Episode 310: Cardiac Workup Guidelines with Drs. Thompson, Steppan and Suffredini
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and we've got a great show for you today. I'm very excited to have three people with me today, three fabulous guests, to talk about the new iteration of the guidelines for non-cardiac surgery in terms of working people up, what we need to think about when we assess risk. And those came out recently, as I'm sure people will know, and we'll put a link to those in the show notes.

But we have here three people who are real experts in this and actually one who is the head of the group who wrote these guidelines. So we have Dr. Anne-Marie Thompson, who's a professor of anesthesiology, medicine and population health sciences and vice chair of education at Duke University. She's currently practicing cardiothoracic anesthesiology and critical care. And she was chair of the 2024 AHA ACC guideline for perioperative cardiovascular management for non-cardiac surgery.

That is the group that put out these guidelines, and so she led that up, and I'm thrilled to have her here. I also have Dr. Jochen Stepan coming back to the show.

We did some previous episodes, including one on pulmonary hypertension, right heart failure. That was fabulous. People still write me about that. So, Jochen, happy to have you back here. He's an associate professor of cardiac anesthesia and director of perioperative medicine for high-risk cardiovascular disease. And I have Dr. Giancarlo Suffredini, who is an assistant professor of anesthesiology and critical care medicine in the Division of Cardiac Anesthesiology here at Johns Hopkins. And Giancarlo, I think this is your first time on the show?

It is, yeah. Thank you for having me. I'm thrilled to have you here. Former resident now, that was a long time ago, long time attending, and thrilled to have you as well. So all three of you, welcome to the show. Thank you. Thank you for the kind introduction.

So, Anne-Marie, let's start with you. And I'd love to have you just tell us a little bit about what you're, you know, you have all these different roles I just mentioned, but what does your kind of day-to-day look like? And then also tell us a little bit about what it was like to lead this enormous group taking on this huge task. It must have been just an enormous amount of work, but how did you kind of go about that? How did you harangue everybody and how did you come up with this fabulous, useful product?

So, Jed, first of all, thank you for having me. I'm a big admirer of the podcast and listen to ACRAC frequently when I run. So I learned so much from it, even now, even though I'm no longer a resident. So my day today is probably a little bit similar to yours. In fact, we are both residency directors for the time being, and I'm the vice chair of education.

here at Duke. I would say my practice is roughly about 50% clinical, 50% administrative. And I spend most of my time in the cardiothoracic ORs and in the CT ICU. Although earlier in my career, I was on the other side of perioperative medicine as the director of a preoperative clinic at Vanderbilt for more than 10 years.

Great. So lots and lots of experience. And obviously you balance a lot of different roles as some of us do. Um,

And then how did this fit in? I mean, did you have to take time off to do this, or was this something you did kind of little by little during your administrative time? How did that work? So I didn't get any extra time to do this. I think what I like to sort of let people know, and maybe that's the program director in me, that a lot of times the passion projects become what you do on your nights, weekends, and holidays. If you believe in it enough, if you're passionate enough about it,

you make the time for it. And I think that's what I did for this guideline. I have had a lot of experience in perioperative medicine. My initial passion for going into anesthesiology was the influence in my residency at UCSF, something else we have in common.

with folks that had trained in internal medicine as well as anesthesiology. I have to give a shout out to Sue Carlisle as well as Janine Wiener-Kronisch, who also, they were heavily influential in my career and helped me see...

the role that internists can play in perioperative medicine. And when I heard that anesthesiology, those anesthesiologists, so the internists of the OR, I was pretty much sold. So my experience with that sort of piqued my interest in perioperative medicine and best practices, evidence-based medicine.

I've done some clinical research with that. But I would say my career probably started in a way by accident. I was head of the preoperative clinic. I was right out of two residencies at that point. And they'd ask me, they said, well, you've done internal medicine. Maybe you'd like to be head of this pre-op clinic. And I said, sure.

And you talk about the movie Robots sometimes with this, and it's a very sort of undersold Pixar movie. But one of the concepts of it is see a need and feel a need. And you will not see a need until you have run a preoperative clinic, I think. There are a lot of needs. And when patients fall through the tracks and have unnecessary delays or cancellations, you're going to hear about the need. And it was really at my time in that preoperative clinic that

that we had a need to do some responsible perioperative management of pacemakers and ICDs. And I took that role on. And from there and from the work I'd done at Vanderbilt was on a expert consensus statement with Heart Rhythm Society for that. From there, I was on the writing committee for the 2014 ACC AHA perioperative guideline. And then now this iteration 10 years later.

Fabulous. Well, that I think is such a great testament to not only your own success, but also the kind of path that, you know, if you say yes to some things that kind of make sense early on, you get involved, you develop expertise, and then you never know where it's going to lead. So I think that's fabulous. Let's start by talking about some of the highlights of these guidelines and, you know, in general, kind of what people really need to know. And then also, you know, kind of what's new, what you want to highlight about what's new about these compared to the prior iteration.

So I'll be thrilled to hear what our other guests say about it, having reviewed the guidelines with AC. There is a lot in them. I mean, it is 72 pages, and that doesn't include the references. You know, there were 32 writing committee members on this from a breadth of perioperative medicine, from interventional cardiology to general cardiology, hospitalists, surgeons, anesthesiologists.

It was a great group of people that really have a passion for perioperative medicine. Many of them are sort of leaders in the clinical research in that area. And it...

It's hard to sum up what are the essential points in over two years' worth of work, but we'll give it a go. So I think this is – there are a lot of big changes from the 2014 guideline, and you said we'd talk about the algorithm. Let's just bring it up right now. You know, the algorithm from 2014 – and, again, I was on that writing committee –

people said, well, where does that come from? Is that data driven? And the truth is, is it's kind of made up, if you will. It is created by folks who have spent a long time reading the data and reviewing the literature at the time. And it is their expert recommendation for how to incorporate that data into the daily clinical practice.

So the algorithm from 2014 really focused largely on who needs to be tested to look for occult ischemic cardiac disease.

A big departure in the 2024 algorithm was the idea that ischemic heart disease, while important, isn't the only and potentially not even the major cardiovascular disease process that we should be paying attention to. So I think one of the biggest departures with this algorithm is that it really took a moment or had a place

where it would consider other cardiovascular conditions that might not be fully represented in current risk calculators.

