CAD Management

in
Surgical Patients

Dr. Erwin Mulia, SpJP(K)

RS Bumi Waras
Lampung
 Questions
•
Which one should go
first?
•
Should we intervene
CAD problem or treat
it conservatively first?
•
How to balance
between ischemia and
bleeding risk during
surgery and or
revascularization?
Stepwise Approach

Eur Heart J 2014;35:2383-2431.

Eur Heart J 2014;35:2383-2431.
 Step 2
Active or Unstable Cardiac
Conditions If Yes•

Conditions
•

•
Unstable angina •
Postpone the
pectoris procedure
•
Acute heart failure •
Treatment options
•
Significant cardiac should be discussed
arrhythmias in a multi-disciplinary
team involving all
•
Symptomatic valvular Surgery
peri-operative care
heart disease physicians
Eur Heart J 2014;35:2383-2431.
•
Recent myocardial
 Step 3
Risk of Surgical Procedure
“30 day cardiovascular death & MI”

Without consideration of
patient’s comorbidity
Eur Heart J 2014;35:2383-2431.
 Low Risk Surgical Procedure
•
Identify risk •
Initiation of titrated low
factors dose beta blocker before
•
Lifestyle & surgery (Class IIb/ Level B)
medical •
ACEi in patient with heart
treatment failure & systolic
based on dysfunction (Class IIa/
guidelines Level C)
•
Initiation of statin therapy
Eur Heart J 2014;35:2383-2431. for vascular
Surgery surgery (Class
IIa/ Level B)
 Step 4
Intermediate/ High Risk Surgical Procedure
•
Additional functional capacity (METS):
ü
≥ 4 METS (good)
•
Initiation of titrated low dose beta blocker before
surgery (Class IIb/ Level B)
•
ACEi in patient with heart failure & systolic dysfunction
(Class IIa/ Level C)
•
Initiation of statin therapy for vascular surgery
(Class IIa/ Level B)

Eur Heart J 2014;35:2383-2431. Surgery

Eur Heart J 2014;35:2383-2431.
 Step 5
Consider risk of surgery
•
Additional functional capacity (METS):
ü
<4 METS (moderate or poor) with
intermediate risk surgical procedure
•
Non invasive testing (Class IIb/ Level B)
•
Baseline ECG (Class I/ Level C)

Surgery
Eur Heart J 2014;35:2383-2431.
 Step 6
< 4 METS with High Risk Surgical Procedure

•
Cardiac Risk Factors
•
If cardiac risk factors
≤2  rest echo &
biomarkers of LV
function (Class IIb/
Level B-C)  Surgery

Eur Heart J 2014;35:2383-2431.

•
If cardiac risk factors
≥3  cardiac stress
 Step 7
Cardiac Stress Test
1. No/ moderate stress-induced ischaemia  Surgery
2. Extensive Ischaemia

SURGERY
Eur Heart J 2014;35:2383-2431.
 Exercise Stress Testing
Class IIa
•
For patients with elevated risk and excellent
(>10 METs) functional capacity, it is
reasonable to forgo further exercise testing
with cardiac imaging and proceed to surgery.
(Level of Evidence: B)
Class IIb
1. For patients with elevated risk and unknown
functional capacity, it may be reasonable to
perform exercise testing to assess for
Circulation 2014;130:278-333.

functional capacity if it will change

 Exercise Stress Testing

Class III: No Benefit

•
Routine screening with noninvasive stress
testing is not useful for patients at low risk
for noncardiac surgery. (Level of Evidence: B)

Circulation 2014;130:278-333.
 Pharmacological Stress Testing
Class IIa
•
It is reasonable for patients who are at an
elevated risk for noncardiac surgery and have
poor functional capacity (<4 METs) to
undergo noninvasive phar- macological stress
testing (either dobutamine stress
echocardiogram [DSE] or pharmacological
stress MPI) if it will change management.
(Level of Evidence: B)
Circulation 2014;130:278-333.
Class III: No Benefit
Circulation 2014;130:278-333.
 Diagnostic Test

Eur Heart J 2014;35:2541-2619.

 Risk Scoring
•
To assess short-term (in hospital or 30 days) outcomes:
Ø
STS score
Ø
EuroSCORE, EuroSCORE II
Ø
ACEF
Ø
NCDR CathPCI

•
To assess medium to long term (≥ 1 year) outcomes:
q
SYNTAX, SYNTAX II, Logistic Clinical SYNTAX
Eur Heart J 2014;35:2541-2619.
q
ASCERT CABG, ASCERT PCI
 Principal Therapy

Eur Heart J 2016.

 Preoperative Coronary
Angiography
Class III: No Benefit
•
Routine preoperative coronary angiography
is not recommended. (Level of Evidence: C)

Circulation 2014;130:278-333.
 Indication for Revascularization in
Stable Angina or Silent Ischaemia

Eur Heart J 2014;35:2541-2619.

Eur Heart J 2014;35:2541-2619.
 Coronary Revascularization
Class I
•
Revascularization before noncardiac surgery
is recommended in circumstances in which
revascularization is indicated according to
existing CPGs. (Level of Evidence: C)
Class III: No Benefit
•
It is not recommended that routine coronary
revascularization be performed before
noncardiac surgery exclusively to reduce
Circulation 2014;130:278-333.

perioperative cardiac events. (Level of

 Prophylactic Coronary Revascularization in
Stable Cardiac Patients

For high risk surgery  prophylactic

revascularization may be considered
For low and intermediate risk surgery 
prophylactic revascularization is not recommended

Eur Heart J 2014;35:2383-2431.

 Timing for NonCardiac Surgery
with Previous PCI
Class I
1. Elective noncardiac surgery should be
delayed 14 days after balloon angioplasty
(Level of Evidence: C) and 30 days after BMS
implantation. (Level of Evidence B)
2. Elective noncardiac surgery should
optimally be delayed 365 days after drug-
eluting stent (DES) implantation. (Level of
Evidence: B)
Circulation 2014;130:278-333.
 Timing for NonCardiac Surgery
with Previous PCI
Class III: Harm
1. Elective noncardiac surgery should not be
performed within 30 days after BMS
implantation or within 12 months after DES
implantation in patients in whom dual
antiplatelet therapy (DAPT) will need to be
discontinued perioperatively. (Level of
Evidence: B)
2. Elective noncardiac surgery should not be
Circulation 2014;130:278-333.

performed within 14 days of balloon

1. New generation DES/ DCS
2. DEB/ DCB

Circulation 2014;130:278-333.
Eur Heart J 2014;35:2541-2619.
 Take Home Message
•
Use the simplest algorithm and risk scoring
•
Do balance the ischemia and bleeding risk in
each patient
•
Do optimize guideline-based medical therapy
•
Work as a team (Heart Team/ Jetty’s Team)
•
“Decision making” should be based on each
patient’s clinical condition
Thank you