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Harris DE. Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications. AORN J 2022; 116:517-531. [DOI: 10.1002/aorn.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
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Yagi Y, Mizunoya K, Mori T, Saito H, Morimoto Y. Intraoperative myocardial infarction and refractory cardiogenic shock during major hepatectomy: a case report. JA Clin Rep 2022; 8:19. [PMID: 35266074 PMCID: PMC8907374 DOI: 10.1186/s40981-022-00510-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Myocardial infarction (MI) complicated by cardiogenic shock during non-cardiac surgery is a rare but fatal complication. The management of intraoperative MI is challenging. CASE PRESENTATION A 77-year-old hypertensive man with good functional capacity was scheduled for hepatectomy. After the start of liver resection, the electrocardiogram monitor showed ST depression, and the patient developed refractory cardiogenic shock. Transesophageal echocardiography revealed severe hypokinesis of the anteroseptal wall. The surgery was suspended, and an intra-aortic balloon pump was placed following immediate abdominal closure. Coronary angiography revealed severe stenosis of the left main coronary trunk, and percutaneous coronary intervention (PCI) was performed. Myocardial wall motion improved, and blood pressure stabilized. Two days after PCI, hepatectomy, which had been suspended, was successfully completed. CONCLUSIONS Once intraoperative MI has occurred, early diagnosis and multidisciplinary approaches are important to manage the difficult clinical situation.
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Affiliation(s)
- Yasunori Yagi
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Kazuyuki Mizunoya
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Toshihiro Mori
- Department of Anesthesiology, Sapporo City Hospital, N11, W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
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Thompson A, Gregory SH. Prevention of Ischemic Injury in Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Management of perioperative acute coronary syndromes by mechanism: a practical approach. Int Anesthesiol Clin 2020; 59:61-65. [PMID: 33252573 DOI: 10.1097/aia.0000000000000310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ratcliffe FM, Kharbanda R, Foëx P. Perioperative ST-elevation myocardial infarction: with time of the essence, is there a case for guidelines? Br J Anaesth 2019; 123:548-554. [PMID: 31543267 DOI: 10.1016/j.bja.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/02/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Fiona M Ratcliffe
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
| | | | - Pierre Foëx
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
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Mamilla D, Araque KA, Brofferio A, Gonzales MK, Sullivan JN, Nilubol N, Pacak K. Postoperative Management in Patients with Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:E936. [PMID: 31277296 PMCID: PMC6678461 DOI: 10.3390/cancers11070936] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/26/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.
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Affiliation(s)
- Divya Mamilla
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Katherine A Araque
- Adult Endocrinology Department, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alessandra Brofferio
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Melissa K Gonzales
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - James N Sullivan
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
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Keller K, Hobohm L, Engelhardt M. Impact of Atrial Fibrillation on Postoperative Adverse Outcomes of Surgical Patients With Knee Endoprosthetic Surgery. J Arthroplasty 2018; 33:3567-3573. [PMID: 30007790 DOI: 10.1016/j.arth.2018.