So I think if you put the 2014 algorithm with the 2024 side-by-side and compare, you'll see that they're very different in that way. Yeah, and so say a little more about that. What are some of the conditions? I think that's a surprise to people to think there are things that might be more important than occult coronary artery disease, right? Which I think is, and I think you're exactly right. Whether correct or not, I think what a lot of people took from the 2014 guidelines was

What I need to know is, A, does my patient have active, like, are they having ACS right now? And the answer to that is almost always going to be no. And then after that, do they have four METs? And if they have four METs, I'm good to go. And if they don't have four METs, then I have to get testing. I know that's just a vast oversimplification, but I think that's what a lot of people do. I think you got a lot of it right, Jed. I mean, I think that is sort of the distilled takeaway people have from that, from that algorithm. Yes.

Yeah. And I think that the – and what they felt was, okay, what I'm trying to figure out is do they have a cold coronary artery disease? Do they – is it possible that they have a partially blocked LAD and when I get them under anesthesia and they have surgical stress –

that's going to, they're going to have an MI, right? I mean, it's an incredible simplification. I think that was a concern. And we believed, okay, well, if you have four METs or more, then that's probably not going to happen. If you have less than it might happen. And so that was kind of what it was. Now you're saying, okay, yeah, we do want to know if somebody might have a cold coronary disease, but there are other things that might even be more important. So tell me more about that. What, what are we, what are we thinking about?

Yeah, and I'll refer to the Sean Van Diepen study that was a large database study looked at patients, all comers, not just high risk cardiac surgery, non-cardiac surgery, excuse me, it's

It's not just looking at patients who are undergoing elevated risk, non-cardiac surgery, but really all comers. And what the group that was targeted in this study were patients that had either heart failure, either ischemic or non-ischemic heart failure, coronary artery disease, and then think about common things, atrial fibrillation.

And what was interesting is in the unadjusted mortality, coronary artery disease had around a little bit less than 3% in this all-comers group. Heart failure, the mortality was three times coronary artery disease. Atrial fibrillation was roughly two times.

So this is pretty interesting. It sort of suggests that, as you had mentioned from the 2014 algorithm, we're really focused on that occult coronary disease. But perhaps heart failure and maybe even atrial fibrillation are even more important or bigger drivers of poor perioperative outcomes than occult coronary artery disease.

And what the authors of this study also suggested, given that it was looking at these patients in all types of surgery, not just elevated risk surgery, that perhaps even low-risk surgeries may not be as low risk as we are often led to believe if people have advanced cardiac conditions.

Great. All right. So that's really important. And I think it's going to be shocking to people to hear that heart failure and even AFib. And when we say AFib, I guess we should clarify that. Is that someone who has pre-existing atrial fibrillation that is not? For this study, yes. Yes. So unknown atrial fibrillation.

Yeah. So this is not necessarily people with known, rate-controlled, medically optimized AFib. These are people who have undiagnosed or it could be... These are people with any diagnosis of AFib. So the guideline looked at sort of two groups, how to manage folks who have pre-existing atrial fibrillation. But there's also some new information about folks who develop atrial fibrillation potentially for the first time in the perioperative space. So...

Atrial fibrillation is common. It's not going away anytime soon. And there are some real perioperative considerations around it. And one of the things we haven't thought about is perhaps these people carry more of a risk of MACE and mortality than we had ever considered. Yeah, great. And you said MACE, which reminds me, we should probably go over some acronyms. So MACE, Major Adverse Cardiac Event. What is included in MACE?

So that's a great question. It's almost a trick question. So another study by Bosco looked at this, looked at what was the definition of major adverse cardiac events, or sometimes you'll see MACCE, which is major adverse cardiac and cerebrovascular events. So the FDA defined it as in 2008 to try to get a standardized definition for research.

It was a three-point criteria, non-fatal acute MI, non-fatal stroke, and cardiovascular death.

Subsequently, in a study done in 2021 by Bosco, there was an assessment of the studies that reported MACE as an outcome to see what was MACE. As it turns out, again, the classical three-point MACE established in 2008 of non-fatal acute MI, non-fatal stroke, and cardiovascular death

In 2008. In this study in 2021, only 9% of the studies reported the classical three-point mace.

So you can see what makes it difficult to analyze and to compare studies in perioperative medicine when only 9% follow the recommended three-point MACE. So I do caution people when you're reading perioperative studies, make sure that you read what the outcomes were. And in some of these studies, potentially, some of the outcomes are different.

may have been analyzed sort of secondarily after the study was done, potentially to increase the strength of the study or the positive findings. But do know in very few studies, less than 10% are the classical three-point MACE criteria followed. Okay, that's important to know. So let's

So let's look at the algorithm. And I think that's what people are going to kind of use the most, right? So the first step, I think, remains the same, which is to ask yourself, is my patient currently having an unstable cardiac event, right? Yeah.

Right, exactly. Well, in the first, the top of the algorithm is really who is this for? And it's really for people with cardiovascular risk factors. And these are the ones that we all know and learned in medical school, high cholesterol, hypertension, women greater than 65 years of age, men greater than 55 and so on. Right.

And it's also to look at people, look at conditions where you have some time to think about patients and really consider all of their comorbidities. If it's an emergency surgery, you simply don't have that kind of time. You can do what you can, but generally you proceed with surgery.

If it is for elective non-cardiac surgery, the next step in this is, as you had said, do these people have any acute decompensating conditions? Do they have decompensated congestive heart failures? Do they have unstable arrhythmias? Are they having an acute MI? If they have any of those conditions,

Obviously, elective non-cardiac surgery should be postponed until those conditions are managed. So you're right. That top of the algorithm is very, very similar to the 2014 algorithm.

Great. All right. So we we let's say we've assessed our patient and it's not emergency surgery. Like you said, if it is, if it's life or death, we go to the OR, they die. We're just going to go to the OR. But it's not an emergency. It's elective non-cardiac surgery. They're not having acute heart failure or acute MI or unstable arrhythmia. What's the next step?

