Iva 🫀

#Cardiology #ACCFIT #CardiacImaging #cardiooncology #ACCWIC

[Iva 🫀 @IvaMD_Cardio]

@elonmusk Would you be able select/edit the music or sound to the videos you create? Or even add your own voice/sound recording?

[Iva 🫀 @IvaMD_Cardio]

@elonmusk @grok @elonmusk what about grok use in healthcare and medical research?

[Iva 🫀 @IvaMD_Cardio]

@HeartOTXHeartMD Congratulations! He is adorable!

[Iva 🫀 @IvaMD_Cardio]

@barret_zoph How can you reach out/pitch in ideas?

[Iva 🫀 @IvaMD_Cardio]

@purviparwani Such a tragedy! So many dreams cut short!

[Iva 🫀 @IvaMD_Cardio]

@AmitRPatelMD @robertomlang @AkhilNarangMD @docbfreed @ASE360 @NBE_96 @UChicagoMed @UChicagoCardio @WilliamZoghbi @AllanLKleinMD1 @JLindnerMD @ChrisKramerMD A huge loss for the cardiology community! He was a wonderful doctor and a great mentor!

[Dr. Purvi Parwani @purviparwani]

It was an incredible experience to be on the writing committee for the 2024 ACC/AHA Perioperative Guidelines, released earlier in September 2024.

https://t.co/hZtDGw8l3v

Here is a thread featuring major takeaways from the new Perioperative guidelines. (from perspective of a cardiologist)

#ACCAHAPerioperativeGuidelines #AHA24

We have a session at #AHA24 on Monday, Nov 18th, 8 am. Please plan to join.

[Dr. Purvi Parwani @purviparwani]

#ACCAHAPerioperativeGuidelines #AHA24

RISK ASSESSMENT IS IMPORTANT

➡️Low-risk patients undergoing low-risk surgery rarely require any cardiovascular testing

➡️Don’t forget the Clinical Evaluation of the patients presenting before NCS
(Functional Capacity with DASI score Class 2a, perioperative risk assessment 2a, Frailty Assessment >65 yo 2a, EKG with symptoms of CVD 2a,

➡️Low risk <1%, Elevated risk > 1%

➡️Regardless of the Etiology of the functional limitation, compromised functional capacity is associated with worse outcomes

➡️Frailty is strongly associated with the risk of postoperative complications, delirium, institutionalization, and mortality.

➡️Incorporation of routine frailty screening into the preoperative assessment was associated with a significant reduction in 30-day mortality.

➡️In selected patients, prehabilitation before NCS may be associated with improved outcomes, in others it will be Goals of Care and Decision-Making

[Dr. Purvi Parwani @purviparwani]

#ACC/AHAPerioperativeGuidelines #AHA24

Cardiac Biomarkers are useful

➡️BNP(IIa) and cardiac troponin (cTn)(IIb) have high prognostic value and excellent negative predictive value for perioperative cardiac complications

➡️Adding troponin value to RCRI can substantially improve the perioperative risk stratification

➡️Adding NT-proBNP to RCRI results in a net absolute reclassification of risk in 258 per 1000 patients
Cardiac Biomarkers are useful

[Dr. Purvi Parwani @purviparwani]

#ACCAHAPerioperativeGuidelines #AHA24

AVOID OVERSCREENING

➡️Cardiovascular screening and treatment of patients undergoing NCS should adhere to the same indications as nonsurgical patients

➡️Perioperative MACCE occurs in 1 of every 33 hospitalizations for non-cardiac surgery

➡️ Vascular, thoracic, and solid organ transplantation surgery had the highest incidence of cardiovascular events

➡️Unclear if abnormal stress test provides incremental value over RCRI and Biomarkers

➡️Preoperative revascularization does not reduce perioperative MACE or cardiac mortality

➡️Registry data shows no Benefit of Stress tests in NCS patients: LESS IS MORE

➡️CARP trial: Coronary artery Revascularization before elective vascular surgery does not alter long term outcomes (Patients with left main CAD, LVEF <20%, or severe AS were excluded from this trial)

[Dr. Purvi Parwani @purviparwani]

#ACCAHAPerioperativeGuidelines #AHA24

CCTA for Perioperative Evaluation of NCS
New addition, 2b recommendation in selected cases along with stress test (see the algorithm)

➡️CCTA may be considered in select cases if high-risk coronary anatomy is suspected and there is a guideline-concordant indication for testing independent of planned surgery

➡️On CCTA, patients with single- and multivessel disease represent 3X and 5X risk of perioperative MACE

➡️CCTA is >5 times as likely to inappropriately overestimate risk among patients who will not experience MACE.

➡️ if a patient has a prior CAC of 0 within 2 years, proceeding to surgery without additional testing would be reasonable.