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/04/2018] [Accepted: 06/18/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Atrial fibrillation/flutter (AF) is associated with increased mortality, thromboembolism, heart failure, and adverse perioperative outcomes. We aimed to investigate the impact of AF on adverse in-hospital outcomes of hospitalized patients who underwent knee endoprosthetic surgery (KES). METHODS The nationwide German inpatient sample of the years 2005-2015 was used for this analysis. Patients who underwent KES were identified based on the surgical and interventional procedural codes (surgery and procedure code [Operationen-und Prozedurenschlüssel] 5-822), and patients were further stratified by AF (International Classification of Diseases and Related Health Problems code I48). We compared patients with and without AF who underwent KES as well as survivors vs nonsurvivors among patients with AF. Logistic regression models were used to investigate the impact of AF as a predictor for adverse in-hospital outcomes. RESULTS Overall, 1,642,875 hospitalized surgical patients (65.4% females, 49.5% aged >70 years) were included in the analysis. Of these, 93,748 patients (5.7%) were diagnosed with AF. Overall, 0.1% of the patients who underwent KES and 0.6% of the patients who underwent KES with additional AF died during in-hospital stay. All-cause death (risk ratio 5.97 [95% confidence interval {CI} 5.41-6.58], P < .001) and adverse in-hospital events (risk ratio 2.62 [95% CI 2.50-2.74], P < .001) occurred both more often in patients with AF compared to those without. AF was an important predictor for in-hospital death (odds ratio 2.09 [95% CI 1.88-2.32], P < .001) and adverse in-hospital events (odds ratio 1.76 [95% CI 1.68-1.85], P < .001) in patients who underwent KES independent of age, sex, and comorbidities. CONCLUSION In patients who underwent KES, AF is associated with increased in-hospital mortality and adverse in-hospital outcomes. Pneumonia, pulmonary embolism, shock, myocardial infarction, intracerebral bleeding, and stroke were the key complications promoting in-hospital death.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Team Doctor of the German Bundesliga Club 1. FSV Mainz 05 in the Soccer Season 2014/2015, Mainz, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Martin Engelhardt
- Department for Orthopedics, Trauma Surgery and Hand Surgery, Klinikum Osnabrück, Osnabrück, Germany; Olympic Doctor of the German Olympic Sports Confederation responsible for taking care of the German team at the Olympic Summer Games 2004 in Athena and 2008 in Beijing.; Head of the Institute for Applied Training Science Leipzig (IAT), Leipzig, Germany
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Helwani MA, Amin A, Lavigne P, Rao S, Oesterreich S, Samaha E, Brown JC, Nagele P. Etiology of Acute Coronary Syndrome after Noncardiac Surgery. Anesthesiology 2018; 128:1084-1091. [PMID: 29481375 PMCID: PMC5953771 DOI: 10.1097/aln.0000000000002107] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The objective of this investigation was to determine the etiology of perioperative acute coronary syndrome with a particular emphasis on thrombosis versus demand ischemia. METHODS In this retrospective cohort study, adult patients were identified who underwent coronary angiography for acute coronary syndrome within 30 days of noncardiac surgery at a major tertiary hospital between January 2008 and July 2015. Angiograms were independently reviewed by two interventional cardiologists who were blinded to clinical data and outcomes. Acute coronary syndrome was classified as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina; myocardial infarctions were adjudicated as type 1 (plaque rupture), type 2 (demand ischemia), or type 4b (stent thrombosis). RESULTS Among 215,077 patients screened, 146 patients were identified who developed acute coronary syndrome: 117 were classified as non-ST-elevation myocardial infarction (80.1%); 21 (14.4%) were classified as ST-elevation myocardial infarction, and 8 (5.5%) were classified as unstable angina. After coronary angiography, most events were adjudicated as demand ischemia (type 2 myocardial infarction, n = 106, 72.6%) compared to acute coronary thrombosis (type 1 myocardial infarction, n = 37, 25.3%) and stent thrombosis (type 4B, n = 3, 2.1%). Absent or only mild, nonobstructive coronary artery disease was found in 39 patients (26.7%). In 14 patients (9.6%), acute coronary syndrome was likely due to stress-induced cardiomyopathy. Aggregate 30-day and 1-yr mortality rates were 7 and 14%, respectively. CONCLUSIONS The dominant mechanism of perioperative acute coronary syndrome in our cohort was demand ischemia. A subset of patients had no evidence of obstructive coronary artery disease, but findings were consistent with stress-induced cardiomyopathy.