So now you're down to someone with risk factors who's undergoing elective non-cardiac surgery. So in the next step of the algorithm, and this is where it changes a little bit from 2014.

We still use risk calculators. There are many of them. There is the MICA. There is the NISQIP calculator. You've had guests on your show, Bobby Jean Schweitzer and Gina Blitz, who have talked a lot about these. And then the RCRI, the Revised Cardiac Risk Index. Those three are probably the three most commonly used calculators.

The recommendation of the committee was not to recommend one over the other. Some people who work in perioperative clinics will use multiple risk calculators to compare within the same patient. So our recommendation was to use a validated risk calculator. There is a list in the guideline itself.

And use that to see what patients might be at elevated risk of perioperative cardiovascular morbidity. But again, as before, that might not be enough.

So the committee thought about this and said, look, there are probably some cardiovascular conditions that aren't fully accounted for in risk calculators. I'll give you an example. You know, we'll take something that's even in the risk calculators. Have you had a stroke? Yes.

Okay, what do you get? You get one point. Well, what does one point mean? Who knows? You know, so there needs to be a little more consideration beyond that. And we can spend some time talking about stroke later. But again, the idea was use the risk calculator, but also consider other cardiovascular conditions that we know contribute to morbidity and mortality that may not be fully accounted for in our traditional risk calculators. And we called that group RAD.

risk modifiers. And this was just a first stab at what sort of additional cardiovascular conditions are really serious that should... If patients have these conditions, clinicians should pause to think about how to best manage these before going forward. And there's a list. We have severe pulmonary hypertension, for instance. And

If you've had prior cardiac revascularization, either with stent or cabbage, you may have anticoagulation to manage with that. So that's one of the conditions. If you have severe valvular heart disease and those type of conditions, stroke also, as well as frailty. So it's also the first time sort of frailty makes it.

on the list of things to consider because we know patients that are frail have a higher risk, not just of cardiovascular complications, but other perioperative complications. So that combination of a risk calculator plus looking through those risk modifiers is

helps the clinician figure out what they might consider doing as next steps. So if we go from that, you know, patients could have no risk factors and maybe they don't have any risk modifiers either. They don't have severe pulmonary hypertension or valvular heart disease. If they have no risk factors and no risk modifiers, they can go on to surgery.

The second subdivision are patients who do have risk factors but don't have any of those cardiovascular risk modifiers. They don't have the pulmonary hypertension. They don't have frailty, but they do have some elevated cardiac risk. From that point on,

The recommendation is, and it's a weak recommendation, a 2B, is you can get an ECG on these patients. We know they have risk factors. We know they have some elevated risk. You may want to get your preoperative ECG. You want to do your guideline-directed medical therapy if they're not on a statin and they meet...

criteria for statins, the strong feeling of the committee is this is a point of opportunity into the medical system and that it may be, yes, appropriate to prescribe a statin perioperatively. I know that's not something maybe that people universally do or universally agree with, but it was an idea that this is a sort of teachable moment or an opportunity to optimize patients.

Now, the third group is patients, regardless of whether they have any risk factors by the traditional risk calculators, regardless, they may have some and they may have not. But if they have any of these associated conditions, that's where it gets a little bit more interesting in the management. And that's where people said, you know, you need to think about these patients and make a plan. These are patients that have pacemakers and ICDs, frailty, strokes. Again, the conditions that I've talked about and they're in the paper. The

Depending on the type of condition, you may consider, for instance, an echo if you suspect you are worsening left ventricular dysfunction. If they have severe valvular heart disease and haven't had an echo in two years, or if they had moderate and haven't had an echo in two years, this might be a time to make sure you're not dealing with something more serious before you take

them to non-cardiac surgery, again, with the guideline-directed medical therapy also. So there are sort of three pathways from go to surgery to do guideline-directed therapy, maybe get an ECG, and then the third category where you may consider other tests, ECG got a 2A recommendation in that group. So it's a little bit stronger with patients with these special cardiac conditions. And then

From there, the next question is, so you know a lot about the patient. You know about their surgery. You don't really know what they can do yet. So that is where the assessment of functional capacity comes in. And fortunately, we have a good scale that is validated by Wiji Sundara as part of the METS investigators looking at DASI, the Duke Activity Status Index.

They even set the threshold that you should look at, which is if you're less than 35, you are at risk potentially for cardiovascular, for MACE. Just remember that the DASI scale is a scale. It's a longitudinal scale and sometimes complex.

you know, for ease of use, we try to put it at one point at 34. But I will say there may be a big difference between someone who's 34 on the scale versus someone who's four on the scale. In the same way that we don't know that someone at 34 and 35, you know, they may share, they may have a lot more in common than that person whose day C is four. So do understand there's like a

like a demarcation, but it's a little bit more complicated than that. So once you've done that, if patients have good functional capacity, you know at this point that they have some risk, you've managed the risk, they have reasonable functional capacity, you would go on to surgery. If they have poor or unknown functional capacity, again, this borrows from the 2014 algorithm, you now stop and ask yourself, okay,

Would any further testing change my management? And if the answer is no, if it won't change the procedure, if it won't change the timing, if you can't further optimize the patient, then you can consider either moving on with surgery or discussing other options.

However, if it would change your management, if further testing would change your management, this is where biomarkers really come in very strongly as sort of the next step. And part of the purpose of biomarkers, I think, is to really further define and further identify the group of patients that would benefit

potentially benefit from invasive testing. We actually don't want to over test and we don't want to over treat. And I think biomarkers in this role helps us to think about

patients at risk that may not necessarily need to go down the road of formal stress testing and cardiac cath. So you would get these biomarkers in patients. The cardiac biomarkers recommended are pro-BMP or internal pro-BMP or the cardiac troponins.

So, the cardiac troponins have essentially a weak or a 2B recommendation. It's not quite as well studied as the BMP in the preoperative environment. So, the idea is you get those. If they're positive, you have to think about that then, you know, at that point.

You get your team together and say, look, I have a positive pro BMP. I didn't get an echo earlier. I didn't think that this person had any heart failure. You know, take another look at the patient, see if there's any additional studies that you would want to do. And, yeah.