@AChoiHeart @RonBlankstein @lesleejshaw @ChinnaiyanMD

[Dr. Purvi Parwani @purviparwani]

#ACC/AHAPerioperativeGuidelines #AHA24

Stepwise Approach to Perioperative Cardiac Assessment

➡️Note the downgrading of stress tests/ new addition of CCTA to class 2b
➡️Note the addition of biomarkers BNP class 2a and troponin class 2b with elevated risk and poor functional capacity
➡️Note the addition of GDMT optimization for long-term CV benefit

[Dr. Purvi Parwani @purviparwani]

#ACCAHAPerioperativeGuidelines #AHA24

Optimal BP control is crucial

➡️Uncontrolled HTN or perioperative hypotension is associated with worse mortality
➡️In Most patients with hypertension planned for Noncardiac surgery, Continue Meds
➡️Cancel Surgery if > 180/110 in patients with elevated risk surgery with cardiovascular risk factors for MACE ~RCRI >1
➡️Maintain intraoperative MAP>60, SBP>90
➡️Treat Hypotension in postoperative period when MAP<60, SBP<90
➡️Restart Meds ASAP after surgery to avoid post op hypertension

@AHAScience @AHAMeetings
@AnastasiaSMihai

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines

GDMT works, Optimize Medication Mx to avoid post-operative complications

➡️Class Ic: Patients with HF, undergoing NCS, hold SGLT2i for 3-4 days to reduce peri-op metabolic acidosis

➡️Class 2a: In compensated HF patients, continue GDMT in the perioperative period (except SGLT2i) to reduce the risk of worsening HF

➡️ Peri-operative Medical therapy has an impact on patient outcomes, Risk factor assessment and Management is crucial during peri-operative visit

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines

GDMT works, Optimize Medication Mx to avoid post-operative complications

➡️Large cohorts, meta-analysis report statin safety and possible reductions in cardiovascular complications associated with continued use of lipid-lowering throughout the perioperative period. (LOAD trial negative(n= 648), another smaller RCT positive),

➡️Reloading with statin decreases in peri-operative MACE at 30 days, as well as reductions in AF and length of stay (N=500), more data on reloading is needed.

➡️The measurement of LDL-cholesterol concentrations to guide initiation of statin therapy in patients with appropriate indications, should not delay surgery

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACC/AHAPerioperativeGuidelines

OMT works, Optimize Medication Mx to avoid post-operative complications

➡️Weekly formulations of GLP-1 agonists should be held >1 week before elective NCS for weekly dosed GLP-1 agonists and
the day before for daily dosed GLP-1 agonists to reduce the risk of pulmonary aspiration of gastric contents during surgery.

➡️In Patients with DM, Metformin can be continued during the perioperative period.

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines

Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at the highest risk for thrombotic complications and is not recommended in the majority of cases.

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines

Myocardial injury after NCS(MINS) is a newly identified disease process with an increased risk of adverse CV events.

➡️2b recommendation Check troponin at 24 and 48 hours after the surgery in those with known CVD, symptoms of CVD, > 65 with CVrisk factors undergoing elevated risk NCS

➡️2a recommendation in patients with MINS, particularly those without known CV risk, outpatient follow up is reasonable

➡️Diagnosis of MINS requires >1 elevated cTn (>99th percentile of the upper reference limit) of presumed ischemic origin excluding PE, CVA, and sepsis)

➡️It is reasonable to check troponin in patients with known CVD, and cardiovascular risk factors, and in individuals undergoing high-risk surgery to identify patients at elevated risk of postoperative events.

➡️Heterogeneous population – has significant underlying atherosclerosis

➡️80% to 90% of patients with MINS without ischemic signs or symptoms, 30-day mortality is substantial (up to 10%)

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines #EPeeps

Post-Op AF Needs Rx and Monitoring

➡️Patients with newly diagnosed atrial fibrillation identified during or after NCS have an increased risk of stroke requiring further surveillance and treatment plan

➡️POAF is associated with increased risk of short- and long-term stroke and mortality, and anticoagulation should be considered to reduce thromboembolic risks

➡️Patients with paroxysmal POAF have a high risk of recurrent AF after discharge. (39% risk of AF recurrence at 5 years, with an increased risk of HF and death).

➡️ Outpatient follow-up within 3 to 6 months of NCS to evaluate the incidence of AF after NCS is recommended

➡️Hemodynamically stable patients with POAF may require specific therapy to achieve an optimal heart rate (<110 bpm).

[Dr. Purvi Parwani @purviparwani]

#AHA24
#ACCAHAPerioperativeGuidelines

Kidney and Liver Tx patients’ have the highest surgical risk, but still follow the same recommendation for screening and Treatment as above.

Check out the AHA statement CAD screening in patients undergoing Kidney/Liver transplantation
https://t.co/eWTrOkeSek

Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has failed to demonstrate any improvement outcomes