Garbage clearances

[neutro]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

“given the lack of clarity on this patient’s work up, it would be against standard of care for me to proceed. You're more than welcome to seek a second anesthesiologists opinion regarding this patient but I can’t proceed until x, y, z is clarified.
In the meantime we’d be more than happy to call your next patient early”


One of the best things about being an independent contractor and having no boss is that I really get to decide who I put to sleep. I do not need interference or opinions from other people. I follow guidelines and try to keep up with the evidence - and ofcourse believe in my gut instincts.

Don’t get me wrong, I’m a firm believer in pushing cases and getting things done for patient. But when push comes to shove I’ll do it. As every anesthesiologist should.

It’s not my fault that all this time the surgeon and cardiologists didn’t to do a proper work up.

I prefer admit plus work up in-house and optimization approach a lot more - that seems to go over well as opposed to just canceling right off the bat.

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[cytocide]

Only read the first one - the guy with multiple positive stresses - at an asc? That’s ******ed.

 

[Full Metal IC]

This comment just highlights our frustration with people’s lack of understanding of, yet no shortage of confidence in, anesthetic management considerations.

Just because you use your 50 fentanyl and 2 of versed on stable valvular patients and it works most of the time does not mean there is all there is to it. If Gastro was able to do it with just light sedation LoneWolf would never have been involved. The spectrum of sedation is quite a lot vaster, the impact of acute on chronic pathology more important than you appreciate, and the acuity of the procedure important when the pathology being treated and the pathology affecting anesthesia are different (as opposed to TAVI)

Your opinion on safe sedation means as little to us as my opinion on which stent to use just because I access alot of femoral arteries would mean to you. Especially as we all have experience with being called to the lab to bail out some frothing disaster on the table who was given versed until he “stopped moving”

Yes I agree completely, my opinion on safe sedation shouldn't matter at all to you, an anesthesiologist. But at the end of the day procedural cardiologists who administer moderate sedation (and do procedures with anesthesiologists) do have some sense of the graded risks of anesthesia in the selected subset of patients with cardiac pathology. My original point about that endoscopy case he described was simply that from a cardiac perspective moderate sedation is pretty well tolerated, so proceeding may not be inappropriate. The patient with NSTEMI should be on DAPT. Even if he's not actively bleeding anymore it is very reasonable to look for a source now regardless because he is going to be on DAPT for a while. If it requires more intensive anesthesia then sure maybe the risk isn't worth it. Not arguing that.

And regarding the cath lab bail-outs - congratulations, you are doing your job. No, we are not experts in airway and sedation management. I hate dealing with that ****, and I am very weary of all the bad things that can happen with anesthesia. If I could have an anesthesiologist for every procedure, all the STEMIs and shock disaster cases in the middle of the night, boy I would love that. But that's not going to happen is it? So if you want us to feel bad about needing you to bail us out for airway and sedation issues, not going to happen.

 

[vector2]

Sounds like the 90 year old has stable CAD managed medically for many years. Nothing else to do there. Revascularization does nothing to reduce his periop risk outside of the possibility of left main disease, and we can usually gauge the risk of this from the stress test itself and history. I'm with the family doc here - do the shoulder so gramps can live his life.

You really seem to be inferring quite a bit even though the OP didn't provide a ton of cardiac history. We don't know the rest of the pt's medical history or his risk factors. We don't really know whether the pt has any rest symptoms. We don't even know what kind of stress test(s) he's had. And yet you're content to call this "stable CAD." Are you not curious why this guy has had *multiple* abnormal stress tests but no LHC or CCTA?

Furthermore, there are other scenarios beyond just left main disease where the pt could derive some benefit from perioperative revascularization, namely 3v disease/LM equivalent and/or the pt has impaired LV function.

But going back to the guidelines, a total shoulder is an intermediate risk procedure. The pt cannot do four METS. If he's had a pharmacological stress test and that test is abnormal, the decision tree ends with "Coronary revascularization according to existing CPGs" ....as a class I recommendation. So yes, the guy needs to see a cardiologist at minimum for an evaluation and a nuanced discussion of the risks/benefits of further testing and treatment.

 

[Full Metal IC]

Only read the first one - the guy with multiple positive stresses - at an asc? That’s ******ed.

Ha. I missed that part. That is ****ed

 

[TheLoneWolf]

It isn't semantics, it reflects a fundamentally poor understanding of how pre-operative testing and the downstream management works.

Seems like you are going to die on this hill. I'm not saying it is wrong to send this particular patient to a cardiologist, just that the management is not as inappropriate as you think it is. Everything you have stated about this case suggests that the 90 year old does not need more work-up before his surgery, and PCPs are qualified to make this call and know when sending the patient to us will change nothing.

Not once did I say that this particular patient was low risk for complications. He's 90. He could be an active marine with 2 hearts, I'm still calling him high risk. But at the end of the day it doesn't matter. Whether I say low risk, intermediate risk, high risk ultimately changes nothing for the patient when it comes to stable CAD outside of very rare scenarios. There are many primary care physicians who know this and manage patients accordingly. Every cardiologist does primary care clinic in residency, and even at that stage we do these pre-op evals without sending everyone to cardiology even if *gasp* they got a D on their stress test.

At the end of the day for every 1 so-called "garbage clearance" you complain about there are 50 garbage pre-op referrals that accomplish absolutely nothing for the patient and bloat our clinics to no end. These referrals are not about the patient, they are about about YOU and how comfortable YOU feel about doing the case and what the world and jury will think if there is a complication. Which is what 90% of "clearances" are about and the crux of this issue. The surgical team wants a cardiologist's blessing and name in the chart.

Not once in the ACC/AHA guidelines do they specify who needs to be sent to a cardiologist preoperatively. Your reply illustrates exactly what I am talking about with regards to the role of CYA.

Like I said earlier I have nothing against CYA at all. It is part of practicing medicine in the US and we all do it. But to not acknowledge the dominant role it plays in this space is just ridiculous. In the case we were discussing, my point was that the family doc probably managed the patient appropriately from a medical standpoint. So LoneWolf is essentially getting mad at the family doc for not sending the patient to cardiology to cover HIS OWN ass.

So everyone on here has fundamental misunderstandings of the ACC/AHA guidelines except you. Bravo....why don't you take a lap in your mind.

I think you fundamentally misunderstand and are willfully downplaying patient safety and potential risks. It's the hill you already died on a few posts ago.

What urgency is there to proceed this moment on an elective shoulder replacement?

Revascularization may or may not alter his overall management. Only cardiologists can make that call.

Can you please explain how a family doc can determine if a patient, per the above guidelines, needs coronary revascularization (grade 1 recommendation)? Please regail us with their deep expertise on the subject.

You keep saying it's "cover your ass" to workup the patient prior to an elective case. I think these is a strong medicolegal basis, sure. That is not the sole issue. I want this guy to do well and survive the intra and postprocedure course. Again, disingenuous.

Let me explain it is simple words as you clearly didn't get the MRI metaphor.

Your car makes bad noises and violently shakes when you take it for a short drive (Failed stress test, your favorite term). You call your barber (family doc) and he says no biggie, put some tape over the check engine light and proceed on a road trip. This is the***critical point here, focus, otherwise you will have to reread it*** Your barber is a layman with no expertise on the inside and outs of your vehicle. What both you and the barber should have realized is auto mechanics are the experts on cars (cardiologists). Problem could be small or critical. Won't know unless it dies on you (bad) or you take it to a mechanic.

I think you may need to reasses your lassiez fare approach to patient safety and a creative reinterpretation of the ACC/AHA guidelines. That's putting it as politely as I can.

 

[TheLoneWolf]

Ha. I missed that part. That is ****ed

Dude what have I been saying for multiple posts. At an ASC. There is no cardio, there is no nothing. Just surgeons, anesthesia, some nurses and a cars cart. Closest hospital with a cath lab is 35 minutes away.

 

[TheLoneWolf]

You really seem to be inferring quite a bit even though the OP didn't provide a ton of cardiac history. We don't know the rest of the pt's medical history or his risk factors. We don't really know whether the pt has any rest symptoms. We don't even know what kind of stress test(s) he's had. And yet you're content to call this "stable CAD." Are you not curious why this guy has had *multiple* abnormal stress tests but no LHC or CCTA?

Furthermore, there are other scenarios beyond just left main disease where the pt could derive some benefit from perioperative revascularization, namely 3v disease/LM equivalent and/or the pt has impaired LV function.

But going back to the guidelines, a total shoulder is an intermediate risk procedure. The pt cannot do four METS. If he's had a pharmacological stress test and that test is abnormal, the decision tree ends with "Coronary revascularization according to existing CPGs" ....as a class I recommendation. So yes, the guy needs to see a cardiologist at minimum for an evaluation and a nuanced discussion of the risks/benefits of further testing and treatment.

