uh so hi everyone welcome to another Monty heart lecture series it's a great pleasure to have today Dr Pur parwani who will be presenting about the ACC aha guidelines for per operative cardiovascular management for non-cardiac surgery that was just published it's a real honor to have her here today Dr per parwani is an associate professor of medicine at the lomalinda University and the director of the echolab and cardiac imaging services at lomalinda University Health her Clin and research interests include Advanced cardiac imaging including structural Echo and CMR and women's cardiovascular disease she's a immediate past early career chair and board member of the Society of cardiac MRI and serves as a member of the ASC and ACC imagine leaderships council at the ACC she has contributed to this guidelines as she will be speaking today and many others and importantly she has received recently the women woman of Distinction by California legislature assembly ER this year right was that this year 202 2020 well congratulations on that and welcome to New York she will be speaking in person today thank you Leandra for that kind introduction uh very excited to be here you all have great team and uh yeah so although uh you know I'm an imager I thought that we would pick this very recent uh topic um because the guidelines just released day before yesterday and I had been serving on the writing committee when it came out so I thought it would be a great um kind of introduction to what are the new things that got released so last guidelines were in 2014 and uh you know these guidelines 2024 so 10 years wealth of knowledge lot of new data and this is why I chose so I think the guidelines are wide so what I've done is given you 10 take-home to uh points and we're going to discuss through the 10 take-home points in this 50 minutes of present so my first take on point is probably you all are very aware of risk assessment is important so when we are seeing patients for peroperative evaluation patients that are low risk and going for low risk surgery do not need any further uh cardiovascular testing so of course we all have seen as you know imager and cardiologist the misuse of cardiovascular testing um which of course we are well um you know aware of and cost consideration is important in medicine so let's discuss what is the risk assessment how would you decide who lowest patients and what are the surgeries that are low risk surgeries so everything starts in your clinic you get a patient with symptoms the Right medical history you have vitals you can you have physical examination where you can detect what is the cardiovascular problem uh patients may be presenting where or maybe they're not presenting with any but what guidelines tell you a two-a recommendation to do risk assessment functional capacity assessment Frailty assessment which is a new recommendation in this guideline for anyone that is more than 65 or if they are Les less than 65 year old then um but if they appear frail you'll do Frailty assessment and and and and if they have symptoms suggestive of cardiovascular disease getting an EKG so not EKG for every single patient that walks in for preop but rather focusing on the patients that truly needed and we literally spent probably like a month talking about EKGs because it's a very misused test although it is very cheap so all of these recommendations have been given two ways so let's go through it um so I guess when we talk about risk assessment there is patient risk and then there is surgical risk and we're going to speak about both so when we look at the patient risk we are all very aware of the RC score because we use it very commonly we cite it in our clinical um you know notes Etc there are five tools that guidelines have shown you I've just shown you two here the nsqip which is you know widely used by the anesthesia practice because it has 21 components the shorter one you may know as Gupta score so anesthesia uses it quite a bit we I think in cardiology more commonly use RC it's simple to process you know you get the risk the common thing about all the risk assessment tools is it's divided into less than one and more than one so there is no intermediate risk and high risk it's either low risk or not low risk which is all high risk okay so keep keep keep in mind of course when we look at the RCR the clinical variable that Mets is ischemic heart disease congestive heart failure stroke any studies that you take all of these rors diabetes CKD have been associated with more risk of mortality and this is why it is important so you decide first whether the patient is low risk or high risk then you decide on the surgery is the surgery low risk or high risk so let me tell you all your cataracts are low risk breast uh you know any breast surgeries are low risk any obese surgeries are low risk and your high risk would be your solid organ transplant the patients that we see very commonly your vascular surgeries um you know an important thing to keep in mind that you may be dealing with a low-risk surgery that has potential to become highrisk if they open up the patient and not go you know minimally invasive so keep that in mind but I think it's important to indicate your patient risk as well as Surgical risk depending on what the patients are coming for now the new thing with these guidelines is dasi score which I'm not sure how many of you are aware of has been given a 2-way indication so what is dasi score it's a functional capacity assessment tool that was you know that was actually um I think uh it was a Duke paper that came out where they have all these components um that you can incorporate in your note and why they're giving dasis score 2A recommendation is because we know that number one when patients have inability to walk they are not able to walk they are not able to do their routine they have higher mortality in peroperative Period and number two this lanet paper that I have quoted here when you do subjective assessment when you just ask the patient are you able to take two flights upstairs or can you walk four blocks which is consistent with four Mets which has been associated with low versus high functional capacity that is actually not as good as doing a comprehensive assessment by doing all the components that I've suggested it so particularly for anesthesia we know that you know when anesthesia