And do those other tests that come up if you're if you have positive biomarkers and you're thinking about further workup is echocardiography. Again, comes in again, coronary CTA, and that's another one that makes its appearance first time in the algorithm. And you can consider noninvasive testing at this point.

So again, non-invasive testing is pushed a little bit farther down in the algorithm than in 2014. And if any of those tests are positive,

Think again, you know, are you ready to go? Do you feel like you need to do a next step in terms of invasive cardiac testing? Or are you just going to continue with medical management, modify your surgery or go to surgery? And the recommendation at that point, if patients have risk, is to consider doing postoperative troponins to screen for MIMS.

Yeah. And so MINS is another one of those acronyms and that's myocardial injury after non-cardiac surgery, right? Correct. Correct. And what does that mean? So,

So that's great. It came out of the 2014 vision trial. This was really coming out with the publication of the 2014 version of the perioperative guideline. And this is essentially a positive troponin after surgery,

It does not indicate sort of why the troponin is elevated. It can include STEMIs, ST-segment elevation, myocardial infarction, but more often than not, it is felt to be due to a supply-demand phenomenon, either due to pain or tachycardia-associated

with pain, could be anemia, blood loss, hypotension, but these are these, the troponin just suggests that there has been some myocardial injury in the perioperative period.

And so if the elevated troponin is from an MI, then that's both MINS and MACE, right? But if it is not, if it's not an MI, then it would not be MACE. It would just be MINS. Right. That is correct. Great. So if I'm understanding correctly, we've got this patient. They don't have the

They don't have at least 34, 35 on the DASI. And so we've now said, okay, we're going to do some more workup. And we maybe decide after that workup, we're going to go ahead with surgery. But because maybe things were not, they are high risk, we're going to check troponins afterwards. Because if they do have MINS, we either are catching an MI. If it's not an MI, they're still at risk because they have MINS and MINS puts you at risk for later MIS.

cardiac events, right? So we want to keep a closer eye on those patients. Yes. In studies, they have a higher 30-day mortality. This doesn't mean that it's a high number, but it is a higher number. It's a very difficult thing to message to patients, as you can imagine. Yes.

So I want to go back to the three buckets for a minute when you were talking about, okay, if you have a patient with no risk factors at all and no risk modifiers, we're good to go. We don't even have to worry about whether they have what their DASI is, right? No risk factors, no risk modifiers. Go ahead. The second bucket was the patients who have – they may or may not have risk factors, but they do have the risk modifiers. Okay.

So for some of those are, I think, obvious, like you said, right? A patient who had revascularization and hasn't really had any echo or assessment of function in years or a patient who used to add heart failure diagnosed years ago and hasn't had an echo recently. Those kind of make sense. We should probably get that information. But some of them are a little harder, right? So like, what about the frail patient?

You know, it's not a quick, let's do an echo. So for the patient who's frail and isn't going to be unfrail anytime really soon, what do we, when we do the pause, okay, here's a risk modifier, they're frail. What do we do during that pause for that patient? Well, it's, uh, that's a great point that you bring up. So we do know that frailty does increase the incidence of major adverse cardiac events, as well as other complications such as infection, bleeding, fall risk. Um,

There is not there. I think this is an area where there is going to be study. Can we make frail patients less frail? Does prehab work? Is prehab an option for folks? Depending on the timing and the need for elective non-cardiac surgery, that could be a potential option.

thing to do, to send patients to a physical therapy or to some sort of prehab to sort of strengthen them and get them in better physical condition for surgery. The other thing is, is once you've identified that they're frail, it may be a time to really set expectations.

not just with family members and with the patient, but actually with the whole team. Like, what is the goal of this surgery? I think many of us have taken care of patients in the ICU where family members have come and said, you know, we had no idea we were going to end up here. We had no idea this was going to happen. But you have looked at the history and you have seen, you know,

How could that be? How is that not explained? And maybe it is, and people tend to look at the bright side and tend to think about, you know, the positives without thinking about what is a more likely outcome. So I think it is that opportunity for discussion, but I also think it's an area of potential research, right?

to look at how can we make the frail patient less frail. Yeah, great. Okay, that's really helpful. And then, you know, I think one of the things that's difficult to wrap your mind around with these new guidelines is that unlike the old guidelines where, like we talked about up front, it kind of felt like, look,

As long as you've got the exercise tolerance, you're good to go. Here, the step before assessing exercise tolerance is to ask about these risk modifiers. And so, you know, is it accurate to say that if someone has these risk modifiers, even if they're a marathon runner, we still are going to say, well, you know, we need to figure this out.

Absolutely. So we should manage these. So if it's the marathoner who exercises but has a defibrillator for whatever reason, maybe had a cardiac arrest or maybe had some sort of condition where they had, that needs to be thought about and managed before the day of surgery. So

Folks have these things for a reason that even if they have a high level of fitness and health, you need to have a plan. And that's where those risk modifiers sort of come in. If you know they have a condition, you need to have a plan regardless of

of their exercise tolerance. They may be great at exercise, but if that moderate aortic stenosis hasn't been looked at and they now have severe aortic stenosis, every anesthesiologist wants to know that. And not just before major elevated risk non-cardiac surgery, you want to know that before sedation for a colonoscopy. Stay with us. We'll be right back.

Thank you.

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acknowledge and then plan for that risk modifier. And with the person with the defibrillator, that might be as simple as making sure it's working and having a plan to reprogram it for surgery, depending on what kind of surgery and where, you know, whether they're using electrocautery and all that. So it just means think about these risk modifiers and make sure you have made a plan for them and made sure you've kind of appropriately worked them up. And then you can go ahead and that is, it's not a hard stop. It's a stop to make sure you've planned for them.

Right. Absolutely. Another great example is stroke, which I said I'd get back to a little bit later. So you can get a point for stroke on a cardiac. Well, the reason it was included in the risk modifiers is there's been some recent studies that have shown that patients who have their elective non-cardiac surgery within three months of a stroke have a much higher risk, much higher risk.

of having a recurrent stroke. They also have a higher risk of other major adverse cardiac events, but it really is that recurrent stroke and that by waiting at least three months, you can at least minimize or reduce the risk. It never comes down to the risk of someone who's never had a stroke,

But these are things that you can do if you know about it. If it's up in your consciousness to think about this, you can actually impact the patient's perioperative course and outcomes. Great. And then the other thing is AFib. So you mentioned up front how AFib carries quite an impressive potential risk, maybe even more so than coronary artery disease.