^ This is what is have been saying

@vector2 says it much more eloquently

 

[Full Metal IC]

You really seem to be inferring quite a bit even though the OP didn't provide a ton of cardiac history. We don't know the rest of the pt's medical history or his risk factors. We don't really know whether the pt has any rest symptoms. We don't even know what kind of stress test(s) he's had. And yet you're content to call this "stable CAD." Are you not curious why this guy has had *multiple* abnormal stress tests but no LHC or CCTA?

Furthermore, there are other scenarios beyond just left main disease where the pt could derive some benefit from perioperative revascularization, namely 3v disease/LM equivalent and/or the pt has impaired LV function.

But going back to the guidelines, a total shoulder is an intermediate risk procedure. The pt cannot do four METS. If he's had a pharmacological stress test and that test is abnormal, the decision tree ends with "Coronary revascularization according to existing CPGs" ....as a class I recommendation. So yes, the guy needs to see a cardiologist at minimum for an evaluation and a nuanced discussion of the risks/benefits of further testing and treatment.

Yeah I am because he himself didn't provide any information to suggest otherwise. *Multiple* abnormal stress tests doesn't necessarily mean anything. If he had a mildly abnormal stress test 10 years ago and it was medically managed, it's still going to abnormal now. The fact that he has had multiple stress tests over time that are abnormal argues overhwhelmingly in favor of stable CAD. If it was one abnormal stress test, that would be more questionable. And I mean if the patient has rest symptoms I would hope that would be the first thing OP mentions.

Your second point is frankly wrong in 2023 for a variety of reasons, but I'm not going to get into a discussion of revascularization in stable CAD subsets here. Bottom line is perioperative revascularization of stable CAD has not been shown to improve perioperative MACE in any of those subsets. The largest preoperative RCT did not include left main disease, so that is one subset that we assume may be so high risk that they derive benefit. For this 90 year old, nothing we do outside of possibly stenting severe left main disease if he had it is going to reduce his perioperative risk.

Coronary revascularization according to CPGs is indifferent to whether or not the patient is undergoing surgery. If the 90 year old didn't have a reason to be revascularized before, he doesn't now. And a competent PCP could make that call especially in this geriatric population that is high risk for procedures like PCI and CABG.

 

[Full Metal IC]

Dude what have I been saying for multiple posts. At an ASC. There is no cardio, there is no nothing. Just surgeons, anesthesia, some nurses and a cars cart. Closest hospital with a cath lab is 35 minutes away.

I'm sorry, I missed that part. Completely agree doing the case in that setting is indeed garbage.

 

[TheLoneWolf]

Yeah I am because he himself didn't provide any information to suggest otherwise. *Multiple* abnormal stress tests doesn't necessarily mean anything. If he had a mildly abnormal stress test 10 years ago and it was medically managed, it's still going to abnormal now. The fact that he has had multiple stress tests over time that are abnormal argues overhwhelmingly in favor of stable CAD. If it was one abnormal stress test, that would be more questionable. And I mean if the patient has rest symptoms I would hope that would be the first thing OP mentions.

Your second point is frankly wrong in 2023 for a variety of reasons, but I'm not going to get into a discussion of revascularization in stable CAD subsets here. Bottom line is perioperative revascularization of stable CAD has not been shown to improve perioperative MACE in any of those subsets. The largest preoperative RCT did not include left main disease, so that is one subset that we assume may be so high risk that they derive benefit. For this 90 year old, nothing we do outside of possibly stenting severe left main disease if he had it is going to reduce his perioperative risk.

Coronary revascularization according to CPGs is indifferent to whether or not the patient is undergoing surgery. If the 90 year old didn't have a reason to be revascularized before, he doesn't now. And a competent PCP could make that call.

That is an eloquent and satisfactory answer, but as all would admit, really outside the scope of anyone who is not a cardiologist if we start talking about the most recent data and patient subsets. Maybe academic cardiac anesthesia.

 

[Full Metal IC]

That is an eloquent and satisfactory answer, but as all would admit, really outside the scope of anyone who is not a cardiologist if we start talking about the most recent data and patient subsets. Maybe academic cardiac anesthesia.

That's totally fair and it definitely dawned on me as I wrote the reply that...this is exactly why people see cardiologists for this issue hahaha. And it is also true that PCPs will be very variable in how competent they are with pre-operative evaluations. I simply feel that you can give the family doc some BOTD in the case you described. In elderly patients, many PCPs take a conservative approach to medical and cardiac care and it is often very appropriate. I just didn't see something so readily wrong with what you described and I think a positive stress test is universally seen as a very high risk scary thing that requires intervention when it is not necessarily so. Contemporary data is pushing us more and more towards initial non-invasive management for stable CAD (even with severe ischemia) based on trials like ISCHEMIA. So not every positive stress test is necessarily getting a cath or CCTA, though most still will.

As an aside, I do think that preoperative referrals have positives to them as well. We do sometimes uncover disease in patients that otherwise may not have been noted by the patient or their docs who are too busy managing all of their other issues. Most of these cases still do not warrant revascularization simply for the purposes of surgery, but it does allow us to institute better medical therapy, risk factor reduction, and educate patients.

 

[anbuitachi]

That's totally fair and it definitely dawned on me as I wrote the reply that...this is exactly why people see cardiologists for this issue hahaha. And it is also true that PCPs will be very variable in how competent they are with pre-operative evaluations. I simply feel that you can give the family doc some BOTD in the case you described. In elderly patients, many PCPs take a conservative approach to medical and cardiac care and it is often very appropriate. I just didn't see something so readily wrong with what you described and I think a positive stress test is universally seen as a very high risk scary thing that requires intervention when it is not necessarily so. Contemporary data is pushing us more and more towards initial non-invasive management for stable CAD (even with severe ischemia) based on trials like ISCHEMIA. So not every positive stress test is necessarily getting a cath or CCTA, though most still will.

As an aside, I do think that preoperative referrals have positives to them as well. We do sometimes uncover disease in patients that otherwise may not have been noted by the patient or their docs who are too busy managing all of their other issues. Most of these cases still do not warrant revascularization simply for the purposes of surgery, but it does allow us to institute better medical therapy, risk factor reduction, and educate patients.

yea i do agree its easier saying that as a cardiologist. but different specialists usually are not reading other fields literature and analyzing them on a frequent basis. as anesthesiologists we deal with the entire body, but clearly our expertise is in anesthesia. i definitely cant even tell you the specifics even for the latest medical management and the studies behind them for heart failure, or pulmonary hypertension, etc. at the same time, family docs probably are not analyzing all the latest studies on the entire body either.

im totally fine with the cardiologist saying, patient optimized, nothing more to do. but i wont automatically think fam doc is up to date on latest guidelines and evidence for every system in the body. id rather let cardiologist tell me that about the heart for high risk patients. its not just CYA. its for patient safety.

its kind of analogous to getting consults and the resident or fellow first leaves the note. yea sure i read them, but i definitely wont be treating it as finalized until attending attests to it, even if the resident/fellow may be great. its not my area of expertise

 

[vector2]

Yeah I am because he himself didn't provide any information to suggest otherwise. *Multiple* abnormal stress tests doesn't necessarily mean anything. If he had a mildly abnormal stress test 10 years ago and it was medically managed, it's still going to abnormal now. The fact that he has had multiple stress tests over time that are abnormal argues overhwhelmingly in favor of stable CAD. If it was one abnormal stress test, that would be more questionable. And I mean if the patient has rest symptoms I would hope that would be the first thing OP mentions.

Your second point is frankly wrong in 2023 for a variety of reasons, but I'm not going to get into a discussion of revascularization in stable CAD subsets here. Bottom line is perioperative revascularization of stable CAD has not been shown to improve perioperative MACE in any of those subsets. The largest preoperative RCT did not include left main disease, so that is one subset that we assume may be so high risk that they derive benefit. For this 90 year old, nothing we do outside of possibly stenting severe left main disease if he had it is going to reduce his perioperative risk.

Coronary revascularization according to CPGs is indifferent to whether or not the patient is undergoing surgery. If the 90 year old didn't have a reason to be revascularized before, he doesn't now. And a competent PCP could make that call especially in this geriatric population that is high risk for procedures like PCI and CABG.

In 2023 we also have clowns that signed off on the 2021 ACC/AHA/SCAI revascularization guidelines despite the fact that AATS and STS withdrew their endorsement, one of the main reasons being the (non-evidence based) downgrade of CABG from I (strong) to IIb (weak) to improve survival compared with medical therapy in patients with three-vessel CAD and normal left ventricular function. And they did this based primarily off one trial (ISCHEMIA) that wasn't even powered to make this determination about CABG.