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Affiliation(s)
- Mohammad A Helwani
- From the Division of Clinical and Translational Research, Department of Anesthesiology (M.A.H., S.R., S.O., E.S., J.C.B., P.N.) the Division of Cardiology, Department of Internal Medicine (A.A., P.L.), Washington University School of Medicine, St. Louis, Missouri
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Kim J, So E, Kim HJ, Seo KS, Karm MH. Cardiac arrest due to an unexpected acute myocardial infarction during head and neck surgery: A case report. J Dent Anesth Pain Med 2018; 18:57-64. [PMID: 29556560 PMCID: PMC5858010 DOI: 10.17245/jdapm.2018.18.1.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/08/2018] [Accepted: 02/13/2018] [Indexed: 11/15/2022] Open
Abstract
Major cardiac complication such as acute myocardial infarction can occur unexpectedly in patients without risk factors. We experienced cardiac arrest due to an unexpected acute myocardial infarction in a patient without any risk factors during head and neck reconstructive surgery. The patient was diagnosed with acute myocardial infarction after return of spontaneous circulation. With immediate percutaneous coronary intervention, the patient recovered without complications.
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Affiliation(s)
- Jimin Kim
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Eunsun So
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
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Vieira Marques F, Montenegro Sá F, Lapa T, Simões I. Postoperative myocardial infarction in an orthognatic jaw surgery. ACTA ACUST UNITED AC 2017. [PMID: 28625607 DOI: 10.1016/j.redar.2017.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiovascular complications, in particular perioperative myocardial infarctions, are central contributors to morbidity and mortality after non-cardiac surgery. We present a case of a 41-year-old male, smoker and dyslipidemic, who underwent bimaxillary orthognathic jaw surgery with the development of an acute coronary syndrome in the immediate postoperative period. We managed to early diagnose the myocardial infarction and promptly performed a percutaneous transluminal coronary angioplasty, resulting in a positive outcome.
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Affiliation(s)
- F Vieira Marques
- Departamento de Anestesiología, Centro Hospitalar é Universitário de Coimbra, Coimbra, Portugal.
| | - F Montenegro Sá
- Departamento de Cardiología, Hospital de Santo André, Leiria, Portugal
| | - T Lapa
- Departamento de Anestesiología, Centro Hospitalar é Universitário de Coimbra, Coimbra, Portugal; Facultad de Ciencias de la Salud, Universidad da Beira Interior, Covilhã, Portugal
| | - I Simões
- Departamento de Anestesiología, Centro Hospitalar é Universitário de Coimbra, Coimbra, Portugal
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Mohamad MF, Mohammad MA, Hetta DF, Ahmed EH, Obiedallah AA, Elzohry AAM. Thoracic epidural analgesia reduces myocardial injury in ischemic patients undergoing major abdominal cancer surgery. J Pain Res 2017; 10:887-895. [PMID: 28442930 PMCID: PMC5396972 DOI: 10.2147/jpr.s122918] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background and objectives Major abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery. Patients and methods One hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded. Results There was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group. Conclusion Perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.
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Affiliation(s)
| | | | | | | | - Ahmed A Obiedallah
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Arab Republic of Egypt
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Relation of perioperative elevation of troponin to long-term mortality after orthopedic surgery. Am J Cardiol 2015; 115:1643-8. [PMID: 25890628 DOI: 10.1016/j.amjcard.2015.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 11/21/2022]
Abstract
Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision-coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors.
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.09.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2101] [Impact Index Per Article: 210.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354-94. [PMID: 25249586 DOI: 10.1161/cir.0000000000000133] [Citation(s) in RCA: 747] [Impact Index Per Article: 74.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e344-426. [PMID: 25249585 DOI: 10.1161/cir.0000000000000134] [Citation(s) in RCA: 636] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Dovzhanskiy DI, Hackert T, Krumm J, Hinz U, Roggenbach J, Hofer S, Büchler MW, Werner J. Clinical impact of perioperative myocardial infarction after pancreatic surgery. J Gastrointest Surg 2014; 18:929-34. [PMID: 24424714 DOI: 10.1007/s11605-014-2453-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 01/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the incidence, clinical impact and outcome of perioperative myocardial infarction (PMI) in patients undergoing pancreatic surgery. METHODS A data of 1,625 patients undergoing pancreatic resection were prospectively collected and analysed with regard to PMI. Demographic aspects, co-morbidities and clinical course were evaluated. Cardiac risk factors (ASA and NYHA), postoperative complications and mortality were compared in a match-pair analysis (1:3) with patients without PMI. RESULTS Twenty-nine patients with PMI after pancreatic surgery were identified. PMI occurred after all types of pancreatic operations and was observed most frequently (72.2%) within the first postoperative week. In a total of 90%, PMI fulfilled the criteria of non-STEMI. Nearly half of the patients (48%) were clinically asymptomatic. Both ASA III and heart failure were more frequent in patients with PMI. The in-hospital mortality was significantly increased after PMI (p < 0.002), with post-pancreatectomy haemorrhage (PPH) as the most relevant underlying risk factor. CONCLUSION PMI is a rare but severe complication after pancreatic operations, contributing significantly to in-hospital mortality. Clinical management mainly includes an anti-coagulant approach. This may be related with an increased risk for PPH. Therefore, the use of anti-coagulant drugs in the early postoperative period-especially in asymptomatic patients-should be critically evaluated.