So how does that play in? Is AFib one of those risk modifiers? And do we stop and say we need this to be ablated? We need this to be rate controlled? What do we do with the AFib? So atrial fibrillation in this round did not make it into the list of

of risk modifiers. And I think there was some debate about that and maybe in future iterations it will. But we do know that patients with atrial fibrillation are often on anticoagulation that actually has to be managed perioperatively. It doesn't mean stop it in everybody. It doesn't mean that you can continue in everyone. Does it mean that patients need bridged or not? Well, it depends. You know, if they've had a prior stroke

We have a really nice table in the guideline that recommends when patients should be bridged or not. One of the other interesting things about atrial fibrillation is new atrial fibrillation with atrial

Perioperatively. So postoperatively, for instance. I think many folks used to think, well, that's atrial fibrillation. It'll probably go away. It's here. It's gone. Don't need to worry about it. There are studies now that suggest that we actually do need to worry about it. The incidence of recurrence increases.

is higher than thought and that these people actually need appropriate follow-up and potential consideration for rhythm control or rate control and anticoagulation.

Right. Now, what about the patient who no history of AFib and then they go into AFib in the pre-op holding area and they're asymptomatic and they're rate controlled. They're in AFib at 85 beats per minute. I know I had, as you mentioned, I had Bobbi Jean Schweitzer on. She, you know, feels strongly that there's not great data for postponing surgery in that setting. Do you agree or do you think we need to do anything differently?

Yes, I agree. I think if you're fairly comfortable that this patient doesn't have thyrotoxicosis or some other condition that with modification could potentially subdue the AFib for surgery, then it's fine to proceed. I think the caution is once someone has AFib in the perioperative space,

it's not just sort of look at it and then forget it, you know, that these patients do have a certain percentage have a risk of recurrence and do need some sort of follow-up afterwards. So it doesn't mean you necessarily have to postpone the surgery, but they should receive some follow-up afterward. Great. All right. Jochen, let's turn to you because you're going to tell us about some of the data behind these guidelines that Anne-Marie so expertly walked us through. Sure, happy to.

So what do we what do you think is important to know? Anne-Marie mentioned a couple of things like she said this was a 2B, this is a 2A. You know, give us a little bit of what you think are the important things to know about the evidence behind these guidelines.

So I think most of the evidence by the guidelines is actually quite high. And there's a lot of things that we know that have been very randomized controlled studies or observation trials that have been really, really large. So we have very good evidence for, I would say, for most of those studies. I mean, for instance, if you start looking with something simple like the pre-operative ECG, if this is important or not,

We certainly do know that if you get an EKG before the operation and there's some new abnormalities, let's see, there's SDA segment elevations, there's new Q waves or anything like that,

that it should be evaluated but we also have very good evidence that not everybody needs an ezg especially for a lot of the operations that we do that are right low risk or the patients have healthy um no risk we probably do not need one for instance um unless the surgery is um at least intermediate or high risk and there's probably no benefit um to getting an ekg and that just brings them based on a study by um sober b they came out probably more than 10 years now and

where they looked at 30,000 patients who were just undergoing lithotripsy, so very low-risk surgery. And then they looked at, well, how many cancellations were done because the patient had abnormal ECG. And it was only 13 cancellations, so less than 0.04% of patients were canceled. And then if they looked at those 13 patients, well, I think like 10 or 11 or so had a completely normal work above that, and ultimately all of them underwent that procedure.

So there's really a very little correlation between improved possibility of death and the ability to predict an MI in those patients. So unless you are undergoing at least like intermediate risk surgery, there's probably no need to get one. And Jokic, sorry, let me ask you because I realized we didn't really talk about that. What –

How do we know what is a low-risk, intermediate-risk, or high-risk surgery? Is there a list that we refer to? There's actually a list for that. There's a list for that. And is the list, Emery, is it in the guidelines, or where do people find it? No, it is described in text in the guidelines. It was not included as a table. I can refer to you to NatSmart. I can tell you a couple of examples if you want to. In 2007.

I think. Let me just pull it up. But anyway, no real surprises from 2014. What was considered the highest risk were things like vascular and thoracic surgeries. I think transplant and neurosurgery are also on that list. And then there's your medium risk surgeries, which is everything else except the low risk, which is often gynecologic procedures, breast surgeries. Okay, great.

All right. So there's a list. People can find it. That I'm not worried about. We're going to put the guidelines, a link to the guidelines in the show notes. And that's got a ton of references, including this one, of course. Great. All right. So, Jochen, so great. So you were saying for low risk surgery, don't need it. And is that true no matter what the age of the patient is?

Pretty much. It's almost independent of that. I mean, certainly if the patient needs an ECG regardless because you're suspicious that they have any active coronary syndromes or they have signs and symptoms of coronary disease, by all means, go ahead and get it. But in the absence of that, there's really no need to do that. Great. Other highlights of the evidence you want to point out?

I'm sure I think what Anne-Marie mentions was bringing the echocardiogram earlier up in the algorithm. And she mentioned a little bit about the higher risk that you have with congestive heart failure versus if you have coronary disease. So I was thinking about some of the studies that are behind that. One of them is by Hamlet, I think 15 years ago, an anesthesiologist who

where they actually looked at more than 150,000 patients that were undergoing non-cardiac surgery, and they found a significantly higher risk of mortality and heart failure readmissions in patients with heart failure. And then also for the questions, should we just get an echo in everybody? Of course,

regardless of the financial implications that they would have, but would that actually lead to improved outcome? There's a very nice study out there that came out in the British Medical Journal a couple of years back where they looked at, I think, almost a quarter million of patients, like 250-something thousand patients. And then they looked at 40,000 of those who had an echocardiogram before the operation, and they then were propensely matching that with another core of like 70,000 patients,

And there was basically no difference in between like 30-day mortality or one-year mortality in those patients. So getting an echo in everybody is certainly not going to be beneficial, not only financially, of course, but also from a medical standpoint. And as I'm saying, a lot of the studies that this is based on is really large, large studies with really good evidence behind it.