My point is that anyone throwing accusations at anyone else about being "frankly wrong" in almost anything related to revascularization is probably not making a reasonable or slam-dunk statement given the currently unresolved questions that exist today. And that goes doubly so for perioperative revascularization trials. The bulk of the literature on perioperative revascularization being used for all these pooled analyses today mostly comes from the mid-2000s (notably the CARP trial which is two decades old). I don't have to tell you that optimal medical therapy, PCI, and CABG have all changed and improved dramatically since that time. I think if you make the statement that routine revascularization of stable CAD does not improve MACE or mortality for all-comers, that's likely a true statement. But imo you're erring if you automatically extrapolate this to the perioperative setting.

Again, I don't think this patient definitively needs a LHC or revascularization, however not seeing a cardiologist preoperatively in this scenario seems pretty unreasonable. Neither you nor I knows the stress modality, what the actual abnormality was, or why he wasn't referred for further workup, so just saying that it's nothing is a statement based mostly on assumptions at this point. But regardless, I suspect that you're so dug in that you can't even admit that we've delved well past the scope of what the average PCP knows when it comes to perioperative cardiac risk in a 90 year old patient who is potentially this complex, so I guess we'll just agree to disagree.

 

[coffeebythelake]

Not once in the ACC/AHA guidelines do they specify who needs to be sent to a cardiologist preoperatively. Your reply illustrates exactly what I am talking about with regards to the role of CYA.

Like I said earlier I have nothing against CYA at all. It is part of practicing medicine in the US and we all do it. But to not acknowledge the dominant role it plays in this space is just ridiculous. In the case we were discussing, my point was that the family doc probably managed the patient appropriately from a medical standpoint. So LoneWolf is essentially getting mad at the family doc for not sending the patient to cardiology to cover HIS OWN ass.

I want to know why a family medicine doc is ordering stress tests if he isn't going to do anything if it is abnormal because its always been that way. When u order a test u are obliged to follow up on the results. And that unfortunately means working it up if it is abnormal. If you don't want to do that don't order the test.

 

[coffeebythelake]

yea i do agree its easier saying that as a cardiologist. but different specialists usually are not reading other fields literature and analyzing them on a frequent basis. as anesthesiologists we deal with the entire body, but clearly our expertise is in anesthesia. i definitely cant even tell you the specifics even for the latest medical management and the studies behind them for heart failure, or pulmonary hypertension, etc. at the same time, family docs probably are not analyzing all the latest studies on the entire body either.

im totally fine with the cardiologist saying, patient optimized, nothing more to do. but i wont automatically think fam doc is up to date on latest guidelines and evidence for every system in the body. id rather let cardiologist tell me that about the heart for high risk patients. its not just CYA. its for patient safety.

its kind of analogous to getting consults and the resident or fellow first leaves the note. yea sure i read them, but i definitely wont be treating it as finalized until attending attests to it, even if the resident/fellow may be great. its not my area of expertise

The Cardiologist had a lot more tools in their toolbox when evaluating a patient with cardiac issues. I don't know if a family medicine doc is going to offer to cath a patient?

 

[Full Metal IC]

In 2023 we also have clowns that signed off on the 2021 ACC/AHA/SCAI revascularization guidelines despite the fact that AATS and STS withdrew their endorsement, one of the main reasons being the (non-evidence based) downgrade of CABG from I (strong) to IIb (weak) to improve survival compared with medical therapy in patients with three-vessel CAD and normal left ventricular function. And they did this based primarily off one trial (ISCHEMIA) that wasn't even powered to make this determination about CABG.

My point is that anyone throwing accusations at anyone else about being "frankly wrong" in almost anything related to revascularization is probably not making a reasonable or slam-dunk statement given the currently unresolved questions that exist today. And that goes doubly so for perioperative revascularization trials. The bulk of the literature on perioperative revascularization being used for all these pooled analyses today mostly comes from the mid-2000s (notably the CARP trial which is two decades old). I don't have to tell you that optimal medical therapy, PCI, and CABG have all changed and improved dramatically since that time. I think if you make the statement that routine revascularization of stable CAD does not improve MACE or mortality for all-comers, that's likely a true statement. But imo you're erring if you automatically extrapolate this to the perioperative setting.

Again, I don't think this patient definitively needs a LHC or revascularization, however not seeing a cardiologist preoperatively in this scenario seems pretty unreasonable. But I suspect that you're so dug in at this point that you can't even admit that we've delved well past the scope of what the average the PCP knows when it comes to a 90 year old patient who is potentially this complex, so I guess we'll just agree to disagree.

I agree with you about 3VD and CABG, for the purposes of long-term survival benefit. But the reality is the surgeons have not tested "modern CABG" in any large scale clinical trials compared to modern medical therapy. We have to use the totality of contemporary data, and ISCHEMIA is a part of that.

Sure maybe "frankly wrong" was too strong wording. There is obviously some subtlety to this topic. Yes CARP is old now but that is not a valid reason for dismissal - the hypothesis itself that revascularization in stable patients may improve perioperative outcomes really has never had a great leg to stand on. Perioperative MACE events are rare to begin with. The benefits of revascularization in stable multivessel CAD in normal EF has come over the long term, not the short term. There is no compelling evidence to suggest that the perioperative period is so magical that patients will benefit in the short term from revascularization whether it is CABG or PCI.

 

[Full Metal IC]

The Cardiologist had a lot more tools in their toolbox when evaluating a patient with cardiac issues. I don't know if a family medicine doc is going to offer to cath a patient?

Of course we do. But not referring for cath or revascularization is not the same as not doing anything. A positive stress test does not obligate a cath or further work-up. Perfectly reasonable to manage medically after making the diagnosis of CAD by stress testing esp in a 90 year old.

 

[Radetzky]

Yes I agree completely, my opinion on safe sedation shouldn't matter at all to you, an anesthesiologist. But at the end of the day procedural cardiologists who administer moderate sedation (and do procedures with anesthesiologists) do have some sense of the graded risks of anesthesia in the selected subset of patients with cardiac pathology. My original point about that endoscopy case he described was simply that from a cardiac perspective moderate sedation is pretty well tolerated, so proceeding may not be inappropriate. The patient with NSTEMI should be on DAPT. Even if he's not actively bleeding anymore it is very reasonable to look for a source now regardless because he is going to be on DAPT for a while. If it requires more intensive anesthesia then sure maybe the risk isn't worth it. Not arguing that.

And regarding the cath lab bail-outs - congratulations, you are doing your job. No, we are not experts in airway and sedation management. I hate dealing with that ****, and I am very weary of all the bad things that can happen with anesthesia. If I could have an anesthesiologist for every procedure, all the STEMIs and shock disaster cases in the middle of the night, boy I would love that. But that's not going to happen is it? So if you want us to feel bad about needing you to bail us out for airway and sedation issues, not going to happen.

You’re right, the sedation may be appropriate when balancing risks and benefits. Once assessed by someone qualified to make that call. However to deny that there is any contraindication to going ahead that needs to be considered and simply saying “proceed” is just plain dumb.

I’m not trying to make you feel bad, I’m just highlighting that there is an overconfidence amongst cardiologists because “I’m a grown up, I give sedation too!” that often translates to unsafe practices and bad outcomes for patients

 

[cytocide]

Ha. I missed that part. That is ****ed

Sometimes they sneak through to the ASCs. And then you have to deal with the surgeon or in this case family “come on, just put him to sleep and numb half his diaphragm while your at it”. Maybe the FM doc is good will hunting and was able to interpret the stress because he took a week long seminar. I doubt it.

 

[pgg]

Your second point is frankly wrong in 2023 for a variety of reasons, but I'm not going to get into a discussion of revascularization in stable CAD subsets here. Bottom line is perioperative revascularization of stable CAD has not been shown to improve perioperative MACE in any of those subsets. The largest preoperative RCT did not include left main disease, so that is one subset that we assume may be so high risk that they derive benefit. For this 90 year old, nothing we do outside of possibly stenting severe left main disease if he had it is going to reduce his perioperative risk.

This is the crux of the issue - I would not have confidence that a PCM would have the knowledge or confidence to opine on the nuances of revascularization in stable CAD subsets, if indeed this is even stable CAD in the first place, or whether the clear class 1 indication in the guidelines is mooted in part or whole by that RCT.

Thanks for posting in the anesthesia forum, by the way. We all benefit when other specialists contribute here, even if we argue.


Anyway, beyond the medicolegal CYA issue, there are exactly two things I want to hear from a cardiologist:
1) your subspecialist expert opinion of the type and severity of the patient's disease
2) whether or not that patient can be meaningfully optimized prior to the proposed procedure

This is useful information to me, that can inform my decision making.

 

[vector2]

I agree with you about 3VD and CABG, for the purposes of long-term survival benefit. But the reality is the surgeons have not tested "modern CABG" in any large scale clinical trials compared to modern medical therapy. We have to use the totality of contemporary data, and ISCHEMIA is a part of that.

