Over 200 million adults undergo noncardiac surgical procedures worldwide every year. Of these, more than 8 million people will suffer a major cardiac complication. In 2016, the Canadian Cardiovascular Society introduced new guidelines on perioperative cardiac risk assessment and management for patients who undergo inpatient noncardiac surgery. With funding from VPSA, a multidisciplinary team of VCH physicians has developed standardized order sets and protocols and to educate surgical staff on the clinical practice changes needed to comply with guideline-driven perioperative care.
“The new Canadian guidelines represent a radical departure from previous European and American guidelines,” said cardiologist Dr. James McKinney who co-leads the project with Dr. Erin Sloan, General Internal Medicine. “There is a higher risk for myocardial injury in the post-operative period than was originally thought. The guidelines will help us to identify high-risk patients and to make sure they are followed after their noncardiac surgeries. Ten per cent of people die within 30 days if they have a postoperative elevation in troponin, and 93 per cent of those people have no ischemic symptoms.”
“The guidelines identified a simple blood test, BNP (Brain Natriuretic Peptide) or NT-proBNP, as an independent predictor of perioperative morbidity and mortality,” commented Dr. Sloan. “All patients 65 years and older, and all patients over age 45 with defined cardiovascular risk factors should undergo preoperative BNP screening prior to inpatient noncardiac surgery. Patients with an elevated preoperative BNP are at increased risk of perioperative myocardial infarction, cardiac arrest and cardiovascular related death within 30 days following noncardiac surgery and should be monitored with an ECG and routine postoperative troponin measurements.”
Dr. Sloan continued, “An elevated postoperative troponin further identifies patients at increased risk of cardiovascular complications, and recent studies have demonstrated that the risk remains elevated for at least one year compared to patients without an elevation in postoperative troponin. Given that most patients with troponin elevation do not have ischemic symptoms, routine postoperative troponin monitoring is essential to identify these high-risk patients. When consulted for a patient with an elevated postoperative troponin, we use clinical judgement to determine if the troponin elevation is due to an ischemic or a non-ischemic etiology (e.g., sepsis, pulmonary embolism, etc.). If the troponin rise is felt to be ischemic in origin, the Canadian guidelines recommend long-term treatment with Aspirin and statin. In addition, we make case-by-case decisions regarding optimization of hemodynamic parameters, medication management and next steps for the type and timing of further cardiac investigations.”
Working across a multitude of disciplines including anesthesia (Drs. Kevin Froehlich, Don Young, Beau Klaibert), internal medicine (Drs. Erin Sloan, Iain Mackie, Zachary Schwartz, Terence Yung), laboratory medicine (Dr. Morris Pudek), and cardiology (Drs. Jimmy McKinney, Ken Gin, Rudy Chow, Ken Kaila) in Vancouver Acute, the team has been meeting for over a year to bring all the players together and identify local practices.
“We have discussed and critiqued current evidence and developed orders and protocols to standardize processes,” said Dr. McKinney. “We have spoken to most of the surgical sub-specialties and are expanding to involve other areas of medicine and surgery.”
“There has been a shift in identifying who to screen and how to screen for patients at increased perioperative cardiac risk,” said Dr. Sloan. “In addition to developing a preoperative BNP protocol and postoperative troponin surveillance protocol, we have doubled the capacity of IMPCT (Internal Medicine Perioperative Consult Team) in order to accommodate an anticipated higher volume of patient referrals now that we are screening for and routinely monitoring high-risk patients. We can facilitate timely preoperative assessment for both outpatients and inpatients, in addition to postoperative co-management with the surgical teams for high-risk or medically complex patients. The new protocols are in the final stages of approval and will soon be available at VGH. A next step could be to roll out the perioperative order sets across the health authority, but this would require a similar degree of multi-disciplinary engagement at each site, in addition to local expertise on how to manage patients with MINS (Myocardial Injury After Noncardiac Surgery).”
Benefits of VPSA funding
The project co-leads credit VPSA with funding the physician time to come together for collaborative meetings.
“The VPSA funding has been highly valued; everyone is busy and so much work in medicine goes unpaid,” said Dr. Sloan. “Having the funding has allowed us to make strides towards effecting positive change for patient safety and perioperative outcomes. The silver lining has been the face-to-face meetings with our colleagues. This has led to the development of strong rapport between divisions, fostered a good sense of community, and facilitated relationships for ongoing collaboration and interdisciplinary research opportunities.”
Dr. McKinney agrees. “VPSA has supported this project in a way that allows people to get together who would not normally cross paths. It has facilitated connections. The project’s lasting benefit is improved patient care. But it’s also made our working relationships better by working together rather than in silos.”