Right. And so the role of the echo, as you say, is not that everyone should get one, but that you are going to use this as a targeted intervention in these patients who have risk modifiers or risk factors that make you think they may need an echo, right? So you're using it in a way where you feel it will give you information based on a patient's history or risk factors, but not just as a screening tool. Right.

Right. And I think that the more important thing is kind of, is very central to the algorithm. But I feel like if there's one thing that could be improved would be to kind of the bold and put it in, in red, because is it, does it change management if you do so? Because actually I just literally had a consult last week where they were, where I was told by the cardiologist, oh, well, because the new guideline, we are unable to estimate excess capacity in this patient. So therefore he needs an echo. And then we had to do, of course, a lot of education. I guess it's not what the guidelines say, but,

But a lot of our consults, especially if they don't work in the anesthesia field, don't really know if that's

if that study is actually changing our management or not. And oftentimes they go a little bit towards the side of more conservative and more caution and get more studies than what's oftentimes needed. So I think especially us as part of the physicians who know what we're going to be doing in trouble, we need to be good stewards in making sure that the tests that we're ordering is actually going to change the management. And that, in all fairness, is essential to the algorithm is actually.

Yeah. Well, let's explore that example because I think it's a great one. So this cardiologist said, if I'm understanding you, the patient presumably had risk factors. They couldn't they could not assess exercise tolerance. Maybe they have arthritis of the knees or something. And so then they said, therefore, we can't we need an echo. Is that right? Exactly. And talk about why that's wrong.

Well, that's wrong. First of all, a lot of people would be getting an echo in the first place. But just because we know how to... Sorry, let me back up here a little bit. Certainly it's wrong because it really needs to change the management. If you get an echo and...

just to find out if the ejection fraction is like 40% versus 50% versus 30% or 60%, that really doesn't change the management of what we do in a lot of the cases. And oftentimes, we can treat a patient with a certain amount of medications, certain type of medications, maybe put an NTR line in there, and we can do it regardless if you have an exact ejection fraction on the patient, unless we have something actionable where we think, okay, if the

We've got to find out the echo. Maybe this patient has new symptomatic aortic stenosis, and we might actually do an intervention before we undergo the procedure. That would be something that changes how we treat for the patient. But if the option is just to use etomidate versus propyl-4-D induction, we could do that without knowing the echo. We could just use the approach that is a little bit more of a, quote-unquote, cardiac induction without having a new echo before that.

And what if the concern is that this patient might have undiagnosed heart failure or undiagnosed coronary artery disease? In other words, we like to think, for better or for worse, I think we like to think about exercise tolerance as a way to quote-unquote rule those things out. Now, that doesn't mean that's accurate, but if a patient can run exercise

10 miles, we probably worry less about them having, uh, needing a stress test. Right. I mean, so if they, if we have no idea about exercise tolerance, how do we, do we, do they need something? Uh, let's assume it's a medium or high risk surgery. It's not a cataract, right? Let's say they're having, you know, uh,

thoracic surgery, you know, do we feel like we need to assess somehow whether that's a stress test or a stress echo or, you know, or not? In other words, what was the cardiologist wrong in saying, I can't assess their exercise tolerance. So I need something else. Or was it just that the echo might not have been the right workup?

Well, I think it's both. The ECOWAS is certainly not going to be the right modality in this case to get. I think the thing I want to point out is that it's not going to be an automatic just because you're unable to judge excess capacity. In an automatic, you need an ECOWAS as a replacement of that.

The guidelines are actually very clear that the echo should only be requested if you have, as I said, at least an immediate type of surgery, but also if you have signs and symptoms of heart failure or a valve disease. If you don't have any inkling that a patient has, you know that you don't need that.

If you look at this patient and you have, for instance, we're now going back to the risk modifier, so you have a patient who looks very frail, but is unable to. There's a difference between not being able to exercise and somebody who is completely incapacitated and not being able to do activities of daily living. For instance, the DASI would be a very good screening tool for that. I think you can use all of those in order to get a better idea of what you're dealing with. It's

without making a connection just because you're unable to get a quantitative excess capacity in a patient you definitely would need an echo that makes sense so yeah it sounds like the lesson is you might need an echo or you might need a stress test or you might need some other workup but it's not an automatic you couldn't get the exercise so therefore you definitely do this you have to ask yourself am i concerned about something in this patient do i have reason to be concerned and would that concern lead me to something that would change my management so if they did have

you know, some mild heart failure, if they did have some coronary heart disease, would I cancel a surgery? Would I do something else? And if the answer is yes, then obviously you should get the workup. And if the answer is no, then there's no reason to get the workup.

But I think that's a fair summary. And you have some options before you get an echo in the algorithm. If you're not sure, you can use a screening BMP to see if the patient has an elevated BMP that would suggest perhaps that there is either systolic or diastolic dysfunction.

Great. And so, Giancarlo, let's talk about the biomarkers because they've come up already, and I think they're one of the major differences in this iteration of the guidelines. So why don't you tell us a little more in detail about when we would use them? Is there a certain patient population that should always get biomarkers for certain surgeries? Is it going to be based on certain criteria in the patient or the surgery? How do we decide? Yeah.

So let me tell you first just a little bit more detail about the two biomarkers. Yes, please. So the first are the nitroetic peptides. So we have BNP and NT-proBNP. So people are probably relatively familiar with these, but these are hormones released by the heart in response to pressure volume overload. They're commonly used to help diagnose and monitor heart failure, but they can also be increased if you have kidney disease. So that can be a red herring there.

if you have atrial fibrillation, or if you have ischemia. And so what the guidelines tell us about natriuretic peptides are that if you have known cardiovascular disease, if you're suspected to have it, and you're undergoing an elevated risk surgery, so meaning that your risk of having a MACE is greater than 1% based on any of those risk calculators, then yes, it is reasonable to get these preoperatively.

And how do they perform? You know, they have a very good, excellent, you know, negative predictive value. So ruling things out. So if these are very low, then it can be very reassuring for you. And, you know, they can have a high prognostic value. So if I told you, you know, Jed, you know,

On a Tuesday, you have a patient. You're going to get a BNP. You're going to say, well, how do I interpret the values? Are there cutoffs in the guidelines? Do they give me numbers that I'm supposed to go off of? And the answer is no.