Sure maybe "frankly wrong" was too strong wording. There is obviously some subtlety to this topic. Yes CARP is old now but that is not a valid reason for dismissal - the hypothesis itself that revascularization in stable patients may improve perioperative outcomes really has never had a great leg to stand on. Perioperative MACE events are rare to begin with. The benefits of revascularization in stable multivessel CAD in normal EF has come over the long term, not the short term. There is no compelling evidence to suggest that the perioperative period is so magical that patients will benefit in the short term from revascularization whether it is CABG or PCI.

In both cases we're talking about the totality of the evidence, right? In the latter regarding perioperative MACE, you're looking at the sum of the data dating back decades and coming to (a likely reasonable) conclusion that there is not strong evidence that revascularization in stable CAD reduces perioperative MACE. But then, in regard to CABG, you're willing to overlook the totality of the data dating back decades because of....one recent trial that wasn't even powered to say what the 2021 guidelines are saying. ISCHEMIA is in frank conflict with the totality of the literature. SYNTAX, EXCEL, and especially FAME 3 all point to CABG being superior to PCI in certain subsets. Which lead to serious contradictions when looking at the current guidelines wrt implications of superiority between OMT, PCI, and CABG.

​

Not given important consideration by the committee in downgrading the recommendations for CABG in patients with three-vessel CAD was the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial.8 Patients enrolled in SYNTAX were representative of patients a heart team would refer for revascularization. The SYNTAX trial found a 40% higher mortality among patients with triple-vessel disease with PCI compared with CABG. If CABG was no better than medical therapy in improving survival, then PCI would have to be dangerous compared with medical therapy. Similar results were found in the Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, 9 and more recently, in the very early results of the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3 (FAME 3) trial, where 50% better freedom from death, myocardial infarction, repeat revascularization, or stroke was observed among the patients randomly assigned to CABG vs PCI. 10 If CABG did not improve survival over medical therapy, how would one explain the survival benefits of CABG over PCI in the EXCEL trial, without suggesting that PCI causes harm compared with medical therapy? Despite this, the committee not only downgraded the COR for CABG in the treatment of three-vessel CAD, but also gave an equal COR of IIb for PCI and CABG in patients with three-vessel CAD and normal ventricular function.​

​

The American Association for Thoracic Surgery and The Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI Coronary Revascularization Guidelines

The American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS) have decided not to endorse the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Coronary Artery Revascularization...

www.jtcvs.org

​

Getting back to perioperative MACE, again, I agree with you that the periop revascularization data to prevent events is not particularly robust, but I disagree with the characterization that the perioperative period doesn't have some "magical" quality to it. If indeed we remain myopic and only focus on full-blown occlusive ACS and mortality in the periop period, maybe it doesn't look like the event rate is high or that pre-op intervention is warranted, but I think there's a good chance that we are simply not performing enough surveillance to capture the full incidence of cardiovascular complications that are occurring in the perioperative period. This point is highlighted in this paper from Circulation about MINS (myocardial injury in noncardiac surgery).

​

Perioperative mortality after noncardiac surgery is ≈1% to 2% among inpatients ≥45 years of age.1 Approximately half of these deaths are attributed to cardiovascular complications of surgery.2 Substantial efforts have been made to investigate the causes, pathophysiology, and consequences of cardiovascular complications in postsurgical patients.​

​

Cardiac biomarkers indicative of myocardial damage such as cardiac troponin (cTn) are frequently elevated after noncardiac surgery. Historically, these biomarker abnormalities were ignored because associated clinical symptoms, such as chest pain and shortness of breath were rare in the postoperative setting. However, even clinically silent cardiac biomarker elevations after noncardiac surgery are associated with mortality and major vascular complications.3–5 Based on the prognostic importance of postoperative cardiac biomarkers, a new clinical diagnosis, myocardial injury after noncardiac surgery (MINS), has been established. MINS includes myocardial infarction and ischemic myocardial injury that do not fulfill the Universal Definition of Myocardial Infarction (myocardial injury with a rise or fall of cTn above the 99th percentile of the upper reference limit and at least 1 of the following: ischemic symptoms, new ischemic electrocardiographic changes, development of new pathological Q waves on ECG, imaging evidence of myocardial ischemia, or angiographic or autopsy evidence of coronary thrombus).6​

​

This American Heart Association scientific statement offers a clinical perspective of MINS, including a review of its definition, epidemiology, pathophysiology, prediction, surveillance, prevention, prognosis, and management. This document also explores directions for future investigation of MINS.​

​

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001024

​

Truly, the point is that "Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction." The data is associative and retrospective so we shouldn't get too carried away with inferring causation, but what it does highlight is the possibility that late perioperative complications from ASCVD are occurring (especially in a higher risk patent like say a 90 year old with a positive stress test and ?stable CAD) but simply not being picked up during the immediate post-operative period. Again, there's a lot of nuance, and many things to think about beyond the scope of an average PCP's knowledge about risk stratification.

 

[Greenbayslacker]

And regarding the cath lab bail-outs - congratulations, you are doing your job. No, we are not experts in airway and sedation management. I hate dealing with that ****, and I am very weary of all the bad things that can happen with anesthesia. If I could have an anesthesiologist for every procedure, all the STEMIs and shock disaster cases in the middle of the night, boy I would love that. But that's not going to happen is it? So if you want us to feel bad about needing you to bail us out for airway and sedation issues, not going to happen.

True emergencies are understandable. What irks me are the calls to "come push some propofol" for an elective prone angioplasty case or TEE/CV that won't "hold still." Wake them up and rebook with anesthesia and proper PAT.

 

[Full Metal IC]

In both cases we're talking about the totality of the evidence, right? In the latter regarding perioperative MACE, you're looking at the sum of the data dating back decades and coming to (a likely reasonable) conclusion that there is not strong evidence that revascularization in stable CAD reduces perioperative MACE. But then, in regard to CABG, you're willing to overlook the totality of the data dating back decades because of....one recent trial that wasn't even powered to say what the 2021 guidelines are saying. ISCHEMIA is in frank conflict with the totality of the literature. SYNTAX, EXCEL, and especially FAME 3 all point to CABG being superior to PCI in certain subsets. Which lead to serious contradictions when looking at the current guidelines wrt implications of superiority between OMT, PCI, and CABG.

​

Not given important consideration by the committee in downgrading the recommendations for CABG in patients with three-vessel CAD was the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial.8 Patients enrolled in SYNTAX were representative of patients a heart team would refer for revascularization. The SYNTAX trial found a 40% higher mortality among patients with triple-vessel disease with PCI compared with CABG. If CABG was no better than medical therapy in improving survival, then PCI would have to be dangerous compared with medical therapy. Similar results were found in the Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, 9 and more recently, in the very early results of the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3 (FAME 3) trial, where 50% better freedom from death, myocardial infarction, repeat revascularization, or stroke was observed among the patients randomly assigned to CABG vs PCI. 10 If CABG did not improve survival over medical therapy, how would one explain the survival benefits of CABG over PCI in the EXCEL trial, without suggesting that PCI causes harm compared with medical therapy? Despite this, the committee not only downgraded the COR for CABG in the treatment of three-vessel CAD, but also gave an equal COR of IIb for PCI and CABG in patients with three-vessel CAD and normal ventricular function.​

​

The American Association for Thoracic Surgery and The Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI Coronary Revascularization Guidelines

The American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS) have decided not to endorse the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Coronary Artery Revascularization...

www.jtcvs.org

​

Getting back to perioperative MACE, again, I agree with you that the periop revascularization data to prevent events is not particularly robust, but I disagree with the characterization that the perioperative period doesn't have some "magical" quality to it. If indeed we remain myopic and only focus on full-blown occlusive ACS and mortality in the periop period, maybe it doesn't look like the event rate is high or that pre-op intervention is warranted, but I think there's a good chance that we are simply not performing enough surveillance to capture the full incidence of cardiovascular complications that are occurring in the perioperative period. This point is highlighted in this paper from Circulation about MINS (myocardial injury in noncardiac surgery).

​

Perioperative mortality after noncardiac surgery is ≈1% to 2% among inpatients ≥45 years of age.1 Approximately half of these deaths are attributed to cardiovascular complications of surgery.2 Substantial efforts have been made to investigate the causes, pathophysiology, and consequences of cardiovascular complications in postsurgical patients.​

​

Cardiac biomarkers indicative of myocardial damage such as cardiac troponin (cTn) are frequently elevated after noncardiac surgery. Historically, these biomarker abnormalities were ignored because associated clinical symptoms, such as chest pain and shortness of breath were rare in the postoperative setting. However, even clinically silent cardiac biomarker elevations after noncardiac surgery are associated with mortality and major vascular complications.3–5 Based on the prognostic importance of postoperative cardiac biomarkers, a new clinical diagnosis, myocardial injury after noncardiac surgery (MINS), has been established. MINS includes myocardial infarction and ischemic myocardial injury that do not fulfill the Universal Definition of Myocardial Infarction (myocardial injury with a rise or fall of cTn above the 99th percentile of the upper reference limit and at least 1 of the following: ischemic symptoms, new ischemic electrocardiographic changes, development of new pathological Q waves on ECG, imaging evidence of myocardial ischemia, or angiographic or autopsy evidence of coronary thrombus).6​

​

This American Heart Association scientific statement offers a clinical perspective of MINS, including a review of its definition, epidemiology, pathophysiology, prediction, surveillance, prevention, prognosis, and management. This document also explores directions for future investigation of MINS.​

​

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001024

​

Truly, the point is that "Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction." The data is associative and retrospective so we shouldn't get too carried away with inferring causation, but what it does highlight is the possibility that late perioperative complications from ASCVD are occurring (especially in a higher risk patent like say a 90 year old with a positive stress test and ?stable CAD) but simply not being picked up during the immediate post-operative period. Again, there's a lot of nuance, and many things to think about beyond the scope of an average PCP's knowledge about risk stratification.

