Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association
New Guidelines For Cardiovascular Management In Noncardiac Surgery Released
The 2024 guideline for cardiovascular management of adults undergoing noncardiac surgery reflects a decade of updates and new evidence since the guideline's last release in 2014. It is published today in the American Heart Association's flagship, peer-reviewed journal Circulation and simultaneously in JACC, the flagship journal of the American College of Cardiology.
The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" presents the latest evidence for the appropriate assessment of cardiovascular disease risk for patients scheduled for noncardiac surgery and management of cardiovascular disease risk factors before, during and after noncardiac surgery. The recommendations address patient evaluations and assessments, use of cardiovascular testing and screening, and evidence-based management of cardiovascular conditions and risks before, during and after surgery in those patients.
There is a wealth of new evidence about how best to evaluate and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery."
Annemarie Thompson, M.D., M.B.A., FAHA, chair of the guideline writing group, professor of anesthesiology, medicine and population health sciences at Duke University Medical Center in Durham, North Carolina
"Worldwide, there are approximately 300 million noncardiac surgeries each year, which underscores the need to summarize and interpret the evidence to assist clinicians in managing patients who present for surgery," Thompson said. "This new guideline is a comprehensive review of the latest research to help inform clinicians who manage perioperative patients, with the ultimate goal of restoring health and minimizing cardiovascular complications."
The guideline targets the many disciplines of health care professionals who care for people undergoing surgery that requires general or regional anesthesia and who have known or potential cardiovascular risk.
"From prior studies, conditions such as high blood pressure, Type 2 diabetes, age older than 55 in men and 65 in women, smoking and obesity are known risk factors that predispose patients to cardiovascular disease. Others have a family history of premature coronary artery disease, which can also put them at increased risk," Thompson said. "This guideline is written with the understanding that these and other cardiovascular risk factors and conditions can contribute to negative surgical outcomes if they are unrecognized or not optimized before surgery."
Perioperative management of cardiovascular conditionsAs in 2014, the 2024 guideline includes a perioperative algorithm to guide health care professionals in care decisions for patients with cardiovascular conditions having noncardiac surgery. The new guideline reviews blood pressure management before, during and after surgery, and highlights specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea and previous stroke.
Updated screening recommendationsThe new guideline recommends that health care professionals be judicious and targeted about ordering screenings, such as stress testing, to determine cardiac risk prior to surgery.
The guideline also includes recommendations on using emergency-focused cardiac ultrasound for patients undergoing noncardiac surgery with unexplained hemodynamic instability (unstable blood pressure) if clinicians with expertise in cardiac ultrasound are readily available. Focused cardiac ultrasound has emerged as a screening option since the last guideline; it can be performed in the operating room during surgery to help determine if heart problems are causing unstable blood pressure.
Considerations for medication managementNewer medications for Type 2 diabetes, heart failure and obesity management have important perioperative implications, according to the 2024 guideline. SGLT2-inhibitors should be discontinued three to four days before surgery to minimize the risk of perioperative ketoacidosis, which is unbalanced pH levels in the blood that can negatively impact surgical outcomes.
Emerging data suggest that glucagon-like polypeptide-1 (GLP-1) agonists, medications that are used for managing type 2 diabetes and/or obesity, may cause delayed stomach emptying. In addition, nausea is a common side effect of GLP-1 agonists, and patients taking these medications may be at increased risk of pulmonary aspiration, or inhaling stomach content into their lungs, while under anesthesia. Other organizations have recommended to withhold these medications prior to noncardiac surgery (for one week for patients on weekly doses and for one day for patients taking daily doses) to reduce the risk of pulmonary aspiration during surgery; however, the need for discontinuation and timing are an emerging area of investigation.
For patients who are taking blood thinners, the new guideline recommends that in most cases it is safe to stop blood thinners several days before surgery, proceed to surgery and then start taking blood thinners again after surgery, most commonly after hospital discharge. Clinicians are encouraged to refer to the guideline for exceptions and modifications.
Additional research needs identifiedMyocardial injury after noncardiac surgery (MINS), or injury to the heart that occurs either during or shortly after noncardiac surgery, is diagnosed by elevated cardiac troponin levels after surgery. MINS occurs in about one in five noncardiac surgery patients. This newly identified condition is associated with worse short- and long-term outcomes for patients, yet little is known about what causes MINS, how to prevent it and how best to manage it. In patients who develop MINS, outpatient follow-up is recommended to counsel patients on how to reduce their heart disease risk factors.