attendings are seeing these patients they are going more into complete assessment um you know of uh and using all of this so now based on these guidelines what you can do is create a smart phrase and come up with the Dari score in your note when you're are doing pre-op assessment and decide if it is truly um you know that has functional capacity or not now Frailty assessment is completely um oh what happened allow or didn't I allow allow yeah not see there maybe yes go to the bottom sorry you can share again [Music] sorry guys no it's not working okay perfect thank you so Frailty assessment is a new recommendation in this guidelines and again given two a recommendation and why it has been given to a recommendation is because we have multiple studies and metaanalysis indicating that when patients are frail they don't do well Po postoperatively and in fact when you do the Frailty assessment and decide whether the patient is frail or not and do Rehabilitation based on that information patients may do better and this is the data that has been um you know shown so prehabilitation before the non-cardiac surgery or maybe you go all the way on the other side and decide that this patient is too frail and we need to discuss the goals of care right so it's either ways but nonetheless uh it also gives you all the assessment tools um I think out of all of this clinical Frailty scale has performed well in the studies so just keep that in mind when you are seeing these patients um and you know uh do the Frailty assessment when these patients so number two cardiac B biomarkers are useful so don't throw tomatoes on me you know I know we all have love and hate relationship with troponin but I'll show you the data and I will tell you why um you know this has been given a recommendation so BNP is the two-way recommendation in the new guidelines and tropins are 2B recommendation the these are absolutely new they were not included in 2014 and I will tell you that European guidelines have class one for both of these biomarkers so we are really like taking a seat back because we we understand what propin uh measurement can do to our Healthcare right so I think uh these are the recommendations I'm going to read it out to you so because it's important in patients with nonca CBD so anyone with cardiovascular disease anyone with more than 65 or more than 45 with that have cardiovascular disease that are undergoing non-cardiac surgery elevated risk non-cardiac surgery so these are not the low risk we already decided low risk we are not going to do anything including biomarkers these are elevated risk patients you do BNP before the surgery because it's going to supplement your evaluation by you know uh that you do by RCI or by any other risk markers and for the same you know thing we have given to B for troponin and let's talk about it now just to tell you there are no studies so far to show change in mortality based on the biomarker although we have tons of data that these biomarkers are prognostic in peroperative Period there are no studies that have tested it in the patients um and then again to reiterate you are not going to do it in the lowrisk patients so this is only for elevated risk patients going for elevated risk surgery so that's your solid organ transplants that's your vascular surgery Etc okay so let's look at some data of course there are so many papers on this and I have just highlighted few important ones but you know if you take BNP or if you take troponin we know that when you add it with the RC score it incrementally makes your risk assessment better and it reclassifies your patient into low versus high risk and the numbers here are not negligible when you use probnp uh you know almost 250 58 patients per thousand got reclassified into New risk and same with troponin um you know t or even the high sensitivity tropon in same data that when you use it it does have incremental value on your risk assessment and I will show you in a minute how none of our Imaging testing have any incremental value on the functional assessment tool like RC so I think you know I think what guidelines are saying do the risk assessment um you know do your use your tools like RCI and then do biomarkers and accordingly decide whether that patient is um appropriate to go for surgery or not so avoid over screening so this is where we are going to discuss the stress testing and stress testing in that bucket Echo CT uh MRI everything and I'm going to touch upon at least um you know um Echo and uh uh CT so I think that we all know that there are lot of patients that are go getting non-cardiac surgery and most of our patients that we are seeing Beyond 45 they 45% of them almost half of them have cardiovascular risk factors and more importantly they have athrosclerotic cardiovascular disease and we you know when we read CTS we know we when we do calcium score we know these are these are not lowest patients they do have atherosclerosis and the surgeries as I've told you um you know vascular solid organ transplant Remain the most uh highest surgery and if we look at the big data analysis since the early 2000 there's still like you know mortality Still Remains kind of steady although we have invent of gdmt and we are doing so many things in medicine the mortality has not decreased in the perioperative period that tremendously the curves are still kind of going at the same Pace in fact for stroke the mortality relatively has kind of stayed up or gone up um you know and it has plateaued so we definitely can do better and what's happening we are testing way more patients right we are doing way more with gdmt why are these patients not improving because we are underutilizing the things that are protective and over utilizing the testing and you know so let's look at the data right so this was the study Believe It or Not these are the studies that are quoted in 2014 guidelines helium study 53 patients on the first one on the right side Mayo Clinic stress echo study 530 you know published with Dr pela Etc and you know my favorite people but this is observational data and what they showed was the bigger the defect on the stress testing the worse your patients did and that makes sense you know we know that you know that has been correlated in multiple studies but the question is does that information add beyond the risk assessment you have done for your