Again the evidence for both PCI and CABG over modern medical therapy in 3VD is overall weak, so both are assigned a 2b. This does not mean that they are saying CABG and PCI are equal, though I can see why people seem to interpret it that way. In fact the guidelines specifically state the recommendation for PCI in 3VD "reflects a weaker endorsement for PCI than for CABG in patients with multivessel CAD," as it should. In the real world I think if you surveyed most cardiologists, you would find that most of us agree that CABG is superior to PCI for multivessel disease in general. Contemporary PCI still cannot compete with an IMA to the LAD over the long-term.

As far as the trials quoted, EXCEL was a left main trial, not 3VD. FAME 3 showed superiority of CABG, but the difference was overwhelmingly driven by repeat revasc, not mortality.

With regards to what you have written about perioperative MACE. We can talk about menial troponin elevations and climb the ranks of professorship by publishing slick new acronyms like "MINS" but at the end of the day what we care about most are hard endpoints, because our procedures carry real risk to the patient. And the data is just not there. Trust me, I wish it was - I like doing PCI (most of the time).

 

[Full Metal IC]

True emergencies are understandable. What irks me are the calls to "come push some propofol" for an elective prone angioplasty case or TEE/CV that won't "hold still." Wake them up and rebook with anesthesia and proper PAT.

I understand it is annoying and I'm sure some of our calls are probably inappropriate. But unfortunately sometimes even elective cases can end up requiring your services for the safety of the patient. For example, if I starting working on an outpatient's LAD and he starts getting restless and is ready to jump off the table before I can place stents, it is simply unsafe to stop and wake him up. Once we do PTCA (ballooning) there is a real risk of acute vessel closure until the now injured vessel is stented and stent expansion optimized. Losing or giving up wire position after ballooning a vessel can be catastrophic and if the vessel shuts down we may not be able to get back in. Suddenly a stable outpatient is having a massive MI because we couldn't get them to stop moving. In general once we start ****ing around with wires and balloons, we are pretty much committed to completing the PCI to prevent serious harm to the patient.

TEE/CV on the other hand I agree should just be a rebook if you guys are tied up, but it is quite inconvenient for the patients (especially those that come from far away).

 

[vector2]

Again the evidence for both PCI and CABG over modern medical therapy in 3VD is overall weak, so both are assigned a 2b. This does not mean that they are saying CABG and PCI are equal, though I can see why people seem to interpret it that way. In fact the guidelines specifically state the recommendation for PCI in 3VD "reflects a weaker endorsement for PCI than for CABG in patients with multivessel CAD," as it should. In the real world I think if you surveyed most cardiologists, you would find that most of us agree that CABG is superior to PCI for multivessel disease in general. Contemporary PCI still cannot compete with an IMA to the LAD over the long-term.

As far as the trials quoted, EXCEL was a left main trial, not 3VD. FAME 3 showed superiority of CABG, but the difference was overwhelmingly driven by repeat revasc, not mortality.

If your opinion was so clearcut from an evidentiary basis then the AATS and STS presumably would've actually endorsed the guidelines. And if your opinion were so clearcut then EACTS, whose 2018 ESC/EACTS guidelines are not going to be in concurrence with ACC/AHA when their update is published, wouldn't have said:

Chapter 7.1 arbitrarily downgraded coronary artery bypass grafting (CABG) from a class of recommendation (COR) I to IIb in patients with stable multivessel coronary artery disease. No new randomized controlled trials are cited to support this downgrade and to reject the previously held supporting evidence [1–3] showing a convincing mortality benefit for CABG. The guidelines imply that the results may not have been favourable for the CABG subgroup in the ISCHEMIA trial. This subgroup analysis has not been published to date. Furthermore, this COR is the same (IIb) for percutaneous coronary intervention, whereas the recommendation states that ‘the usefulness of PCI to improve survival is uncertain’. The downgrading of CABG and placing percutaneous coronary intervention in the same COR do not meet our interpretation of the evidence and may lead to avoidable loss of life.​

​

IACTS position statement on “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization”: section 7.1—a consensus document - Indian Journal of Thoracic and Cardiovascular Surgery

American College of Cardiology (ACC), American Heart Association (AHA) and Society for Cardiovascular Angiography and Interventions (SCAI) recently released the Clinical Practice Guidelines for myocardial revascularization [1]. The guidelines were the felt need of the fraternity and this single...

link.springer.com

​

With regards to what you have written about perioperative MACE. We can talk about menial troponin elevations and climb the ranks of professorship by publishing slick new acronyms like "MINS" but at the end of the day what we care about most are hard endpoints, because our procedures carry real risk to the patient. And the data is just not there. Trust me, I wish it was - I like doing PCI (most of the time).

Not much I can do if you think the fact that periop mortality is 1-2% in older age groups with half of these deaths being attributable to CV causes, or that biomarker elevations even in the absence of symptoms are independently, strongly associated with mortality and MACE....aren't epidemiological endpoints worth considering (with the intention of creating RCTs with hard endpoints). IMO, at minimum the data on MINS is quite hypothesis generating and possibly indicative that many of us are too flippant with the assumption that unless a patient has a full-blown STEMI on post-op day 2 then there was nothing that could've been done to better stratify or optimize CV risk. And just to step back for a second, again, I'm not arguing that the pt in the OP's example needs PCI or revasc even if he does have CAD. The original question is whether the patient needs a cardiology consultation given the current ACC/AHA periop guidelines, his stress test results, and the potential complexity/nuance involved in OMT vs revasc decisions, and I think the answer is still a quite clear yes.

 

[GassYous]

I understand it is annoying and I'm sure some of our calls are probably inappropriate. But unfortunately sometimes even elective cases can end up requiring your services for the safety of the patient. For example, if I starting working on an outpatient's LAD and he starts getting restless and is ready to jump off the table before I can place stents, it is simply unsafe to stop and wake him up. Once we do PTCA (ballooning) there is a real risk of acute vessel closure until the now injured vessel is stented and stent expansion optimized. Losing or giving up wire position after ballooning a vessel can be catastrophic and if the vessel shuts down we may not be able to get back in. Suddenly a stable outpatient is having a massive MI because we couldn't get them to stop moving. In general once we start ****ing around with wires and balloons, we are pretty much committed to completing the PCI to prevent serious harm to the patient.

TEE/CV on the other hand I agree should just be a rebook if you guys are tied up, but it is quite inconvenient for the patients (especially those that come from far away).

Well we aren't there to sit around at your beck and call so...

 

[kb1900]

because our procedures carry real risk to the patient

Hey thanks for branching outside your specialty to this forum


I hope, to a degree, you acknowledge some of your bias here. Elective shoulders in 90yos at baseline, even in the absence of CAD comorbidity, are risky - ask any one who has covered a PACU can corroborate. You are certainly downplaying the risk associated with such a surgery in a patient with “stable” (?? We don’t know this at ALL) CAD, either consciously or unconsciously. There is absolutely not enough detail about this abnl stress test in the post to draw any conclusions yet you seemed very adamant. Then you go on to downplay MINS because it’s recent and in your mind some academics acronym claim to fame rather than likely elucidating. Similarity downplay MACE etc.


If this patient has significant ST changes 3 minutes after induction of GA, what would your recommendation be? Should we continue with surgery? Should we stat call IC for emergent cath? Should we abort surgery and see what happens? Should we sit in the OR intubated and see what happens? What about if this plays out in PACU? After all MACE is rare and MINS is hardly real entities right..Wait perhaps they’re so rare because of competent preoperative management and risk stratification.



It’s a ridiculous scenario yet one that does in fact happen not infrequently. The optics at an ASC look awful especially if pre operative management had no cardiology input and the patient could certainly say they were not counseled properly and I would agree with them - regardless of whatever the surgeon and anesthesiologist said to the pt in the holding area 20 mins before induction.


im a resident fwiw. Thanks for taking the time to provide input. My personal bias is I’ve never been called to the lab and been met with anything but disrespect from our interventional cards colleagues. “Just induce” “just intubate” “propofol thanks”. Won’t even stop fluoroing. Not a single vasoactive medication started. Won’t wait for dispo once patient is stabilized by yours truly. Don’t get me started on our CICU or TAVR program lol.