They're not clearly established yet. As a general rule, people within heart failure, they can use diagnosing with a BNP of, we'll say, greater than 100 picograms per ml. That probably still holds true with these guidelines, and it just so happens that it's probably also true for the NT pro BNP. Those values do not go up together, so they split.

So it's not like 100 is equal to 100, 200, 200. So those will split after that, which is why there's not exact values that are given in the guidelines. And then what happens if they come back elevated? So the guidelines don't tell us that there's any specific management that you're supposed to do.

But you should probably have a conversation with the entire perioperative team. You should say, hey, listen, this guy has an elevated BMP. Do we think this is just because he's got some underlying CKD and this is a little bit of a red herring? We're not sure. Or is it because he has a fib or does he have heart failure? Do we need to do some of these other tests that we were just discussing? So that's the –

That's the BNP and the NT-proBNP and the context in which you would want to use it. And then the second biomarker that's brought up are the cardiac troponins. Everyone knows that these are released, you know, when you have myocardial injury, the

The one change that people need to consider is that when you're using high sensitivity troponins, there are five different manufacturers of these. And so we look at cardio, you know, we look at, we look at troponin T and we look at, and also troponin I.

So there's at least three manufacturers for I. And as of 2020 or so, there was only one for T, but there may be another one. So if you can't trust that the values are the same between those different tests, then how are you supposed to interpret it? So laboratory medicine came up with this idea that you have this upper reference limit for each of the tests that are run. So

And this is also different for age and also gender. Okay. So you can't just say, I have a high sensitivity troponin and it's 14. And that means that this patient's now high risk. So you'd have to say that I got a high sensitivity troponin.

you know, troponin I and that this is, you know, this number is the 99th percentile for the upper reference limit of, you know, the Abbott test or the Roche test or, you know, whichever one it is. And that's how you can start to interpret those. And again, these patients, you know, you would get these for patients who either have, you know, known disease or they're, you know, you have a high suspicion that they have, you know, underlying cardiovascular disease.

and that they're undergoing an elevated risk non-cardiac surgery. The guidelines also tell us that these are pretty good.

One of the benefits to getting something as a baseline is that you can then use it postoperatively if you have a concern that someone may have had an injury. And that gives you some sort of reference point because there are people who walk around who do have elevated cardiac troponins. And if you don't have a baseline value, then if that appears as though it's new, you may be –

You may be treating that patient differently than you would if you knew it's the same as his baseline. You know, you may still want to get that person hooked up with a cardiologist and, you know, to have, you know, regular standard of care management. But it may be different than rushing him down to the cath lab to making sure he's not having, you know, an MI ischemia disorder.

Something else that's going on that's causing that. So they tell us that, yes, that these are pretty good, and that they do have fairly good predictive values, and that the big benefit of getting a baseline is that you can compare it with a postoperative value, which I think a lot of people agree is a very good utility of using the cardiac troponins.

Great. So it sounds like the evidence is a little better for pro-BMP because probably what we talked about earlier in that heart failure carries a lot more risk, whereas troponins are looking at, I guess, cardiac injury, maybe a little bit of maybe reflecting coronary disease, but the evidence is a little less good for those.

You mentioned the fact that what do you do if they're positive, right? So I would think with a pro-BMP, if it's positive, you want to at least pause and say, is this patient having heart failure that we could optimize? What about an asymptomatic elevated troponin, right? I mean, okay, maybe you get an EKG. Let's say it's normal.

So is that point, do we just say, okay, we're going to use it like you said so that we can compare postoperative values or is there anything else? Do we know that someone who has an elevated asymptomatic preoperative troponin is at higher risk for MACE post-op? Is that something we know or we don't know?

I don't know the answer to that. I don't think that that's been described. But I will tell you that part of the reason that there's not such a strong recommendation with the cardiac troponins has to do with that definition of the upper reference limit from the 99th percentile. So when you take multiple studies and lots of them say –

we're going to use 14 as, as our magical number 14 may be positive for some, and it may be not positive for others. But when someone says, we're going to, we're going to pull all of these tests together, um, you know, that's, that's why the data is a little bit fuzzy. And that's why these guidelines differ a little bit from other guidelines, uh, like, you know, with, within the European guidelines or, or, you know, uh,

people who feel more strongly that you should be getting baseline, you know, baseline troponins. But if you do have, if you have a baseline, you know, we'll say quote unquote leak, there are some people who are athletes who may have a positive troponin. So is that the same as someone who's 85 and frail that you actually think may have underlying, you know, you know, either bad structural disease or they have bad coronary disease and,

Those are two different people. So I don't think you can only take the number. I think you have to do a full assessment. And that's when you would speak to the whole team and you'd say, listen, this person does look like they're at high risk. They don't move. They're in a wheelchair. They have CKD. They have risk factors for this. I don't think that this is just something that is benign. This is something that we should investigate more. Right. And then

I think some people are going to say, these sound great. We're anesthesiologists. We like to have hard numbers and data. Why not just get these on everybody, right? I mean, okay, maybe the totally healthy patient with no risk factors who's having an ankle repair, the 20-year-old who's, right, maybe not. But for our older patients having higher risk surgery, why are they lower on the algorithm? Why are we first doing all this other stuff? And if I'm understanding the algorithm correctly –

If they have good exercise tolerance, then we're not even going to get the biomarkers. So how do we, and Anne-Marie, you may want to comment on this too, but why weren't the biomarker, why don't we say, hey, let's assess your risk. If you've got some risk factors or you've got some risk modifiers, let's get the ProBNP and the troponin.

There are certainly some guidelines out there, some of the other societal guidelines that prioritize obtaining biomarkers. The feeling of the writing committee was there are a lot of things that contribute to perioperative morbidity and mortality other than, again, occult coronary disease or even heart failure. And the point of it was to really focus

Find a way to practically and quickly think through these things and manage these conditions. Sort of think before you do. To do tests in highly selective patients where the –

where the pretest probability is high versus using it as a general screen and then stepping back and thinking about, oh, the troponin is elevated. Well, this patient has renal failure and this patient had a recent PE to really do the thinking first and the testing second. It felt that the time invested in learning the patient first

and learning the patient's conditions and their goals of treatment should be prioritized over getting what are admittedly relatively inexpensive tests.