patient does it give me any more information over what RCI is telling me right so so the these studies were quoted in 24 guidelines and 2014 guidelines just to revise what they said you all know this you assess the Mets if the Mets is poor and your patient you know is going to get better by doing stress testing you can decide to do stress testing and that was a Class 2 a recommendation and this got flooded in every stress lab around the country right we all started doing stress testing after stress testing every year for kidney transplant I'm sure you know we are a big dobutamine stress echo Center and you know we still like do 10 studies a day and I'm not sure how many of them are truly adding to anything but you know this is the hard part we have to convince the surgeons right so 2014 you know uh guidelines my father is surgeon so I agree with you when you say impossible 2014 guidelines you know stress testing was the main stay of diagnosis right and this has changed in these guidelines so why it has changed is from 2 14 to 2024 we have multiple Big Data analysis done in from orthopedic surgery to your vascular surgery to your transplants no benefit at all beyond your risk assessment tools with stress testing so in spite of doing you know um stress testing in spite of making sure that we have enough information we are not able to change mortality for these patients then why are we doing it let's go One Step Beyond so you know we of course are very well aware that none of these trials in PCI population have shown any outcome benefit and multiple metaanalysis and we very clear in chronic stable angen population chronic CAD it's not beneficial to do revascularization and in fact this was tested in njm trial that some of you must be aware of the carp trial that took very high-risk vascular patients decided to revascularize them and did not see any benefit with revascularization right so Sim ilar to similar theme as you know esamia revive revived you know courage everything similar theme no benefit at all important to remember carb trial excluded left M and you know patients that had low E because of ischemic heart disease now there's a difference right don't mix don't mix the mixed cardiomyopathy in this category when you have lowf due to ischemic heart disease those are the patients that were excluded severe as was are excluded in fact you know look at this right so earlier the the you know for surgery what met us is the short-term mortality and look at these scares although they were not significant you can see the worst scull with coronary vascularization in that early period so the jury is still out there there are no other revascularization guidelines uh I mean sorry the studies randomize control trial in peroperative Period there are some going on but this study showed very clearly that highrisk vascular surgery patient you don't do any benefit to the patient by completely revascularizing them apart from that left M so this is a left M patient you know that I saw in the lab the other day you can see you know normally it's moving the and you know uh at at Peak stress it's Global hypokinesis so um you know these are the patients that are coming about but you know what the the point I'm trying to make is it's unclear if abnormal stress test provides any incremental value over what your C is going to do and I already showed you the biomarkers do have incremental value over your RCI or risk assessment tool and more importantly Rask is not going to decrease your mortality so who are the patients where there is utility in doing stress testing are the patients when you suspect really severe CV cvd you know whether it is left M or triple vessel disease leading to low EF it's difficult to suspect it you know when all your kidney transplant patients are in high risk so that's the difficult part and I I agree with that although this is what we are saying at this point now we all love CT particularly in this Center you know I know how much CT you all are doing so CTA Vision you know decided to uh you know use CT in the peroperative period And it showed that uh uh you know yes you can figure out uh with the patient single vessel disease versus multi vessel disease they had higher risk so if they had single vessel disease it was 3x risk of mortality multivessel disease 5x so it definitely gave us the mortality curve according to the ectic level however CT is a very sensitive modality so it basically overestimated the risk in the peroperative period and hence I you know the guidelines have given CT also Tob recommendations to be done so both stress test and CT are downgraded well CT was never there in 2014 but stress test is downgraded from 28 to TB and CT is downgraded from 2B and you know we all know there is value in identifying that LE M disease on CT then you know it's difficult on stress testing so you can more importantly if your calcium score is zero within the last two years it's it's okay to proceed with surgery again you'll have difficulty convincing a surgeon that c cak is zero so let's go for surgery but I think this is where the education is important um you know to share data with them is important so uh just to reiterate same as 2014 no no recommend I mean class three recommendation for doing routine angiogram on these patients and then you know at the same time I want to make sure that you all understand that if there is any risk of Mi that patient is worse mortality if there is any risk of VCI that patient does have worse outcomes and risk of you know mace is actually proportional to when the cath was and PCI was done and doesn't matter whether the PCI was done for chronic Ana or for uh ACS because once you have PCI that patient is at higher risk of getting thrombotic complications bleeding complications in fact the risk was proportional to the time when the PCI was done regardless of for what reason the PCI was done for for unprotected left main non-randomized trials you know have tested cabage and it is good for you know it improves the outcomes uh and so we think that PCI would do the same for left main disease okay so this is the algorithm that you all are waiting for and you know I I'll point out to you where things are different so of course this part Remains the Same if you have emergence emergent surgery proceed if you have you know any patient with ACS you're going to accordingly manage