 

[DarkHorizon]

I know little to nothing of what is mostly being discussed here. Can I just fix hip and long bone fractures as soon as possible? A pre op cardiac clearance with echo often holds up cases and I have never had to cancel a case because a cardiologist said so or because of echo findings. They just put in a note saying high risk for surgery. Seems like literature is conclusive on this.

Preoperative Echocardiography for Patients With Hip... : Anesthesia & Analgesia

patient survival after surgical repair of hip fractures. METHODS: Drawing from a nationwide administrative database, patients undergoing hip fracture surgeries between April 1, 2008 and December 31, 2016 were included. We examined the association of preoperative echocardiography with the...

journals.lww.com

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture | Bone & Joint

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture

boneandjoint.org.uk

 

[PpfSuxTube]

90 yo... before a low risk surgery.

Not once did I say that this particular patient was low risk for complications. He's 90. He could be an active marine with 2 hearts, I'm still calling him high risk. But at the end of the day it doesn't matter.

You're like like a fish up a tree here buddy?
Are you reading anything you type?

TAVR and TEEs are quite different procedures.

You do know that people on here are full time cardiac anesthesiologists doing a few hundred Tavis and tee per year. Why would you say this?

TAVR is moving that way too.

Where is a tavi "mostly done without an anesthesiologist"Or crna? Where is this place? How do they admin sedation? Rn lead? What if they have to convert?


Sorry buddy but medical clearances for an anesthetic are bull****... if I see rcri=1 once more On a chart it will be top much... it's ridiculous that a bunch of people that would probably kill or maim every single patient if they were to give the anesthetic, actually clears the same patient for someone else to give the anesthesia safely... they just can't understand the intricacies and so can't offer anything other than a basic understanding of the situation

Like a total joint replacement is a low risk surgery... I'm sorry buddy but you're lost

 

[greatnt249]

I know little to nothing of what is mostly being discussed here. Can I just fix hip and long bone fractures as soon as possible? A pre op cardiac clearance with echo often holds up cases and I have never had to cancel a case because a cardiologist said so or because of echo findings. They just put in a note saying high risk for surgery. Seems like literature is conclusive on this.

I would argue there's a degree of value in having the anesthesiologist be aware that the patient that's about to be operated on now has severe aortic stenosis rather than moderate valve disease on the last echo available. Someone can correct me but probably not a whole lot of TEE probes are being brought into the ortho suite, and I would imagine induction is not the time you would want to discover this information.

I think an important element that is lost here are guidelines are just that...guidelines. They're not meant to be "one size fits all"...you have to treat the patient in front of you to the best of your clinical judgment while at the same time not turning it into a game of clinical hot potato. I think we can all agree that, as onerous as it is to admit, much of risk stratification ultimately boils down to an answer of "it depends." Being neither a surgeon nor anesthesiologist, I would probably argue that, regardless of clinical backstory, "90 y/o" and "ASC procedure" don't belong in the same sentence.

 

[gunnershow]

I know little to nothing of what is mostly being discussed here. Can I just fix hip and long bone fractures as soon as possible? A pre op cardiac clearance with echo often holds up cases and I have never had to cancel a case because a cardiologist said so or because of echo findings. They just put in a note saying high risk for surgery. Seems like literature is conclusive on this.

Preoperative Echocardiography for Patients With Hip... : Anesthesia & Analgesia

patient survival after surgical repair of hip fractures. METHODS: Drawing from a nationwide administrative database, patients undergoing hip fracture surgeries between April 1, 2008 and December 31, 2016 were included. We examined the association of preoperative echocardiography with the...

journals.lww.com

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture | Bone & Joint

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture

boneandjoint.org.uk

I usually don't care too much what the cardiologist has to say but I do appreciate having relevant cardiac studies available to me. It directly changes my management of a very tenuous patient population. I'm happy to do any hip fx on a non-palliative patient, but you have to at least give me the tools I need to succeed.

 

[PpfSuxTube]

But at the end of the day procedural cardiologists who administer moderate sedation
.

Please don't try and equate ccu or cath lab sedation with anything we do...

Honestly I love my ccu and cardiology colleagues and I really appreciate you being here offering your advice... but don't make this comparison. There just isn't one. Sometimes the BP is cycled every 15 mins... there's no end tidal...

It's so different... I don't want to say anymore...

But I do want to thank you for coming on here and spurring some excellent conversations. This is a great thread... well done seriously. I learned a lot

 

[Full Metal IC]

If your opinion was so clearcut from an evidentiary basis then the AATS and STS presumably would've actually endorsed the guidelines. And if your opinion were so clearcut then EACTS, whose 2018 ESC/EACTS guidelines are not going to be in concurrence with ACC/AHA when their update is published, wouldn't have said:

Chapter 7.1 arbitrarily downgraded coronary artery bypass grafting (CABG) from a class of recommendation (COR) I to IIb in patients with stable multivessel coronary artery disease. No new randomized controlled trials are cited to support this downgrade and to reject the previously held supporting evidence [1–3] showing a convincing mortality benefit for CABG. The guidelines imply that the results may not have been favourable for the CABG subgroup in the ISCHEMIA trial. This subgroup analysis has not been published to date. Furthermore, this COR is the same (IIb) for percutaneous coronary intervention, whereas the recommendation states that ‘the usefulness of PCI to improve survival is uncertain’. The downgrading of CABG and placing percutaneous coronary intervention in the same COR do not meet our interpretation of the evidence and may lead to avoidable loss of life.​

​

IACTS position statement on “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization”: section 7.1—a consensus document - Indian Journal of Thoracic and Cardiovascular Surgery

American College of Cardiology (ACC), American Heart Association (AHA) and Society for Cardiovascular Angiography and Interventions (SCAI) recently released the Clinical Practice Guidelines for myocardial revascularization [1]. The guidelines were the felt need of the fraternity and this single...

link.springer.com

​

Not much I can do if you think the fact that periop mortality is 1-2% in older age groups with half of these deaths being attributable to CV causes, or that biomarker elevations even in the absence of symptoms are independently, strongly associated with mortality and MACE....aren't epidemiological endpoints worth considering (with the intention of creating RCTs with hard endpoints). IMO, at minimum the data on MINS is quite hypothesis generating and possibly indicative that many of us are too flippant with the assumption that unless a patient has a full-blown STEMI on post-op day 2 then there was nothing that could've been done to better stratify or optimize CV risk. And just to step back for a second, again, I'm not arguing that the pt in the OP's example needs PCI or revasc even if he does have CAD. The original question is whether the patient needs a cardiology consultation given the current ACC/AHA periop guidelines, his stress test results, and the potential complexity/nuance involved in OMT vs revasc decisions, and I think the answer is still a quite clear yes.

Ok. The topic has been discussed at almost every national major meeting since the guidelines were published, with panel sessions involving leadership of all of these societies. There is a lot more agreement than you think between cardiologists and surgeons on this topic, and in day-to-day this specific gripe from the surgical societies regarding the guideline designation really ends up mattering very little. The HEART team approach is still a sacred Class I recommendation, so most of these patients get a collaborative opinion from CTS and cardiology.

The points you are trying to make highlight a very interesting reality - that ICs get crucified for being cowboys and doing unindicated procedure when it is so surprisingly often non-invasive cardiologists and other physicians who pressure us to revascularize patients who don't benefit from it.

In the vast majority of stable CAD patients, EVEN IF the patient has a full-blown STEMI on post-op day 2, there is no evidence that revascularization would have done anything to prevent it. Is it possible that the actual truth is that it helps? Sure. But if there is an effect it is likely very small with a very high NNT that does not justify routine revascularization outside of conventional indications. This isn't some bias only I have, and it is not that controversial within cardiology, outside of very specific scenarios. Maybe one day we will have a study that suggests otherwise. Until then we go by what we have. And of course every patient is approached as an individualized case, I assumed that is self-evident to a forum of physicians so I didn't specifically state it.

 

[Radetzky]

Ok. The topic has been discussed at almost every national major meeting since the guidelines were published, with panel sessions involving leadership of all of these societies. There is a lot more agreement than you think between cardiologists and surgeons on this topic, and in day-to-day this specific gripe from the surgical societies regarding the guideline designation really ends up mattering very little. The HEART team approach is still a sacred Class I recommendation, so most of these patients get a collaborative opinion from CTS and cardiology.

The points you are trying to make highlight a very interesting reality - that ICs get crucified for being cowboys and doing unindicated procedure when it is so surprisingly often non-invasive cardiologists and other physicians who pressure us to revascularize patients who don't benefit from it.