I think that makes a lot of sense. And also what we wouldn't want, right, would be to say, listen, we've got a very high risk patient, but they've got a normal troponin, a normal BMP. Let's do it. Right. We don't want those to become automatic. Go. Don't don't look back markers. We want, as you said, to think about the patient. And you might have a very high risk patient who at the moment doesn't have an elevated troponin or pro BMP. But there are other reasons we might want to think, is this the right move to take this patient to surgery?

Exactly. And that's where those risk modifiers came in. If they have a pacemaker or ICD, that needs to be managed. If they've had a recent stroke, that's a good reason to pause and think before proceeding. And those are things that may not necessarily or wouldn't come out in just biomarker screening. Yeah. Great. All right. John Carlo, anything else to add to the biomarker discussion?

I don't think so. Well, we've covered so much great stuff. Obviously, we could talk for hours more about these guidelines and all the different potential permutations, and maybe we'll do a part two. But for now, I think this has been a great summary of the really important stuff. So I want to thank all of you. Let's turn to the portion of our show where we make random recommendations. We'll start with you, Anne-Marie. What would you recommend the audience check out for fun? Sure.

So I, like I said before, I have heard your podcast so many times, so many different ones. I don't know if this has been mentioned before, but if it has, it bears repeating. I highly recommend the book Aquanaut by Rick Stanton.

And if you're not much of a reader and, you know, it's not that's not your thing, then you should watch The Rescue. It is out on Disney Plus and it is a National Geographic production. And this is about the 2018 rescue of the Thai soccer team and their coach.

And I think it is just the best of the humanity that we all share while we're here on the rock. It was a multinational investment in really rescuing these kids against all odds.

And I think one of the biggest lessons from this was that, you know, these cave divers, when they're interviewed and Rick talks about it in the book, they described themselves as misfits. They were not the best athletes. They were often bullied.

And they had found this common passion that really probably to most people didn't have much use whatsoever. They were using homemade equipment. They had been doing it for 14 years. But boy, was that preparation ever so important. I mean, they were essentially made for the moment. And I think what it does remind me is that

we often have preconceived notions about, you know, what, what is of value. And the truth is, is we really don't know. And you never know at what moment in your life that you are, you're in the right place at the right time with tremendous capacity to save lives and help. We see that in our practice, but it was, it's just amazing to read that book just against

against all odds. And I've seen the movie several times and I would highly recommend it. I think it is one of the warmest human interest story with lots of life lessons.

Couldn't agree more. And I'll add a little log rolling plug to listen to the Akrak episode where we interviewed Harry Harris, who's the anesthesiologist in that story, who was an integral part, maybe the integral part of saving those kids. It was such an honor and it was one of my all time favorite interviews to talk to him about his experience. So that's that's something folks can check out, too. But I agree with you. Watch the documentary and read the book as well. Giancarlo, how about you?

Well, I will tell you that with four kids, it's hard to find a whole bunch of time to do fun things. But there is a book that I am late to getting started on. It's called Thinking Fast and Slow. I just started this several weeks ago. So this is by Daniel Kahneman. And this is – it describes how we –

how we make decisions and how there's, you know, different, I think everyone else has probably already read this. It's a New York times bestseller. And he like won the Nobel prize based on a lot of this. I am about 15 years late, but it is, it is a great, if you haven't read it, I'm about halfway through. It's a, it's very interesting. I think you can get a lot of insight into your own life and how you make decisions and how you approach, you know, everyday decisions. So.

That would be my advice. Thinking fast and slow. Absolutely agree. Um, it's a great book and I'm glad you're reading it. Finally. Okay. And how about you? All right. Let's continue with books then, I guess. Um,

Another book that I recently read is called Midnight in Moscow by John Solomon. He's the former U.S. ambassador in Moscow, and he served under multiple presidents, and he was in Moscow in the U.S. embassy during COVID. He came there before COVID and then stayed there until shortly after the start of the Ukrainian war. I think it's a really fascinating read into kind of the behind the scenes of the war

between the countries, getting an insight that spans both the democratic view of the whole thing, the republican view of the thing, and how the actual...

works on the ground and navigates that. I think it's a really fascinating read. Fascinating. Thanks. That's awesome. And I'm going to add another book, which is I stumbled upon a new fantasy author who I'd never heard of before. His name is Robert Jackson Bennett. He's written several series that have been very well reviewed. I haven't read those, but I just stumbled upon his newest one. The first book of the series is called The Tainted Conqueror.

cup and there's so far two, I don't know if there's going to be more or if it's just going to end it too. I'm about halfway through the second. The second one is called a drop of corruption, but it's really interesting. It's a fantasy. It's set in a fantasy world, but it's a mystery, uh, kind of a mystery novel, the first one. And the second one is the same characters, but a new mystery and, um, very, very interesting and well-written. So, um, I'm excited to check out more books by him, but I would definitely recommend the tainted cup series. All right. Thank you all for coming on the show.

Thank you so much for having us. Yeah, thank you. It's been a pleasure. All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, acrac.com, where you can leave a comment. Others can learn from what you have to say.

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If you are a fan of the show, please consider going to Apple Podcasts or wherever you get your podcasts and leaving a comment and a rating. It really helps others find the show. If you'd like to support the making of the show, please consider going to patreon.com slash ACRAC. That's P-A-T-R-E-O-N dot com slash A-C-C-R-A-C where you can become a patron of the show.

Even if it's just a dollar or two that you pledge, it makes a big difference and we really appreciate it. You can also make donations anytime by going to paypal.me slash akrak or looking up J. Walpaw on Venmo. Thank you so much to those who have already made donations and become patrons. We really appreciate it. Thanks as always to our fantastic Akrak crew.

Sonia Amanat is our tech lead. Taylor Duggan is our social media manager. And William Mao is our production assistant. Thanks so much for all you do. Our original ACRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com.

All right. That is it for today for the ACRAC podcast. I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important and valued. If you're shopping while working, eating, or even listening to this podcast, then you

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