that patient you're going to assess the RC score you're going to figure out if the patient has any of these things which is valvular heart disease pulmonary hypertension Etc okay so you beyond go beyond that you decide that this patient has poor functional capacity by Dy and then you decide that yes further testing is going to make a difference first thing you do is biomarkers and you know probnp 2A tropon in 2B there and then if the biomarkers are normal you don't do anything and proceed to surgery if the biomarkers are abnormal you're going to discuss in a team fashion if doing stress testing or CT is going to change anything and even if your CT or stress testing is showing abnormal findings you're only going to do revascularization if it is truly higher as findings and we all know what is the highest finding so if it's a small um you know small extent of esamia whether it is nuclear stress test or dobutamine or one vessel disease on CT you're going to try to use gdmt and not do any Ras so it's kind of like changing um you know everything that we have so far done in pre-operative testing and only Ras recommendation if it is left main or multivessel disease that is going um that that is leading to less than you know 20% EF so um these are the cut offs that for B&P they have given and I think why they you know why they stress the troponin is because once you have the Baseline troponin you can actually check the tropon in an post-operative period and decide if it is truly an MI or not right so some patients will have chronic myocardial injury any patient with amiloidosis h severe HCM they may have truly myocardial injury and you can you know make sure the surgeons are calm that is truly myocardial injury and you don't have to act on that troponin and this is why they stress on Baseline troponin level um and and you know we'll discuss this more in the discussion part so now let's go so you have now seen the algorithm and I'm now just going to quickly go through the medications that are important so optimal blood pressure control is crucial both hypertension or hypotension has been associated with worse mortality and the guidelines here are almost the same the main thing I have highlighted here is like anytime patient has hypertension you're going to continue the medicines anytime they have really bad hypertension more than 180 by0 and they have elevated risk you're going to hold off on surgery and remember that there can be sit situational hypertension because they come with the anxiety on the day of surgery that's not what we are talking about we are talking about the Baseline blood pressure at home you're going to maintain those map and SBP levels and you know treat hypotension as it is required and finally when you go to see that patient and consult you're going to start the meds if there are if the anesthesia is holding off you're going to restart them as soon as possible because we know that these meds protect our patients in the peroperative period and this is my next point gdmt for heart failure works and it's very important to understand this so you know heart failure literature in peroperative period when you look regardless of the EF there is there whether it is 30% EF or 50% EF all of them have bad outcomes so you know anytime you're taking any patients with a label heart failure whether it is preserved or reduced you are already representing worse mortality for their patient and the guidelines say that you're going to continue G DMT in these patients except for sglt2 Inhibitors so sglt2 Inhibitors have to be hold 3 to four days before the surgery and why that is is because you know they have um uh higher risk of leading to acidosis so apart from sglt2 Inhibitors you're going to continue all the gdmt in fact they say the same thing for diuretics as well to ensure that their patient has optimal management before they go for surgery you know in my Hospital I've had some issues with hypertrophic cardiomyopathy patients going to surgery like the anesthesia freaks out you have to you know like make sure that they are doing okay you have to put all these recommendations so I'm so glad that these guidelines addressed hypertropic cardiomyopathy in a more systemic manner than just writing a paragraph and we have all the things that you know if you look at hypertropic chyom myopathy literature in peroperative Period these patients actually do well now we don't have randomized control trials but we do have observation data that they don't have worse mortality it's all about hemodynamically managing the patients so for all the fellows you know these are like your board 101 you know use Alpha Agonist you know use more fluids um this is all tested in boards but this is the important recommendation that you are going to put in your note when you're going to assess these patients in peroperative Period so take home point6 is Again Medical therapy has an impact on your patient outcome and here medical therapy I just mean risk factor management so all your hypertension patients need to be on optimal hypertensive medicines all your diabetic patients need to be managed carefully all your patients with mixed hyper lipidemia need to be on Statin and so there is class one recommendation to continue Statin but also if your patient is coming to you for the first time and they are not on Statin and they are eligible for Statin you're going to start them on Statin because this is we think that this is the opportunity for clinician to meet that patient and this is the opportunity we all have to reduce the patients overall risk um so you know we we should do that now now the thing is that they don't want you to hold off on surgery while you check their LDL but they want you to continue doing that there is a small trial of 500 people that showed that in fact when they come in peroperative Period and you reload them with Statin you increase their Statin dose they actually do better with apib and Hospital stay Etc but because it was a one trial we you know it didn't make it to any recommendations so it's important to you know just make sure that these patients are optimized you know even if they are just coming to us for the quote unquote clearance it's our responsibility to make sure they are treated same with diabetes we are giving like you know you need to check hba1c you need to again hold off on that stt2 Inhibitors