Noncardiac surgery for patients with coronary artery stents: timing is everything

Clinical and Economic Analysis of Lipid Goal Attainments in Chinese Patients with Acute Coronary Syndrome Who Received Post-Percutaneous Coronary Intervention

AIM

The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups.

METHODS

A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression.

RESULTS

Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of ＜2.6, ＜2.0, and ＜1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of ＜2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain.

CONCLUSIONS

Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.

Enzyme Prodrug Therapy Engineered into Electrospun Fibers with Embedded Liposomes for Controlled, Localized Synthesis of Therapeutics

Enzyme prodrug therapy (EPT) enables localized conversion of inert prodrugs to active drugs by enzymes. Performance of EPT necessitates that the enzyme remains active throughout the time frame of the envisioned therapeutic application. β-glucuronidase is an enzyme with historically validated performance in EPT, however it retains its activity in biomaterials for an insufficiently long period of time, typically not exceeding 7 d. Herein, the encapsulation of β-glucuronidase in liposomal subcompartments within poly(vinyl alcohol) electrospun fibers is reported, leading to the assembly of biocatalytically active materials with activity of the enzyme sustained over at least seven weeks. It is further shown that liposomes provide the highly beneficial stabilization of the enzyme when incubated in cell culture media. The assembled biocatalytic materials successfully produce antiproliferative drugs (SN-38) using externally administered prodrugs (SN-38-glucuronide) and effectively suppress cell proliferation, with envisioned utility in the design of cardiovascular grafts.

[Pertrochanteric femoral fractures in the elderly]

Pertrochanteric fractures are one of the most common injuries in the elderly and due to the demographic changes the incidence and importance of this fracture entity will even increase in the future. The dynamic hip screw (DHS) has been used as the gold standard implant in the treatment of pertrochanteric femoral fractures for many years but recent studies have shown that cephalomedullary nails have some advantages. Due to the high incidence, operative treatment of these fractures is part of the standard repertoire of trauma surgeons and this article therefore provides an overview of existing knowledge and new trends in the treatment of pertrochanteric femoral fractures.

[ENT surgery in patients with anticoagulants and platelet aggregation inhibitors]

BACKGROUND

Patients with antiplatelet and antithrombotic therapy (AP/AT) represent a substantial proportion of ear, nose and throat (ENT) patients. Despite the ubiquitous consideration of bleeding and ischemic/thrombembolic risk, no detailed assessment of the perioperative setting in an ENT cohort is available in the literature.

OBJECTIVES

The goal of the present work is to give a detailed assessment of patients with AP/AT in an ENT cohort resulting in ENT-specific recommendations for daily routine.

MATERIALS AND METHODS

In all, 400 randomized patients were asked regarding analgetic therapy in acute pain. Medical data of 5211 patients who underwent head and neck surgery were analyzed for AP/AT therapy. Therapeutic strategies, the perioperative AP/AT therapy, duration of intensive care treatment and hospitalization (ICT/H), application of erythrocytes and internistic/neurolocigal complication data were analyzed in patients with/without AP/AT.

RESULTS

Nearly 75 % of our patients were taking AP/AT due to coronary heart disease (CHD), peripheral arterial disease (PAD), cardiac arrhythmia, or cardiovascular disease (CVD). Patients' questionnaire revealed that 31 % of our patients use acetylsalicylic acid in acute pain, which represents 10 % of the overall AP/AT cohort. Head and neck surgery in patients with AP/AT showed an elevated bleeding frequency (p = 0.006) without an elevated risk for internistic/neurological complications. ICT/H were remarkably prolonged (p = 0.006; p = 0.0004).

DISCUSSION

Head and neck surgery in patients with AP/AT can be routinely performed. Indication for intensive care, endotracheal intubation, and tracheostomy should be made generously due to high requirements of airway management in ENT. Ischemic/thrombembolic and bleeding risk requires careful assessment in an interdisciplinary setting.

Cardiopulmonary resuscitation with assisted extracorporeal life support during cardiac arrest caused by drug-eluting stent thrombosis: a case report

Discontinuation of dual antiplatelet therapy within 12 months after drug-eluting stent (DES) implantation increases the possibility of stent thrombosis. We now report the case of a 66-year-old man who suffered a cardiac arrest due to stent thrombosis after an elective laparoscopic anterior resection. Ten month ago, he underwent DES implantation and then had been taking dual antiplatelet therapy. Nine days prior to the surgery, he discontinued dual antiplatelet therapy. Forty minutes after intensive care unit admission, cardiac arrest occurred. However, his cardiac rhythm did not restore in spite of resuscitation, so immediately veno-arterial extracorporeal membrane oxygenation (ECMO) was implanted. Four days after the surgery, he was weaned from ECMO support, recovered completely, with no cardiopulmonary or neurological sequelae.

