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Mrs Ana Alegria-Barrero
Severe obesity is a risk factor for cardiovascular diseases. Bariatric surgery is the best means to ensure obese patients with effective weight loss. Weight loss in turn improves other risk factors of cardiovascular diseases. Find here a review of guidelines and the cardiologist's role, indications and tools, pre-operative practice and the results and costs associated with this intervention.
Body mass index - the easy measure of weight in kilograms divided by the square of the height in metres - is the single main criteria driving the decision to perform bariatric surgery, an intermediate-risk noncardiac intervention (1) that promotes weight loss by changing the digestive system's anatomy. For a review of the effects of obesity on health, lifestyle modifications and medical treatment needed for obese patients and description of bariatric surgery, view previous article by same authors.
Current guidelines include a cardiovascular (CV) evaluation of all prospective candidates as an integral part of preoperative management. Furthermore even though results and complication rates are similar for patients with or without CV disease (2,3) if a patient is confirmed to have a CV disease 1) extensive preoperative investigation using various tests to assess risk is necessary and 2) an adjusted drug regimen is in order. Lastly, in the severely obese, a cardiologist should be present on the multidisciplinary team that manages the intervention.
Severely obese patients carry a high risk of several diseases, cardiovascular (CV) events being among the most relevant (Table 1). (4) Bariatric surgery, by improving most of CV risk factors, lowers the risk of most cardiac and cerebrovascular events (5) (Figure 1). Indications are that surgery be performed in patients:
Contraindications are that surgery not be performed in patients with:
The Revised Cardiac Risk Index (8) can be applied to this intervention as any major surgical procedure. It includes six independent prognostic factors: high risk intervention (including intra-abdominal), history of coronary disease, past or present heart failure, stroke, diabetes needing insulin (withdrawn from the simplified index in 2013) (9), and creatinine over 2.0 mg/dL. This score has been slightly improved adding new parameters, such as sensitive troponin elevation. (10) The American College of Surgeons score (NSQIP) was developed primarily for bariatric surgery and includes peripheral artery disease, shortness of breath at baseline, previous coronary revascularisation, age, initial BMI, chronic steroid therapy, and type of bariatric intervention (percutaneous vs. not). (11).
History, physical examination, and a resting 12-lead electrocardiogram are always carried before surgery. However whether echocardiography, new technological ultrasonic approaches, or stress testing is varies.
Stress testing before intermediate-risk interventions - such as bariatric surgery - has received a weak recommendation (grade IIb, C) in European guidelines on preoperative evaluation. (13) Other imaging tests are indicated on an individual basis. The methods for preoperative CV risk assessment before bariatric surgery found in a recent systematic literature search are also diverse:
Revascularised patients can safely undergo the surgery provided the recommended delays are respected: minimum 6 weeks and optimally 3 months following bare metal stent implantation; 12 months following drug-eluting stent implantation; at least 2 weeks following balloon angioplasty; and a minimum of 3 months and optimally 6 months after successful bypass operation.
Perioperative beta-blockers are commonly prescribed for patients with CV disease or abnormal tests, although the evidence in severely obese patients is scarce. Moreover, European guidelines on this topic rely on evidence that has come from a single centre, whose validity has been questioned. There is no reason to initiate a beta-blocker before operating in patients who have no other indication for such a drug. Nevertheless, patients on beta-blockers should continue treatment. In a registry of 8,431 patients undergoing elective colorectal and bariatric surgical procedures - 23.5% of whom were taking beta-blockers prior to surgery - beta-blocker continuation on the day of and after surgery was associated with fewer cardiac events and a lower 90-day mortality. (19)
Thromboprophylaxis is indicated. Main therapies for that purpose are low-molecular weight heparin and mechanical devices. There is no indication for temporary inferior vena cava filters. (20) Antiplatelet therapy should not be started before operation, but patients taking aspirin do not need to withhold their treatment; clopidogrel is to be discontinued 1 week before operation.
Patients taking oral antidiabetic drugs can continue, except for secretagogues. Insulin therapy can be started according to local rules for elective operations in diabetic patients.
Mortality and morbidity related to bariatric surgery are continuously improving and depend mainly on the surgical technique applied and the experience of the team. Mortality rates range from 0.05 to 0.26%, reoperation rates from 1.6 to 3.4 % and total morbidity rates from 5.2 to 14.5%.Bariatric surgery improves many obesity-associated comorbidities and saves costs because obese patients consume 20% less health resources and 68% fewer drugs. As a consequence, the initial costs (7,468 €) become net savings by the third year (apart from supplementary not-counted savings due to the increase in tax incomes from a 57% increase in work productivity for professionals and a 18% reduction in sick leaves. (21) A recent evidence-based review in patients with diabetes showed that bariatric surgery increased both quality-adjusted life years (QALYs) and costs. Cost-effectiveness ratios for severely obese patients with established diabetes were $12,000 per QALY for bypass surgery and $13,000 per QALY for gastric banding. (22) Trying to find out the reimbursement policies of this surgery across European countries has been an excessive challenge. We ask the ESC e-journal readers to contribute their input to lighten this issue by writing your comment in a tweet.