as I said and then more importantly if they're on vobi or OIC any glp or Agonist you have to hold one week before because there is gastric empting is affected and these patients are at higher risk of uh aspiration if you don't hold it I think we went back and forth like you know with multiple guidelines and statements on Metformin and there's a two-way recommendation to continue metformin so now multiple studies kind of clarifying stand on Metformin you don't have to hold metformin with the risk of acidosis or anything but you would do that for stl2 Inhibitors so I think uh take home 7 I think the fellows probably know this very well the antiplatelet and anti-coagulant management uh and this is important right so I think uh it's not much different than 2014 kind of the same so let's go uh one by one so the timing for the PCI is kind of the same you know if you have bare metal stent you're going to delay the surgery 30 days balloon angioplasty 14 days and then a is absolutely 12 months unless you have to do something about it okay so class one recommendation no change at all more importantly for the fellows any prior PCI continue with Aspirin um and you know I see so much variation even without with the Cardiology community that I thought it was important to State it again here that these guidelines remain the same anytime you discontinue their oral anti-coagulant you're going to put them on aspirin to ensure that they are on some thing um you know particularly if they have prior PCI you don't have to start aspirin if they don't have prior PCI so there's no data from po uh trial to suggest that aspirin actually helps U so do not start them on aspirin unless they meet the indication of aspirin with prior ACS or PCI and then routine bridging with IV anet antiplatelet is not indicate at least we don't know of any data for non-cardiac surgery although we do it routinely for our cabbage based on the bridge trial so remember you can do it you know Case by case basis after Consulting with your Interventional cardiologist but there's no guidelines on this because we don't have any data okay finally this is the same the higher and thrombotic risk your mechanical vales your Strokes you're going to bridge them otherwise routine bridging is not recommended so any aibs you're just going to stop there anti coogulant and start it again in peroperative Period so these are the only only things where you're going to Bridge and the guidelines give you really nice you know um uh kind of schedule on how you're going to do that but apart from that U you know no bridging necessary okay take on points is the thing that you probably are waiting for myocardial injury after NCS also known as mint a new term that's introduced um you know for these guidelines at least although the phenomena has been described since 2000 has more than minimum impact and what this is is basically your troponin leaks after non-cardiac surgery and now it has been given the recommendation because we have literally close to 200 papers on this topic showing that troponin is such a good prognostic marker so you cannot ignore all that data although we don't know what to do with that information we cannot ignore that data so let's just go through this right so anytime your patient has tropen and after non-cardiac surgery if they have stemi you're of course going to take care of that by stemi recommendation if they don't have stemi and you think that they have n stemi we downgraded the revascularization to 2A so it really depends if that patient has cardiogenic shock if they are persistently hypotensive if they have persistent chest pain that's when you're going to send them to cathb otherwise you can do gdmt and be okay with it and in fact gdmt for all these patients have been given class one so that's a big difference in the nemi management and we argued a lot on this because we know a lot of people get lab en stemi when they're not true en stemi it's not a plaque rupture and we understand that but still they go to cat lab and there is um you know misuse um anyway so postoperative myocardial injury that is none not stemi or not and stemi just your troponin that's the one we are seeing that these patient need to come back to your Cardiology clinic and what are you supposed to do you're not supposed to send them to cathlab you just have to resect a modification and you have to make sure that they are in best cardiovascular health and that's what all it is so this is a very hetrogeneous population so if you take a patient that has maximal gdmt already you know I'm not sure what you're going to do with those troponins because you're already you made sure that that patient is on everything and gdmt is aspirin Statin and whatever anti-hypertensives that you can recommend them but more importantly you know informing that patient that they're different than the patients that do not have proponent they are at higher risk of getting cardiovascular events later in life and they have to make sure their weight is uh you know optimized they have to make sure their diabetes is optimized that that that um you know clinical information for our patients is very important so this you know class 2B indication to check troponin at 24 hours and 48 hours after surgery and you know do that for our patients and mainly it is gdmt and respector management now there was there is one trial called manage trial which which tested dabigatran and it's 10 milligrams bid so different than the apiose in this population and showed that outcomes were better but this trial was small it had higher rates of you know patient withdrawing and less followup so it has not made it to guidelines so that that that's the only data we have as far as the management of mins is concerned okay finally uh postoperative apib needs treatment and monitoring and this is a new recommendation again because now we know by lot of data that anytime patients have postoperative apib they don't do well so what you need to do is you need to bring those patients back we used to think that oh it's just onetime apib with surgery but we know that these patients have actually higher recurrence and they have higher stroke risk in fact they have higher stroke risk than general population in that peroperative period so all the surgeons are going to fight you but it's important to anticoagulate them because they actually represent