascularization vs none for non cardiac surgery, there were MACEs in BOTH GROUPS. Just because something bad happens after surgery doesn’t necessarily mean that you eff’d up by not sending to cards or cathing them - it just means that they had risk factors, and in our business it’s a numbers game. You do this for long enough in high risk patients and you see complications. That’s no excuse for ignoring the data and letting recency bias govern your practice, IMHO. You can call me young and naive if you’d like, but I’ll stand by my statement : )

I accept that your opinion is certainly valid, even if we don't entirely agree. I would like to point out that I do agree with some of what you've said here though.

I agree that cardiologists don't have a very accurate perception of what goes on in an OR. They've certainly offered some... odd... opinions about how I should run my anesthetics in the past. I also agree that a cardiologist is not the only person that can determine if a patient is medically optimized, we do that every time we do a case. As perioperative physicians, we should be doing our best to keep up with the literature on preop risk stratification. Lastly, I do agree that I would not call this case complex.

However, I can't read and critically appraise everything about all of the perioperative issues there are. In the case of a patient with a positive stress test, I'm getting a consult. I'm not willing to bet the patient's well being that my knowledge of CAD is equal to that of a cardiologist. They might know something I don't. If they do, it could make a difference in the outcome.
 
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cowbydoc

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Some of you people are just naive. Plain and simple. A review of the case by the plaintiff’s expert will destroy you. Your Analysis is flawed as seen by a jury of your peers. That’s who is going to determine your fate. So, for those who don’t get the cardiology note on high risk patients your defense won’t hold up and the case will be settled quickly. You are not viewed as equal to an expert in cardiology by the public. We all take calculated risks each and every day in our practice. I highly recommend good care along with appropriate consults with our colleagues regardless of whether it changes outcome. I guarantee the one outcome it does change is whether you get sued or not.

I probably didn’t make my point clear enough before. I agree with Blade, get a Cards consult on this patient. If they recommend a cath and he declines I have a frank talk with him and his family while documenting the hell out of it and proceed with the case.
My earlier point is that I wish we never even had to discuss the medico-legal aspect of most cases. Much less an 85 year old physician who doesn’t want a cardiac cath. If only we were able to practice medicine responsibly without thinking all the time of the CYA factor.
 
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coffeebythelake

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Some of you people are just naive. Plain and simple. A review of the case by the plaintiff’s expert will destroy you. Your Analysis is flawed as seen by a jury of your peers. That’s who is going to determine your fate. So, for those who don’t get the cardiology note on high risk patients your defense won’t hold up and the case will be settled quickly. You are not viewed as equal to an expert in cardiology by the public. We all take calculated risks each and every day in our practice. I highly recommend good care along with appropriate consults with our colleagues regardless of whether it changes outcome. I guarantee the one outcome it does change is whether you get sued or not.

Agree with this analysis.
Dot all your I's, cross all your T's
Get the cardiology consult even if they refuse cardiac intervention.
(It's funny because patient refusal to go to their appointment is the most likely reason why the surgery will be delayed here)
Everyone on the same page about risks and benefits. Document everything.
Do the case.
 
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