The new guideline emphasizes the importance of paying attention to an irregular heart rhythm known as atrial fibrillation (AFib), which may occur during or after noncardiac surgery. Patients with newly diagnosed AFib have an increased risk of stroke, and guideline authors recommend closely following these patients after surgery to treat reversible causes of AFib and to consider the need for rhythm control and/or the use of blood thinners to prevent stroke. Ongoing studies are evaluating how to best manage AFib that occurs after surgery.
Thompson said, "The U.S. Population is getting older and is living longer with chronic health conditions including chronic heart and vascular diseases. A multidisciplinary, team-based approach, including surgeons, primary care physicians, cardiologists, internal medicine doctors and other medical specialists, is needed to optimize care for patients with cardiovascular conditions and risk factors before, during and after surgery."
This guideline was prepared by a volunteer writing group on behalf of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines, and developed with and endorsed by the American College of Surgeons, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society of Cardiovascular Anesthesiologists, the Society of Cardiovascular Computed Tomography, the Society of Cardiovascular Magnetic Resonance and the Society of Vascular Medicine.
IPF Mortality Predicted By 6-Minute Walk Test Oxygen Desaturation
Desaturation during the 6-minute walk test (6MWT) is a significant predictive factor for mortality in patients with idiopathic pulmonary fibrosis (IPF), according to study findings in Therapeutic Advances in Respiratory Disease.
Investigators assessed the clinical implications of baseline and serial 6MWT findings in patients with IPF.
Patients diagnosed with IPF at a center in Korea were screened between December 2012 and January 2022. A saturation of peripheral oxygen (SpO2) cutoff of 88% during 6MWT performance and a decrease in 6MWD of 50 m were used to evaluate clinical outcomes.
The final cohort included 198 patients with baseline 6MWT data. Their mean age was 66.9 years, and 89% were male. The median follow-up was 28.5 months (interquartile range, 20-37 months), during which time 78 patients received transplants (n=41) or died. Patients who died vs those who survived were younger and had a shorter 6MWD and lower minimum SpO2 values in the 6MWT.
"
[S]horter 6MWD was an independent risk factor for pulmonary hypertension, which is related to poor prognosis.
The overall median survival was 50.0 months (95% CI, 45.0-58.0 months). According to multivariable Cox analysis, only lower minimum SpO2 values had an independent association with increased mortality (hazard ratio [HR], 1.081; 95% CI, 1.024-1.142; P =.005) as well as echocardiographic pulmonary hypertension at IPF diagnosis (HR, 2.466; 95% CI, 1.149-5.296; P =.021).
A reduced minimum SpO2 (odds ratio, 1.088; 95% CI, 1.015-1.167; P =.017) was independently associated with increased mortality along with younger age in the multivariate logistic analysis.
Patients who had a minimum SpO2 less than 88% during 6MWT had a worse survival compared with those with minimum SpO2 of 88% or greater (median survival: 29.0 months vs 50.0 months, P <.001).
Of the cohort, 133 participants (67.2%) had 6-month follow-up 6MWT data, and 144 (72.7%) had 12-month follow-up data. The patients who died had significantly worse performance in 6MWD at 12 months after IPF diagnosis vs patients who survived (mean absolute changes: −43.3 m vs 12.0 m, P <.001).
Individuals who had a decrease in 6MWD of more than 50 m during 12 months after IPF diagnosis had poorer overall survival compared with those who did not (median survival: 45.0 months vs 58.0 months, P <.001).
Limitations include the retrospective design and the use of echocardiography instead of right heart catheterization to diagnosis pulmonary hypertension. Also, selection bias is possible because the interval between serial 6MWT was not constant.
"Notably, shorter 6MWD was an independent risk factor for pulmonary hypertension, which is related to poor prognosis," the study authors stated.
Mom, 41, With Cancer Was Told She Needed A Double Lung Transplant. Then She Got A Second Opinion
When Sarah Minton was a young mother, her husband died in an accident when he was 24. She raised her daughters, now teens, alone since they were 3 years old and 6 months old.