Here is a review the main points discussed in this article:
In all, we encourage cardiologists to consider obese patients for bariatric surgery.
1 - Physical Activity, and Metabolism. Poirier P, et al.; American Heart Association Obesity Committee of the Council on Nutrition,. Circulation. 2011 Apr 19;123(15):1683-701.2 - Treatment of adult obesity with bariatric surgery. Schroeder R, Garrison JM Jr, Johnson MS. Am Fam Physician. 2011 Oct 1;84(7):805-14. 3 - Bariatric surgery is associated with a reduced risk of mortality in morbidly obese patients with a history of major cardiovascular events.Johnson RJ, Johnson BL, Blackhurst DW, Bour ES, Cobb WS 4th, Carbonell AM 2nd, Lokey JS, Scott JD. Am Surg. 2012 Jun;78(6):685-92.4 - Obesity: Recommendations for management in general practice and beyond. Grima M, Dixon JB. Aust Fam Physician. 2013 Aug;42(8):532-41.5 - Bariatric surgery and cardiovascular risk factors: a scientific statement from the American Heart AssociationPoirier P, et al. Circultation 2011; 123:1683-17016 - Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.Mechanick JI, Y. Endocr Pract. 2013 Mar-Apr;19(2):337-72.7 - Standards of medical care in diabetes-2013American Diabetes Association. Diabetes Care 2013;36 (Suppl 1):S11-S66.8 - Consortium Retention Writing Group. Longitudinal Assessment of Bariatric Surgery (LABS): Retention strategy and results at 24 months.Gourash WF, et al.; LABS Surg Obes Relat Dis. 2013 Jul-Aug;9(4):514-9.9 - Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Lee TH, et al. Circulation. 1999 Sep 7;100(10):1043-9.10 - The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients.Davis C, et al. Can J Anaesth. 2013 Sep;60(9):855-6.11 - Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery.Weber M, et al. Eur Heart J. 2013 Mar;34(11):853-62.12 - Development and validation of a bariatric surgery mortality risk calculator. Ramanan B, Gupta PK, Gupta H, Fang X, Forse RA. J Am Coll Surg. 2012 Jun;214(6):892-900.13 - New echocardiographic techniques in the evaluation of left ventricular function in obesity.Di Bello V, et al. Obesity (Silver Spring). 2013 May;21(5):881-92.14 - Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery.Katkhouda N, et al. 2012 Sep-Oct;8(5):634-40.15 - Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.Poldermans D, et al; Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery; European Society of Cardiology (ESC). Eur Heart J. 2009 Nov;30(22):2769-812.arciano R, Rozenman Y, Chisin R. Clin Nucl Med. 2000 Dec;25(12):1019-23. 1216 - Risk stratification using computed tomography coronary angiography in patients undergoing intermediate-risk noncardiac surgery.Ahn JH, Park JR, Min JH, Sohn JT, Hwang SJ, Park Y, Koh JS, Jeong YH, Kwak CH, Hwang JY. J Am Coll Cardiol. 2013 Feb 12;61(6):661-8.17 - Cardiac dual-source CT for the preoperative assessment of patients undergoing bariatric surgery.Tognolini A, et al. 2013 Mar;68(3):e154-63.18 - Challenges in cardiac risk assessment in bariatric surgery patients. Obes Surg.Gugliotti D, et al. 2008 Jan;18(1):129-33.19 - Surgical Care and Outcomes Assessment Program (SCOAP) Collaborative. β-blocker continuation after noncardiac surgery: a report from the Surgical Care and Outcomes Assessment Program.Kwon S, et al; Arch Surg. 2012 May;147(5):467-73.20 - Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database.Li W, et al. 2012 Jun;55(6):1690-5.21 - Is the morbid obesity surgery profitable in times of crisis? A cost-benefit analysis of bariatric surgery.Sánchez-Santos R et al. Cir Esp. 2013 Apr 27. [Epub ahead of print]22 - Cost-effectiveness of bariatric surgery for severely obese adults with diabetes.Henteleff HJ, Birch DW, Hallowell PT; CAGS/ACS Evidence Based Reviews in Surgery Group. Can J Surg. 2013 Oct;56(5):353-5.
Alegría Barrero A1, Alegría Barrero E2, Alegría Ezquerra E.3
1Department of Cardiology, Montepríncipe University Hospital, University of San Pablo-CEU, Madrid, Spain.2Department of Cardiology, Torrejón University Hospital, Madrid, Spain.3Department of Cardiology, Policlínica Gipuzkoa, San Sebastián, Spain.
Authors' disclosures: None disclosed.View here a video and table (scroll to table 6) of each technique.