In the vast majority of stable CAD patients, EVEN IF the patient has a full-blown STEMI on post-op day 2, there is no evidence that revascularization would have done anything to prevent it. Is it possible that the actual truth is that it helps? Sure. But if there is an effect it is likely very small with a very high NNT that does not justify routine revascularization outside of conventional indications. This isn't some bias only I have, and it is not that controversial within cardiology, outside of very specific scenarios. Maybe one day we will have a study that suggests otherwise. Until then we go by what we have. And of course every patient is approached as an individualized case, I assumed that is self-evident to a forum of physicians so I didn't specifically state it.

Agree with our friend here, if you stick in a stent then operate all you get is an inflammatory milieu that predisposes to stent thrombosis. And remember that it’s not necessarily large stable lesions that are the ones that rupture and cause ACS.

 

[PpfSuxTube]

Agree with our friend here, if you stick in a stent then operate all you get is an inflammatory milieu that predisposes to stent thrombosis. And remember that it’s not necessarily large stable lesions that are the ones that rupture and cause ACS.

Agreed. I never really cared much for the concept of revasc. But I definitely do want them on best gdmt.
Entresto for sure, maybe, mra, empa etc make an enormous difference. Despite the periop issues

In the last month alone I've had 3 or 4 patients with lv 30 ish, severe 3b MR come for cabg. Not even a whif of MR intraop, lv back to 40s...

I don't really care for who writes the prescription or indeed the clearance letter... as long as they're on the way up on meds, not down or even not started on them

 

[vector2]

Ok. The topic has been discussed at almost every national major meeting since the guidelines were published, with panel sessions involving leadership of all of these societies. There is a lot more agreement than you think between cardiologists and surgeons on this topic, and in day-to-day this specific gripe from the surgical societies regarding the guideline designation really ends up mattering very little. The HEART team approach is still a sacred Class I recommendation, so most of these patients get a collaborative opinion from CTS and cardiology.

The points you are trying to make highlight a very interesting reality - that ICs get crucified for being cowboys and doing unindicated procedure when it is so surprisingly often non-invasive cardiologists and other physicians who pressure us to revascularize patients who don't benefit from it.

In the vast majority of stable CAD patients, EVEN IF the patient has a full-blown STEMI on post-op day 2, there is no evidence that revascularization would have done anything to prevent it. Is it possible that the actual truth is that it helps? Sure. But if there is an effect it is likely very small with a very high NNT that does not justify routine revascularization outside of conventional indications. This isn't some bias only I have, and it is not that controversial within cardiology, outside of very specific scenarios. Maybe one day we will have a study that suggests otherwise. Until then we go by what we have. And of course every patient is approached as an individualized case, I assumed that is self-evident to a forum of physicians so I didn't specifically state it.

I'm a practicing anesthesiologist and intensivist with a fair amount of my OR and ICU practice dedicated to cardiothoracic care, so I'm quite aware of the heart team approach and the fact that most patients are actually getting revascularized using the old guidelines. I also understand that as an IC you're probably pretty deeply vested in downplaying what is actually a pretty serious disagreement between the professional societies- a disagreement that not only has implications for patient care (and mortality) but also for future reimbursement as CMS and private payers continue to reevaluate what exactly is cost-effective "evidence-based" care. Downplay all you want, but it is incredibly rare to see pretty much every big name in cardiothoracic surgery specializing in revasc, from Houston to Cleveland to Philly to New York to Ottawa, all band together to issue a formal rebuttal.


And with regard to the rest of your post, I believe I've made it quite clear numerous times now that I am not advocating from the position that you definitively had to revascularize the OP's pt. My points remain that 1. Cardiology consultation is likely warranted in a 90yo with a positive stress test undergoing intermediate to high risk surgery like a total shoulder, even if all that consultation results in is an optimization of his GDMT and 2. Perioperative cardiovascular risk is potentially underappreciated given the epidemiological outcomes associated with non-specific perioperative myocardial injury.

 

[pgg]

Agree with our friend here, if you stick in a stent then operate all you get is an inflammatory milieu that predisposes to stent thrombosis. And remember that it’s not necessarily large stable lesions that are the ones that rupture and cause ACS.

Hold up

We're not talking about stenting someone and proceeding to surgery right away. The case that kicked off this thread was a joint arthroplasty. Totally elective.

If that patient got stented, the elective surgery would be postponed for 6+ months. There's no planet where an elective joint arthroplasty gets done right after stenting.

 

[Full Metal IC]

I'm a practicing anesthesiologist and intensivist with a fair amount of my OR and ICU practice dedicated to cardiothoracic care, so I'm quite aware of the heart team approach and the fact that most patients are actually getting revascularized using the old guidelines. I also understand that as an IC you're probably pretty deeply vested in downplaying what is actually a pretty serious disagreement between the professional societies- a disagreement that not only has implications for patient care (and mortality) but also for future reimbursement as CMS and private payers continue to reevaluate what exactly is cost-effective "evidence-based" care. Downplay all you want, but it is incredibly rare to see pretty much every big name in cardiothoracic surgery specializing in revasc, from Houston to Cleveland to Philly to New York to Ottawa, all band together to issue a formal rebuttal.


And with regard to the rest of your post, I believe I've made it quite clear numerous times now that I am not advocating from the position that you definitively had to revascularize the OP's pt. My points remain that 1. Cardiology consultation is likely warranted in a 90yo with a positive stress test undergoing intermediate to high risk surgery like a total shoulder, even if all that consultation results in is an optimization of his GDMT and 2. Perioperative cardiovascular risk is potentially underappreciated given the epidemiological outcomes associated with non-specific perioperative myocardial injury.

You definitely have me beat in terms of experience. If you want to accuse me of bias, it goes both ways. Surgeons make a living off CABG just as we do with PCI. They have just as much incentive to downplay the paucity of data, as I do to downplay the disagreement.

However I do see your point regarding payers using the guidelines to dictate what they reimburse and in turn what we do. That's a very important thing I admittedly hadn't thought about too much. Agree with everything else you said in the second paragraph.

 

[vector2]

You definitely have me beat in terms of experience. If you want to accuse me of bias, it goes both ways. Surgeons make a living off CABG just as we do with PCI. They have just as much incentive to downplay the paucity of data, as I do to downplay the disagreement.

However I do see your point regarding payers using the guidelines to dictate what they reimburse and in turn what we do. That's a very important thing I admittedly hadn't thought about too much. Agree with everything else you said in the second paragraph.

You're absolutely right that surgeons also have a financial incentive to demonstrate the efficacy of surgery. Which is why consensus guidelines are the modus operandi when it comes to diagnosis and treatment of diseases that require multidisciplinary cooperation. Just think of how absurd it is that heart team is a class I rec but yet we have revasc guidelines that arent endorsed by one half of the heart team. I would also say that we should be placing quite a bit of weight on the EACTS position considering the financial incentives of European surgeons are much, much less prominent than their counterparts here.

I'm in academics and salaried so I personally could not care less if I have to anesthetize more or fewer CABG patients or take care of them in the ICU. I'm approaching the issue purely from an evidence standpoint, and as it stands it's just not reasonable from my perspective to downgrade CABG for 3vd in normal EF to class IIb and in depressed EF to IIa. Leave it class I until more data comes out and then I'll gladly change my view if well-done, multicenter trials designed for and powered to answer that question show equipoise.

 

[coffeebythelake]

You definitely have me beat in terms of experience. If you want to accuse me of bias, it goes both ways. Surgeons make a living off CABG just as we do with PCI. They have just as much incentive to downplay the paucity of data, as I do to downplay the disagreement.

However I do see your point regarding payers using the guidelines to dictate what they reimburse and in turn what we do. That's a very important thing I admittedly hadn't thought about too much. Agree with everything else you said in the second paragraph.

I dont think you understand the meaning of the word biased.

 

[Full Metal IC]

You're absolutely right that surgeons also have a financial incentive to demonstrate the efficacy of surgery. Which is why consensus guidelines are the modus operandi when it comes to diagnosis and treatment of diseases that require multidisciplinary cooperation. Just think of how absurd it is that heart team is a class I rec but yet we have revasc guidelines that arent endorsed by one half of the heart team. I would also say that we should be placing quite a bit of weight on the EACTS position considering the financial incentives of European surgeons are much, much less prominent than their counterparts here.

I'm in academics and salaried so I personally could not care less if I have to anesthetize more or fewer CABG patients or take care of them in the ICU. I'm approaching the issue purely from an evidence standpoint, and as it stands it's just not reasonable from my perspective to downgrade CABG for 3vd in normal EF to class IIb and in depressed EF to IIa. Leave it class I until more data comes out and then I'll gladly change my view if well-done, multicenter trials designed for and powered to answer that question show equipoise.

Very reasonable points. The European perspective is definitely important.

I dont think you understand the meaning of the word biased

Ok

 

[addoncase]

Would any of your trust a mid level who says a patients pulmonary artery pressures above 70 is due to “the patient being stressed out” ?