higher stroke risk it's important to do te or CT for exclusion of thrombus because again they are at higher risk because of the entire coagulation pathway getting activated during um you know surgery so it's important to make sure that these patients have uh uh you know anti-coagulation and you see them back in clinic to make sure they get the monitoring to ensure um you know the apib surveillance um because otherwise their outcomes are poor finally liver and kidney transplant that we all love doing pre-ops on that they need special care but a and uh you know came out with this special statement uh in 2022 um you know kind of societal position paper on kidney and liver transon because there is wealth of information and we have esia CKD that did not show any outcome benefit uh you know with revascularization and I can tell you the theme of this statement paper is same as what we discussed do not do uh any functional assessment or stress testing do not do any revascularization unless you have highrisk Anatomy or large esamia on your stress testing so it's kind of the same theme but I know that these are the patients that we deal with the most in Cardiology clinic and uh so I just wanted to put a plugin for these uh positional statement that you can review um you know in detail so finally so I'm just going to go over the 10 points that I discussed with you so risk assessment remember to do it with dassi and not subjective fry assessment for more than 65 lowrisk patients lowest surgery no need to do anything send them for surgery cardiac biomarkers with RCI because they have incremental value do not do CAD screening with stress testing or CT unless you suspect left M or multivessel disease no benefit of doing routine revascularization or cardiac catheterization unless you suspect left M or multivessel cvd optimal blood pressure diabetes and cholesterol control gdmt gdmt gdmt that matters for every single patient no routine bridging for with doax Aspirin for all PC previous PCI and if there is recent PCI avoid non-cardiac surgery unless you have to do it remember mins myocardial injury remember to optimize these patients watch out for that postoperative apib and finally pay attention to your kidney and liver transplant patients but still follow the same recommendations that's it thank you very much thank you very much for that was wonderful let's see for everyone if you have have two computers so we'll try to work on this if you have any questions please put them in the in the chat and we'll read them we can start with the first one do the guidelines recommend using regular troponine in patients going for high risk surgeries with CBD risk factors our institution does not use High sensitivity troponin yet yeah I think they recommend troponin it's a class to be indication but I think when you are that Consulting doctor you can decide you know whether you just want to stick with BNP which is a two-way recommendation versus check troponin um and I think it's it's the comfort that you have with your surgeon whe whether you are going to um you know share the guidelines with them and what they're going to if you if you think that you're going to check tropon and and send every patient to cathlab then that's of course not the you know whole purpose uh basically the recommendation is you check your opponents and BNP and if they are negative you send the patient for surgery and if they're positive then you know you just do gdmt evaluation and if there is anything else needed then you do the stress testing or CT depending on what you decide so I think it's like Case by case manner I would absolutely check B&P in every single patient um you know because that has been given to it I have a s question from Mario Garcia in the back thank you your approach obies ACC to to begin with that's part of the yes that yes we I I discussed the EKG yes yeah the the question about the last thing evaluation in K labor trans not necessary for manag how about for patient selection for Trans oration no that I mean I think yesterday I got the same question right like if we realize that these patients that have high cardiovascular risk and we are not able to modify that mortality by doing anything except gdmt do these patient deserve to go for transplant and is that a vast of you know that organ that can go to a 25 year old and that's more of a philosophical question that you know we're going to deal with in our community medical commun surgical Community but I think we have to realize that that you know yesterday um at Westchester when I was giving this uh you know the surgeon said that well you know I want to make sure that that patient is at the best survival before I send them for transplant and I was like this is exactly what I'm telling you it's in your mind that by revascularizing you are modifying the survival except you are not there is no studies to show that you're doing anything different than you would do with medicines and these patients just represent a worse mortality because they have more atherosclerosis so I think this is the thing philosophically we need to understand this our surgeons need to understand this and then I think we are cooh I think the problem is that anytime a surgeons asks for C you know like okay do angiogram we will do angiogram because we are like yes please yes we'll do it right we need to stop that right we are doing routine angiograms when they ask for we are doing routine pcis when they ask for it and I think as a community we need to come together and put our foot down and understand that we are not modifying the mortality we are just misusing the test so so last you talk about medication and I think we are now not thinking about real clearance about saying yes or no yes absolutely but rather how to man exactly ever hold so that that has been given like entire one page um so the thing is we are saying that if the patient has low blood pressure or like borderline blood pressure whether anesthesia is scared about getting hypertension during the procedure they have Liberty to stop it otherwise as a cardiologists particularly for heart failure patients you're going to continue all of it continue all of it in fact guidelines talk about uh maintaining the map of 60 and systolic blood pressure of 90 and if that is not maintained for more than 15 minutes there is data to suggest that that's when the may