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Affiliation(s)
- Dmitriy I Dovzhanskiy
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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Oberweis BS, Nukala S, Rosenberg A, Guo Y, Stuchin S, Radford MJ, Berger JS. Thrombotic and bleeding complications after orthopedic surgery. Am Heart J 2013; 165:427-33.e1. [PMID: 23453114 DOI: 10.1016/j.ahj.2012.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Thrombotic and bleeding complications are major concerns during orthopedic surgery. Given the frequency of orthopedic surgical procedures and the limited data in the literature, we sought to investigate the incidence and risk factors for thrombotic (myocardial necrosis and infarction) and bleeding events in patients undergoing orthopedic surgery. METHODS AND RESULTS We performed a retrospective cohort analysis of 3,082 consecutive subjects ≥21 years of age undergoing hip, knee, or spine surgery between November 1, 2008, and December 31, 2009. Patient characteristics were ascertained using International Classification of Diseases, Ninth Revision, diagnosis coding and retrospective review of medical records, and laboratory/blood bank databases. In-hospital outcomes included myocardial necrosis (elevated troponin), major bleeding, coded myocardial infarction, and coded hemorrhage as defined by International Classification of Diseases, Ninth Revision, coding. Of the 3,082 subjects, mean age was 60.8 ± 13.3 years, and 59% were female. Myocardial necrosis, coded myocardial infarction, major bleeding, and coded hemorrhage occurred in 179 (5.8%), 20 (0.7%), 165 (5.4%), and 26 (0.8%) subjects, respectively. Increasing age (P < .001), coronary artery disease (P < .001), cancer (P = .004), and chronic kidney disease (P = .01) were independent predictors of myocardial necrosis, whereas procedure type (P < .001), cancer (P < .001), female sex (P < .001), coronary artery disease (P < .001), and chronic obstructive pulmonary disease (P = .01) were independent predictors of major bleeding. CONCLUSION There is a delicate balance between thrombotic and bleeding events in the perioperative period after orthopedic surgery. Perioperative risk of both thrombosis and bleeding deserves careful attention in preoperative evaluation, and future prospective studies aimed at attenuating this risk are warranted.
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Tandar A, Velagapudi KN, Wilson BD, Boden WE. Perioperative antiplatelet management in patients with coronary artery stenting. Hosp Pract (1995) 2012; 40:118-30. [PMID: 22615086 DOI: 10.3810/hp.2012.04.977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery disease is the primary cause of mortality in men and women in the United States. Transcatheter coronary intervention is the mainstay of treatment for patients with acute coronary artery disease presentations and patients with stable disease. Although percutaneous intervention initially only included balloon angioplasty, it now typically involves the placement of intracoronary stents. To overcome the limitations of bare-metal stents, namely in-stent restenosis, stents have been developed that remove pharmaceuticals that reduce neointimal hyperplasia and in-stent restenosis. However, these pharmaceutical agents also delay stent endothelialization, posing a prolonged risk of in situ thrombosis. Placement of an intracoronary stent (eg, bare-metal or drug-eluting stent) requires dual antiplatelet therapy to prevent the potentially life-threatening complication of stent thrombosis. The optimal duration of dual antiplatelet therapy following stent placement is unknown. This article discusses the factors to be considered when deciding when dual antiplatelet therapy can be safely discontinued. Unfortunately, in the hospital setting, this decision to interrupt dual antiplatelet therapy frequently must be made shortly after stent placement because of unanticipated surgical procedures or other unforeseen complications. The decision of when dual antiplatelet therapy can be safely interrupted needs to be individualized for each patient and involves factoring in the type of stent; the location and complexity of the lesion stented; post-stent lesion characteristics; the amount of time since stent placement; and the antiplatelet regimen currently in use, along with its implication for bleeding during the proposed procedure. Having a protocol in place, such as the protocol described in this article, can help guide this decision-making process and avoid confusion and potential error.