The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors

BACKGROUND

When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use.

METHOD

We selectively searched for relevant publications that appeared from 2003 to February 2013, with particular consideration of the guidelines of the European Society of Cardiology, the Association of Scientific Medical Societies in Germany (AWMF), the American College of Cardiology, and the American Heart Association.

RESULTS

Vitamin K antagonists (VKA), low molecular weight heparins, and fondaparinux are the established anticoagulants. The past few years have seen the introduction of orally administered selective inhibitors of the clotting factors IIa (dabigatran) and Xa (rivaroxaban, apixaban). The timing of perioperative interruption of anticoagulation is based on pharmacokinetic considerations rather than on evidence from clinical trials. Recent studies have shown that substituting short-acting anticoagulants for VKA before a procedure increases the risk of bleeding without lowering the risk of periprocedural thromboembolic events. The therapeutic spectrum of acetylsalicylic acid and clopidogrel has been broadened by the newer platelet aggregation inhibitors prasugrel and ticagrelor. Patients with drug eluting stents should be treated with dual platelet inhibition for 12 months because of the risk of in-stent thrombosis.

CONCLUSION

Anticoagulants and platelet aggregation inhibitors are commonly used drugs, but the evidence for their perioperative management is limited. The risks of thrombosis and of hemorrhage must be balanced against each other in the individual case. Anticoagulation need not be stopped for minor procedures.

[Antiplatelet therapy after coronary stenting and its importance in total joint arthroplasty]

Coronary stenting is an effective treatment for reopening atherosclerotic occlusions of coronary arteries. Depending on the manifestation of coronary artery disease (stable CAD or acute coronary syndrome) and on the type of implanted stent, dual antiplatelet therapy is recommended for a period of 4 weeks to 12 months. In this period total joint replacement is associated with high blood loss and high perioperative morbidity. Therefore antiplatelet therapy is often discontinued and replaced by higher dosages of heparin for prophylactic anticoagulation. However, with this treatment regimen protection of the stent is doubtful and there is a high risk of stent thrombosis with myocardial infarction. The surgery should be scheduled after the dual antiplatelet therapy is replaced by lifelong aspirin therapy. On the other hand, if surgery cannot be postponed perioperative bridging of dual antiplatelet therapy can be conducted to minimize bleeding complications with the best possible stent protection. Lifelong therapy with aspirin should not be discontinued in any case.

The perioperative management of patients with coronary artery stents: surveying the clinical stakeholders and arriving at a consensus regarding optimal care

BACKGROUND

The perioperative management of patients with a coronary artery stent is a major patient safety issue currently confronting clinicians. Surgery on a patient on antiplatelet therapy creates the following dilemma: is it better to withdraw the drugs and reduce the hemorrhagic risk or to maintain them and reduce the risk of a myocardial ischemic event?

METHODS

An electronic survey was used to sample a cross-section of local clinicians regarding the perioperative management of patients with an indwelling coronary artery stent. The reiterative Consensus-Oriented Decision-Making model was applied by an institutional task force with representation from anesthesiology, cardiology, primary care medicine, and surgery.

RESULTS

Significant disagreement existed among the multidisciplinary survey respondents regarding various aspects of the perioperative management of patients with indwelling coronary artery stents.

CONCLUSIONS

We clarified the perioperative risk factors for coronary stent thrombosis and an alternate process for immediate access to a cardiac catheterization laboratory at our institution.

Acute coronary syndrome: new and evolving therapies

There are many new developments in both the invasive and noninvasive treatment of ACS. As technology, pharmaceuticals, and research continue to bring new therapies to the forefront, it is essential that clinicians stay current in their understanding of how this new knowledge will impact patients and alter clinical outcomes.

Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics

Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.

The Management of Antiplatelet Therapy in Patients With Coronary Stents Undergoing Noncardiac Surgery

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.

[Perioperative management of patients with coronary stents in non-cardiac surgery]

In patients with coronary stents scheduled for surgery the question arises whether and how antiplatelet therapy should be continued. Risks of perioperative bleeding and of acute stent thrombosis have to be considered simultaneously. The bleeding risk depends primarily on the kind of surgery and on patient comorbidity. The risk of stent thrombosis is increased in these patients due to the thrombogenic surface of the stents. The main determinants are hereby the time duration after stent implantation, the kind of the stent [uncoated (bare-metal stent, BMS) or coated (drug-eluting stent, DES)], as well as angiographic and clinical patient factors. Therefore, perioperative antiplatelet therapy has to be individually adapted for each patient. Bridging with heparin is ineffective. Bridging with intravenous antiplatelet drugs during the perioperative interruption of oral antiplatelet therapy might be a potential procedure in high-risk patients. Whether bedside monitoring of antiplatelet therapy improves the perioperative management of these patients and reduces adverse outcome is object of current studies.