More than a decade ago, Sarah Minton received news that changed her life. Doctors diagnosed her with a rare blood condition and an uncommon liver disease. Then two years later, she was diagnosed with liver cancer and underwent radiation to treat it. Minton's liver struggled to function.
"That's the point where they say, 'OK now it's time for you to get a (liver) transplant," the 42-year-old from Laingsburg, Michigan, tells TODAY.Com. "Even when I was first diagnosed, I knew a transplant was going to be in my future."
While she hoped she could delay her liver transplant until she was older, by the time she was in her late 30s, doctors knew she needed a new one soon. But she also developed lung troubles and doctors worried she'd need a liver and double lung transplant.
"That freaked me out," she says. "I wanted a second opinion."
That second opinion transformed her health. Doctors at the Cleveland Clinic were able to treat her lungs with medication and had her undergo a special test to make sure she was healthy enough for her transplant surgery. She's now enjoying life with a new liver.
"It took two years for my lungs to heal, to recover enough to be safe enough to put me on the transplant list," Minton says. "My doctor had told me I had, at one point, six months to live and when I had my transplant it had been four months since then."
Blood condition, liver disease and cancerWhen Minton was in her mid-20s, she began experiencing several, complicated and rare health conditions. At 26, she learned she had a rare condition, Budd-Chiari syndrome, that causes blockages to the veins carrying blood from the liver, according to the Cleveland Clinic.
After more than a dozen years with a rare liver disease, blood condition and cancer, Sarah Minton needed a liver transplant. While doctors at Cleveland Clinic prepared her body as best they could, she did face some troubles recovering and needed to be on a ventilator for some time.
"It's really rare and it's even more rare that they found it at the time they did," she says. "It's usually found in older men." She was also diagnosed with a rare blood disease polycythemia vera, where the body makes too many red blood cells that thicken the blood and clots according to Mayo Clinic. To address the blockages in the liver's blood vessels, Minton received a stent to keep them open.
"The it was manageable and livable for the next 10 years," she says. "As the time progressed from that, my liver function declined, and it got to the point where they found a cancer spot on my liver."
Doctors treated that with radiation because "they caught it very early," she says. But doctors realized that Minton likely needed a new liver in the near future.
"They started the workup for getting a transplant," Minton says.
Doctors noticed, though, that she had pulmonary hypertension, a condition where the blood pressure in the lungs is high, according to the National Institutes of Health. They worried that medicine wouldn't effectively treat her "very severe" pulmonary hypertension, and they thought she'd need a double lung transplant instead.
"I will need two organs," she says. "(It) scared me to death."
Minton wanted a second opinion and decided to visit Cleveland Clinic. After meeting with many doctors, she learned that they believed medication could lower her pulmonary hypertension.
"It was a 24-hour continuous pump medication," she says. "(It) went into my chest and straight to my heart."
If it worked, doctors thought Minton would be stable enough for transplant surgery.
"That was a very, very long process," she says. "It took two years for my lungs to heal, to recover enough to be safe enough to put me on the transplant list."
While her lungs were recovering, Minton still experienced symptoms related liver disease including extreme fluid build up in her abdomen.
"I looked like I was eight months pregnant," she says. "Every week, I would get this fluid drained off my abdomen and within a week I'd need it again."
Each time they drained about "six to seven liters" of fluid, Minton adds.
"It's a lot of weight you're carrying around," she says. "It's exhausting."
Minton often needed to undergo blood transfusions, too. With frequent transfusions, having fluid drained and feeling generally unwell, it was tough for to manage her health and still work.
"I was getting those like twice a week," she says. "I was working but it was difficult."
In August 2023, Minton was placed on the liver transplant list. At first, she hoped she could receive a partial liver transplant, which means a living donor could provide half of their liver to her. But doctors determined she needed a full liver transplant, which required a deceased donor. This made it harder. But then her dad received a call from a woman who attends the same church as him.
"She said her great grandson just passed away and (they) would like to donate his liver," she says. "She said they needed some of my information, so he gave it to them."
While Minton felt touched by the gesture, she explained to her dad that transplantation is a little more complicated.
"You've got to be a blood match and it's got to be the right size," she says. "There's so many criteria that has to go into it in order to be this perfect match."
Still, the other family contacted Cleveland Clinic and at 10:30 that night, Minton received a call that doctors had a liver that matched her. On December 2, 2023, she received a new liver.