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Affiliation(s)
- Anwar Tandar
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT.
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Gualandro DM, Campos CA, Calderaro D, Yu PC, Marques AC, Pastana AF, Lemos PA, Caramelli B. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: Frequent and dangerous. Atherosclerosis 2012; 222:191-5. [DOI: 10.1016/j.atherosclerosis.2012.02.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 11/16/2022]
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Shaikh N, Mazhar R, Samy H, Sadiq MO, Ibrahim HA. Perioperative myocardial infraction following video-assisted thoracic surgery: A case report and review. Anesth Essays Res 2012; 6:87-90. [PMID: 25885511 PMCID: PMC4173422 DOI: 10.4103/0259-1162.103384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Perioperative myocardial infarction (PMI) during video-assisted thoracoscopy (VAT) surgery is rarely reported in the literature. ST-segment-elevated myocardial infarction (STEMI) is rare in the perioperative period. We report a case of STEMI, following VAT surgery, complicated by acute coronary syndrome. A 53-year male, admitted with recurrent left-sided pneumothorax, an intercostal chest drain was inserted and planned for VAT and lung resection. The intra-operative period was stable, minimal lung resection, and excision of bullae was done. Just before extubation, patient had acute myocardial infarction and cardiogenic shock. An immediate percutaneous coronary intervention (PCI) angiogram showed 90% blockage of the right coronary artery with thrombus. Export thrombectomy and balloon angioplasty was done. Weaned off from inotropes and ventilator. He was transferred to ward from there by day 12, discharged home on double antiplatelet therapy. The PMI can occur earlier than it is commonly thought, and in our patient, it was STEMI, which is rare and occurred during VAT Surgery. In our patient early detection and earlier PCI may have resulted in better outcome.
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Affiliation(s)
- Nissar Shaikh
- Department of Anesthesia/ICU, Hamad Medical Corporation, Doha, Qatar
| | - Rashid Mazhar
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - H Samy
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - M Omer Sadiq
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - H Ali Ibrahim
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
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Schlitt A, Reindl I, Ebelt H, Buerke M, Werdan K. [Cardiac biomarkers in perioperative medicine : significance for noncardiac surgery patients]. Anaesthesist 2011; 60:709-16. [PMID: 21842250 DOI: 10.1007/s00101-011-1928-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Perioperative detection of cardiac biomarkers may help to identify patients at risk. Whether detection of these markers will be recommended in the preoperative setting for patients with cardiac diseases in the future has to be discussed as large prospective trials on this topic are missing. For preoperative evaluation of cardiac insufficiency quantification of brain natriuretic peptide (BNP) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) are useful markers. Troponin is the marker of choice for detection of myocardial ischemia/infarction in the postoperative setting. In unstable patients coronary angiography and/or percutaneous coronary intervention (PCI) are indicated. However, in stable patients the decision for coronary angiography and/or PCI has to be made in each patient individually after interdisciplinary discussion between anesthesiologists, cardiologists and surgeons.