start going low you know on the other side because of hypotension so we understand that it's like you know two things the medicines that are very good but then hypotension that's not good for our patients so I think it's it's basically how your patient looks if this patient is living in 80s because they have systolic heart failure you might hold the a Inhibitors and continue everything else because beta blocker withdrawing has a effect on outcomes as well so I think a Inhibitors are easy to take but if that patient is representing 150s and you're bringing it down to 120 please continue it because you you're you know you're ensuring best outcomes for peroperative period have that sorry to jump in the question but it was recently presented the ESC meeting the stop dral yes the random comparing or toop acation maybe soft blood pressure yes maybe it's it's not it's not hard to stop yeah so I think yeah there's like whole page on a Inhibitors but essentially that's the essence of what you know I said and Daniel supplemented yes Al yeah have many questions but I am just going to to one the consult attending for today right I think the only question that I have is is is um I mean many times you get this patient that has never been seen and we see that in our community and then you go through your algorithm and the patient has like a low functional capacity not testing before you get the dnp ENT which I understand is just for recertification but let's say that you know comes fly so how Beyond risk stimation okay this patients at a higher risk do you do anything about it oh yeah STS I mean other otherwise let's say it's not indicated we don't have any hyper hyper lipidemia no so you don't act upon that you just say it's high risk but then there's no you know no oh this was the class one indication that I showed sorry I had to go through a lot so maybe I didn't pay attention to this but you know that's class one indication to start Statin in that patient in the troponin positive patient absolutely class one indication by acvd even if your troponins are negative if that patient first time coming to you and you think that they're going to meet criteria for Statin here it is uh this is diabetes here class one indication Statin n patient that meet criteria for Statin use and we all know how bad ascvd risk or is so we are not going to go there but anyways if you meet criteria you're going to start Statin in proponent positive you're going to definitely they say that at least aspirin and Statin if everything else is negative but you're going to evaluate that patient with an echo cardiogram there's a clear indication class one for Echo you're going to make sure they don't have heart failure so you are going to is that patient is coming to you for first time and say for example you put the non-cardiac surgery aside you're going to evaluate that patient the way you would evaluate them otherwise and this is just to supplement but if everything else is negative they don't have diabetes I'd be surprised if they positive troponin without anything else but you're going to otherwise also manage their gdmt as if you are their Primary Care you know like all the risk factors because there's good data to suggest I understand that let's say that your acbd and you don't have any indication for satin it just happen to be POS I mean here in the commuter in the Bronx you'll be surprised what you see so then you know even if you're acbd you don't have indication for stating so your CBD is like low risk or you know or War line whatever and then you don't have any other indication for uh for stating you are going to start them for has a low functional capacity and then you get positive absolutely I mean this is what we do in our minoca patients right I see these patients when nothing else me you know matters but then you know you you start them on because there's nothing else right now for troponin positive and I think that you know I tell you that's the limitation we all have right like we don't know what to do with mins all we know is that a worse outcome so how do we fix outcomes of course we're going to give them Statin and one empti platet and that's the thought but you know as next 10 years may be very different you know we'll see okay so Dr J bro and I repeat the question for the audience yeah so so besides the holding of the medication I think that and and this is great and it expands really on the 2014 that essentially treating this as if you're meeting the patient for the first time without the surgery and doing the functional assessment do you have standard functional assessment things for things like the Frailty school because you had the desie there was the Frailty F yeah there are five tools that I showed and the best one I I showed you the clinical fry assessment I can go yeah and and actually it's very nice because you know I think we discuss okay this got stuck but yeah there sorry the question is how to assess Frailty right if there standardized options obiously the RC yes there's the the Desi which could be made yes I could make that into a a smart text clinical clinical Frailty score yeah you can do smart phrase for that as well there is a table with it and in fact if you look at those five tools that they described they also describe how clinical frry score perform better um you know let's see if I can slowly go to that slide so that I can show you H sorry taking it sweet time but nonetheless yes I think you can you can do that as well and in fact we you know even before these guidelines came out we did it regularly for our Trav patients for our because it's important right like our you know any trans catheter option you want to indicate that they're truly frail and you're going for that so I think it's good that guidelines you know kind of uh stressed upon it um let's see sorry guys one more and then we are there I think this is it so here we go let's go forward now and that's the assessment tool and the clinical Frailty scale is the one that perform better than the other ones so there are nine categories so you can I think you can make it a smart phrase of that as well and use it for other stuff as well because it's been validated in different populations regarding the the now that the guy that 2019 uh that compared to the on in 2014 now that we have the the coronary c9r as type two e recommendation but with the