"It only took eight hours. It actually went really smoothly," she says. "The first couple of weeks were really rough. At one point, they almost lost me, and I was on a ventilator for weeks."
After living with liver disease for so long, Sarah Minton would retain so much fluid that she appeared 8 months pregnant.
She also needed oxygen because the transplant "took a hard toll" on her lungs, she notes. By Christmas, Minton was out of the intensive care unit. On January 5, 2024, Minton left the hospital. She stayed in Cleveland for follow up appointments before returning home on January 18. She feels transformed.
"I feel like I'm 18," Minton says. "I feel amazing. I'm not dragging and drained and hurting. I was in so much pain all the time."
The path to transplant surgeryWhile a team of specialists helped prepare Minton for her transplant surgery, Dr. Matt Siuba, a critical care medicine specialist at Cleveland Clinic, made sure she was strong enough to undergo the lengthy and stressful procedure.
"The main limiting factor and feeling like she wasn't going to be a good transplant candidate was the pulmonary hypertension she has, which is high blood pressure in the lungs," he tells TODAY.Com. "It increases the risk of transplantation in the operating room and then in the ICU shortly after because you can develop brain, heart failure and you can die from the pulmonary hypertension."
Anywhere from "5% to 10%" of people with liver disease develop pulmonary hypertension, he notes, for reasons that are somewhat unclear.
Her primary pulmonary hypertension doctor placed Minton on the IV pump to lower the blood pressure in her lungs, an "aggressive" but necessary approach to help her, Siuba says. Before her surgery, Siuba performed a two-hour procedure where he tested her body's ability to withstand such an intense surgery. If she did well during his test, doctors could feel more confident about her fitness for the surgery, he says.
"I have a protocol that I put patients through to try to assess whether or not their heart can handle the stress of surgery," he says. "We did this procedure, what's called a right heart catheterization."
The catheter Siuba inserted into Minton measures "pressure and cardiac output into the heart," and then he and his team "simulated the stress of the operating room." They gave her medications that caused her heart to beat harder and rapidly and introduced extra fluids to see how her body responded to it.
"Her heart seemed to be in acceptable shape to undergo this surgery," he says. "We agreed to move forward."
Following surgery, Siuba follows the patients in the ICU to "make sure they don't develop right heart failure," he says. That's when the right side of the heart can't pump enough blood.
Minton faced some bumps during her recovery. "It was a little rocky at times," he says. "There were some issues that she had with bleeding and things like that, but we were able to support her and support her heart through surgery."
Even though recovery felt tough at times, Sarah Minton continued to heal and recover.
A few months after surgery, Minton returned and Siuba conducted another heart catheterization to determine how she was faring.
"If you take a patient with pulmonary hypertension and liver disease and you transplant the liver sometimes — more than half of the time at least — you can take the patient off the pulmonary hypertension medications, which was a big deal," he says.
Minton no longer needed the IV medications following her surgery, a welcomed development for her.
"Having a foreign material in your body for all that time limits all the ways you can experience life," he says. "Something that was in the back of my mind this whole time was to get Sarah back to where she wants to be and bring back a sense of normalcy."
Living in gratitudeBeing tethered to an IV pump meant that Minton couldn't do many things, including swim. When she was finally able to stop the medications, she enjoyed a beach vacation with her daughters and swam in the pool.
"Where (the pump) goes into your skin and chest, you can't get that wet," she says. "I was so excited because I love the water."
She can't swim in lakes, oceans or rest in a hot tub because they have too many bacteria and her immune system is weakened from the anti-rejection medication she takes for her new liver. Still, she feels thrilled that she can swim in a pool, especially because of how sick she was prior to surgery. At one point, Minton planned her funeral. But the single mother of two was determined to survive for her children.
"I couldn't leave my daughters," she says. "I knew they needed me, which was a big motivation of mine to get through this especially in the ICU when they almost lost me. It was really difficult, and I just thought of them."
Minton feels incredibly grateful for the family that donated their loved one's liver.
Since undergoing her liver transplant last year, Sarah Minton feels like she's 18 again.
"I'm going to live every day in thanks of what he did, what his family did for me," Minton says. "It's amazing that people can be so selfless and so caring to think at others at that time."
This article was originally published on TODAY.Com
View comments
Comments
Post a Comment