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Affiliation(s)
- A Schlitt
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum, Martin Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
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Barash P, Akhtar S. Coronary stents: factors contributing to perioperative major adverse cardiovascular events. Br J Anaesth 2010; 105 Suppl 1:i3-15. [DOI: 10.1093/bja/aeq318] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Antithrombotic therapy in patients at risk for coronary stent thrombosis undergoing non-cardiac surgery. COR ET VASA 2010. [DOI: 10.33678/cor.2010.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Madhavi G, Satyanarayana N. Postoperative myocardial infarction after diagnostic video-assisted thoracoscopy and pleurodesis for catamenial pneumothorax: A unique case report. Indian J Anaesth 2010; 54:342-4. [PMID: 20882180 PMCID: PMC2943707 DOI: 10.4103/0019-5049.68388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myocardial infarction (MI) is uncommon in patients undergoing noncardiac surgery without a history of coronary artery disease. But, patients with compromised pulmonary function and coexisting anaemia superimposed by precipitating factors like prolonged hypotension and tachycardia can culminate in myocardial catastrophe even in the absence of risk factors. We are herewith reporting an unusual case of postoperative non-ST elevation MI without any pre-existing ischemic heart disease. A 39-year-old female patient who was submitted for diagnostic video-assisted thoracoscopy and chemical pleurodesis for recurrent pneumothorax developed postoperative MI. After review of all the factors, it was found that the patient developed Type 2 MI as a sequel to oxygen supply and demand mismatch secondary to hypoxia and prolonged hypotension. This was evident in the 12-lead electrocardiogram and was confirmed by elevated cardiac biomarkers and regional wall motion abnormality on echocardiography.
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Affiliation(s)
- G Madhavi
- Department of Anaesthesiology, Government General and Chest Hospital, Hyderabad, Andhra Pradesh, India
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Kroll HR, Arora V, Vangura D. Coronary artery spasm occurring in the setting of the oculocardiac reflex. J Anesth 2010; 24:757-60. [PMID: 20526723 DOI: 10.1007/s00540-010-0967-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 04/29/2010] [Indexed: 12/30/2022]
Abstract
The oculocardiac reflex (OCR) occurs in up to 90% of ophthalmological surgeries. Several preventive and treatment strategies have been described. Coronary artery spasm (CAS) plays an important role in the pathogenesis of variant angina and myocardial infarction. We describe an unusual case of a perioperative myocardial infarction due to CAS that occurred in the setting of the treatment of the OCR. We offer insight aimed at minimizing the deleterious effects of the OCR and its management.
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Affiliation(s)
- Henry R Kroll
- Department of Anesthesiology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA.
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Infarctus du myocarde peropératoire, quelle prise en charge à la phase aiguë ? ACTA ACUST UNITED AC 2009; 28:692-6. [DOI: 10.1016/j.annfar.2009.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 05/18/2009] [Indexed: 11/23/2022]
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Roggenbach J, Böttiger BW, Teschendorf P. [Perioperative myocardial damage in non-cardiac surgery patients]. Anaesthesist 2009; 58:665-76. [PMID: 19554269 DOI: 10.1007/s00101-009-1577-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Perioperative myocardial damage occurs with a high incidence depending on the operative procedure and the patients examined and is considered to be among the most relevant risk factors for increased perioperative morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of myocardial damage in the perioperative period is still not well understood. Both ischemia with and without acute coronary occlusion and non-ischemic stimuli can put a substantial strain on the heart in the perioperative period. However, in many cases the clinical presentation does not allow a clear differentiation between ischemic and non-ischemic myocardial damage. In the majority of cases perioperative myocardial infarctions occur with only mild or even without any clinical symptoms. This is probably due to a considerable difference in phenotype and pathophysiology between perioperative and non-perioperative myocardial infarctions. As a result of this unexplained etiology of perioperative myocardial infarction it remains an open question whether the contemporary diagnostic and therapeutic recommendations for the acute coronary syndrome can be extrapolated to the perioperative situation. The present review reflects the current state of knowledge and presents an optional approach to the diagnosis and therapy of perioperative myocardial injury.
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Affiliation(s)
- J Roggenbach
- Klinik für Anaesthesiologie und Intensivmedizin, Klinikum der Universität Heidelberg, Im Neuenheimer Feld 110, 69115, Heidelberg.