stress what would you go for as a screen first do you do both either or I I'll repeat the question the question is when to use CCTA versus stresses when you decide to evaluate for C so I think uh that's an excellent question so 2024 guidelines give both stress testing and CCTA 2B indication I will tell you that I'm biased as an imager because what what are we asking here we are asking question about left me so you know I mean that is a straightforward answer right anatomical testing does much better when it comes to question of left M than guessing that okay do I have Global hypokinesis because of hypertensive heart disease or is this truly esia leading to Triple vessel disease Global hyp so I I'm you know I'm biased I think we need to see more CT data and there are some trials going on just really show that benefit in peroperative period because the CTA Vision showed that it was just overly sensitive so they don't routinely recommend it but I do think that if you think about you know all the data that we have with esamia and you know courage actually what we are asking for is question about left M and although the prevalence of left m in society is low if that's the question we are asking we would rather go for anatomical testing in my opinion I guess one thing I add on this I think you need to know who your surgeons are right I mean if you're going to do CT and you're going to find other things you need to make sure that that's not going to preclude your pay from the that's the main thing so CTA Vision exactly showed what you what you mentioned people were freaking out with other atherosclerosis that was not left main so again you need to have that understanding within your team that they understand what you are trying to do right like they need to understand that other atherosclerosis is incidental atherosclerosis that you're going to treat with Statin left m is when you're going to go for revascularization if that's not the case then you're not going to do it because unfortunately there is data to show that whenever we do any test ing every 37 day delay in you know doing surgery and some of these patients I mean they may have you know cancer and that has spread in 37 days right so that's I mean this is the this is the issue that we see all the time is you know that somebody maybe has high-risk markers but they're going for colon cancer surgery and you know if you do a PCI now you have six months of somebody who probably will bleed and you're going to delay definitive cancer treatment for six months because of an elect a semi- elected PCI that wasn't necessary in the first place yeah and I think this is where the RAS guidelin you showed you for n stemy gdmt is class one and it's been downgraded to 2A for revas which we had lot of arguments in the group about how can you hold off because we don't know if we are calling all ACS are all tropon in ACS no and this is where like everyone is getting labeled as and stemi when we know in reality that they're not so again go back to like uh Universal for definition of Mi figuring out if they have Wall motion their clinical markers and putting it all together and act as a clinician so there's a question about you know like when Cardiology consult is indicated so guess what we are staying in business because we I mean you know it's funny the uh I'll just tell you guys so the guideline committee was mixture of internal medicine anesthesia surgeons and cardiologist and guess who was the most concerned about all these consults that were coming to us the Cardiology Group like how are we going to deal with this volume and everyone else was like no no we want the patient to be evaluated by Cardiology so I think that's the point although we are downgrading the recommendation for testing we are saying you know basically they would feel much better if Cardiology has evaluated the patient and I don't know what it is but it was striking how we as a community were like well but where are you going to produce all these cardiologists and I think this is where the concept of Team incorporating you know our NPS and there was a whole argument going on in Europe but maybe this is where you know that concept of Team comes forward how are we going to build the Cardiology teams going forward because we clearly have indications to patients to be seen by cardiologists are expert opinions on this and we can understand this is complex right the IM guy would be like I don't feel comfortable with these complex issues or G one last question Daniel DTI thanks B that was a great lecture you touch us a little bit on aspirin post PCI no again the ESC there was a trial called assure Des that was presented randomiz tring comparing both strategy after one year of the PC I with this all drug understand and there was no difference in bleeding or esic event only a an increasing major bleeding in the aspiring so my question is do you consider in those patients maybe to follow the stting if you have like a surgery that could have more higher bleeding risk in my clinical practice no we are in United States this is there's so much legal you know I mean I think the problem is that it's a very heterogenous group right in the clinical setting that we are seeing you're right that you know latest tense they do you know we probably do much better but you know it's just so much heterogenous if you write anything in the guidelines I mean this is already happening in community how many people have seen Mi because patients are not on aspirin you know in peroperative period with PCI I can tell you I have seen a lot and that like really scares me that's one of the thing even with cabbage like they don't put patients on an aspirin and you see massive Mi so I think that so far you're right that you know there is data to suggest that anti-thrombotic therapy would be lightened up and maybe in 10 years you're going to see difference but you know till we have that wealth of knowledge until all the you know old STS are out in you know like done and we don't have them anymore and it's all new St population I think we're going to sit tight in my opinion no if your surgeon is conf not operating on aspir yeah I mean that's another thing right I always tell my patients find a new surgeon that is feel comfortable because yeah okay thank you very much this was wonderful I can we have food now and thank you everyone for attending