I don’t think so …..
There is some wild “clearances” going on out there imo

 

[nimbus]

Would any of your trust a mid level who says a patients pulmonary artery pressures above 70 is due to “the patient being stressed out” ?


I don’t think so …..
There is some wild “clearances” going on out there imo

In anesthetized patients I’ve seen PASP go from 60s to 30s with fentanyl 50mcg. It’s a dynamic number so it’s possible that a stressed out patient can have a transient elevation in PASP. That said, I wouldn’t trust that clearance. I’d need more information, especially their functional capacity.

 

[addoncase]

In anesthetized patients I’ve seen PASP go from 60s to 30s with fentanyl 50mcg. It’s a dynamic number so it’s possible that a stressed out patient can have a transient elevation in PASP. That said, I wouldn’t trust that clearance. I’d need more information, especially their functional capacity.

How did you measure it? Echo or did you have a catheter in
Baseline O2 requirements, pulmonary cripple Pulm status much worse than his cardiac status which wasn’t great either
Tells me the most active thing he does is plays cards with his gf
guy is old
Last Pulm note in sept which says he refused Pulm rehab 🙄
Pfts show a mixed obstructive and restrictive pattern, former smoker
Doesn’t even know what inhaler he uses and or if it’s daily or as needed
Case is a broken hip going for a nail
And he took his plavix too

 

[nimbus]

How did you measure it? Echo or did you have a catheter in
Baseline O2 requirements, pulmonary cripple Pulm status much worse than his cardiac status which wasn’t great either
Tells me the most active thing he does is plays cards with his gf
guy is old
Last Pulm note in sept which says he refused Pulm rehab 🙄
Pfts show a mixed obstructive and restrictive pattern, former smoker
Doesn’t even know what inhaler he uses and or if it’s daily or as needed
Case is a broken hip going for a nail
And he took his plavix too

PA catheter, I’ve seen it many times. We (still) put them in all our pump cases.

That patient is a train wreck, no wonder he is “stressed” 😂. But he still needs his hip fixed if only for palliation to make his diaper changes less painful. Maybe a day or 2 of diuretics, bronchodilators and steroid would help. He would still be high risk after “optimization”.

BTW @addoncase fits!

 

[addoncase]

PA catheter, I’ve seen it many times. We (still) put them in all our pump cases.

That patient is a train wreck, no wonder he is “stressed” 😂. But he still needs his hip fixed if only for palliation to make his diaper changes less painful. Maybe a day or 2 of diuretics, bronchodilators and steroid would help. He would still be high risk after “optimization”.

BTW @addoncase fits!

I’m not a cardiac anesthesiologist and no way in hell can I monitor those pressures in real time in this cripple

Yea they wanted to do the case
The mid level didn’t even bother with a Pulm consult either
I work at a podunk community hospital very bare bones and this is def not the patient that can be cared for properly here
The cards consult they got “cleared” him and of course it mentioned being high risk
Nothing that I didn’t know already

Gave a tiny amount of fentanyl 50mcg to help with a arterial line placement, guy crumped

De sat to 60s had to remove the nasal canulla and places on face mask tight seal cranked up O2 after about 3-4 mins with him de satting and his HR climbing to 140 he came
Back up to high 80s for pulse ox

I sent him to the pacu and they tried to keep his sats acceptable with nasal canulla but they had to switch him to a non rebreather.
I had him transferred him to a tertiary care center and followed him via epic (we don’t use it but basically every one else in the area does)

Low and behold proper cards and Pulm consult guy gets the things you mentioned and they do the case these with peng block (which I knew about but have never done and did not to try my chances on this crippple pt and have it not work)

My question is how do you know when to diurees these pts yes you can look at jvd, fluids status, leg edema listen to lungs etc
Asking in case I get some future surgeon who won’t transfer out even tho the patient is a terrible candidate

My gut instinct was to transfer from the beginning but the first cards consult ( hospital worked at) estimated his new pulm pressures to be moderate (50s) so I was thinking LMA pre induction art line, good IVs but after the episode above I didn’t proceed
He took is blood thinner so I couldn’t do neuraxial

I also wondered how did this old guy who refused pulm rehab for months and doesn’t even know what inhalers he uses or when have improvement in Pulm art pressues

Are they that liable just like our regualr
BP? Can be 180 one moment then 140 the next and then 100 the next

 

[Beeftenderloin]

I’m not a cardiac anesthesiologist and no way in hell can I monitor those pressures in real time in this cripple

Yea they wanted to do the case
The mid level didn’t even bother with a Pulm consult either
I work at a podunk community hospital very bare bones and this is def not the patient that can be cared for properly here
The cards consult they got “cleared” him and of course it mentioned being high risk
Nothing that I didn’t know already

Gave a tiny amount of fentanyl 50mcg to help with a arterial line placement, guy crumped

De sat to 60s had to remove the nasal canulla and places on face mask tight seal cranked up O2 after about 3-4 mins with him de satting and his HR climbing to 140 he came
Back up to high 80s for pulse ox

I sent him to the pacu and they tried to keep his sats acceptable with nasal canulla but they had to switch him to a non rebreather.
I had him transferred him to a tertiary care center and followed him via epic (we don’t use it but basically every one else in the area does)

Low and behold proper cards and Pulm consult guy gets the things you mentioned and they do the case these with peng block (which I knew about but have never done and did not to try my chances on this crippple pt and have it not work)

My question is how do you know when to diurees these pts yes you can look at jvd, fluids status, leg edema listen to lungs etc
Asking in case I get some future surgeon who won’t transfer out even tho the patient is a terrible candidate

My gut instinct was to transfer from the beginning but the first cards consult ( hospital worked at) estimated his new pulm pressures to be moderate (50s) so I was thinking LMA pre induction art line, good IVs but after the episode above I didn’t proceed
He took is blood thinner so I couldn’t do neuraxial

I also wondered how did this old guy who refused pulm rehab for months and doesn’t even know what inhalers he uses or when have improvement in Pulm art pressues

Are they that liable just like our regualr
BP? Can be 180 one moment then 140 the next and then 100 the next

The absolute number is important in terms of the afterload effect on a potentially pretty sick RV, but just as important is the ratio of PA pressures relative to the systemic pressures. RV is perfused in systole and diastole, but as that ratio creeps up, RV stops getting perfused in systole and starts to circle the drain. It’s not like LV that’s “used to” only getting perfused in diastole. Are they 50% systemic (not great), 2/3 systemic (worse), 3/4 systemic (very bad), systemic/suprasystemic (call a priest)? The ratios are relatively well preserved over relatively short time periods but can better or worsen over time with treatment or disease progression. If systemic SBP shoots from 120 > 180, you’ll probably see a similar nearly 50% bump in PASP. Similarly as systemics come down PAs will as well. Both vascular beds are similarly responsive to effects of catecholamines endogenous or otherwise.

You tell if they need diuresis the same way you do with left heart failure, just may or may not have water in the lungs. Look for pitting edema, JVD, hepatojugular reflex. May see rise in LFTs suggestive of hepatic congestion or rise in Cr. from renal congestion.

Edit: The ratio of PAs/systemics can definitely acutely worsen a la hypoxia, hypercarbia, acidosis, etc. or something acute/catastrophic like a PE or acute valve issue. But in the absence of stuff like that ratios should be relatively preserved.

 

[nimbus]

Edit: The ratio of PAs/systemics can definitely acutely worsen a la hypoxia, hypercarbia, acidosis, etc. or something acute/catastrophic like a PE or acute valve issue. But in the absence of stuff like that ratios should be relatively preserved.

Exactly why I prefer an endotracheal tube and controlled ventilation in these patients….to prevent the “death spiral”.

I think this has been posted before but it’s highly recommended

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136

 

[vector2]

.

Edit: The ratio of PAs/systemics can definitely acutely worsen a la hypoxia, hypercarbia, acidosis, etc. or something acute/catastrophic like a PE or acute valve issue. But in the absence of stuff like that ratios should be relatively preserved.

An important point for folks who don't think about this stuff every day is colloquially when someone is talking about PASP they're actually thinking of pulmonary vascular resistance.

Now frequently these things are correlated, but keep in mind that mPAP (minus PCWP) is proportional to CO * PVR. Someone gets a push of epi or norepi or gets a catecholamine surge from stimulation, the mPAP is going to go up. But that doesn't necessarily mean the PVR worsened. Just as easily RV contractility and stroke volume went up and therefore mPAP increased. Ideally the mPAP wouldn't change at all under these conditions since the pulmonary vasculature (in a healthy person) is compliant enough to accept increased SV without a concomitant increase in PVR (within a certain range), but again, doesn't mean things worsened either.

The TLDR version is, increases in PAP in someone with pHTN can be good, bad, or neutral, and many times it's hard to tell which without invasive monitoring showing how mixed venous sat / CO / PVR truly changed with the change in pressures.