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Mauck KF, Manjarrez EC, Cohn SL. Perioperative cardiac evaluation: assessment, risk reduction, and complication management. Clin Geriatr Med 2009; 24:585-605, vii. [PMID: 18984375 DOI: 10.1016/j.cger.2008.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Perioperative cardiac complications are among the most feared outcomes after surgery. Using evidence-based guidelines and expert opinion, physicians can perform a risk assessment and decide whether further cardiac testing, medical therapy, or coronary intervention is necessary to optimize the patient's medical condition prior to surgery. This article reviews the major concepts and recommendations from the ACC guidelines for preoperative cardiac evaluation and perioperative management to reduce risk. Medical management of the major postoperative cardiac complications is also discussed.
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Affiliation(s)
- Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic and Mayo College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA
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Rodseth RN. B type natriuretic peptide--a diagnostic breakthrough in peri-operative cardiac risk assessment? Anaesthesia 2009; 64:165-78. [PMID: 19143695 DOI: 10.1111/j.1365-2044.2008.05689.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The B-type natriuretic peptides; B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, are increasing being used as biomarkers for the diagnosis, management and prognostication of cardiac failure, but their application in the peri-operative period is unclear. This review examines the current understanding of the role of B-type natriuretic peptides in both the operative and non-operative settings. Normal values, diagnostic thresholds, monitoring targets and significant prognostic levels are identified. Using this as a background, the role of B-type natriuretic peptides in the prediction of peri-operative mortality and morbidity is examined and potential confounders, such as renal failure and body mass index, which may impact significantly on the utility of the biomarkers, are discussed. Clinical recommendations with regard to its use are made and a research agenda is proposed for future peri-operative studies.
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Affiliation(s)
- R N Rodseth
- Anaesthetic Registrar, Department of Anaesthetics, Nelson R Mandela School of Medicine, Congella, South Africa.
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Newsome LT, Weller RS, Gerancher JC, Kutcher MA, Royster RL. Coronary Artery Stents: II. Perioperative Considerations and Management. Anesth Analg 2008; 107:570-90. [DOI: 10.1213/ane.0b013e3181731e95] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
BACKGROUND Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) can significantly decrease cardiovascular mortality and morbidity, irrespective of the patients' cholesterol status. This paper reviews the effects of perioperative statin therapy in patients undergoing noncardiac surgery. METHOD A systematic literature review was undertaken of all published literature on this subject using Medline and cross-referenced. All published relevant papers on the perioperative use of statins were used. RESULTS Perioperative statin therapy is associated with a lower perioperative morbidity and mortality in patients undergoing elective or emergency surgery. The effects are due to a combination of lipid-lowering and pleiotropic properties of statins. CONCLUSION Ideally a large scale multi-centre randomized controlled trial of perioperative statin therapy should be performed but this may be difficult to conduct since there is already overwhelming evidence in the literature to suggest perioperative cardiovascular protective properties. Statins may still be under-prescribed in surgical patients.
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Affiliation(s)
- Y C Chan
- Division of Vascular Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Popescu WM, Gusberg RJ, Barash PG. Epidural Catheters and Drug-Eluting Stents: A Challenging Relationship. J Cardiothorac Vasc Anesth 2007; 21:701-3. [PMID: 17905277 DOI: 10.1053/j.jvca.2007.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Wanda M Popescu
- Department of Anesthesiology, Section of Vascular Surgery, Yale University School of Medicine, New Haven, CT 06520-8051, USA.
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Abstract
Patients in whom any kind of stent, particularly a drug-eluting stent (DES), was recently implanted are at risk for stent thrombosis when they undergo noncardiac surgery, even months or years after their implantation. The risk of DES thrombosis is likely decreased by delaying noncardiac surgery for as long as possible and continuing dual or at least single antiplatelet therapy in the perioperative period. Preoperative identification and close monitoring of patients with DES may allow prevention and prompt detection and treatment of this catastrophic complication.
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