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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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Lee SH, Kim C, Shin S, Kim H, Park JK, Oh SJ, Ahn SG, Cho S, Lee OH, Moon JY, Won H, Suh Y, Cho YH, Cho JR, Lee BK, Lee YJ, Lee SJ, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y, Kim JS. Perioperative Antiplatelet Strategy in Patients Undergoing Noncardiac Surgery Within One Year After Percutaneous Coronary Intervention. Am J Med 2023; 136:1026-1034.e1. [PMID: 37356644 DOI: 10.1016/j.amjmed.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The optimal antiplatelet therapy (APT) for patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention (PCI) is not yet established. METHODS Patients who underwent non-cardiac surgery within 1 year after second-generation drug-eluting stent implantation were included from a multicenter prospective registry in Korea. The primary endpoint was 30-day net adverse clinical event (NACE), including all-cause death, major adverse cardiovascular event (MACE), and major bleeding events. Covariate adjustment using propensity score was performed. RESULTS Among 1130 eligible patients, 708 (62.7%) continued APT during non-cardiac surgery. After propensity score adjustment, APT continuation was associated with a lower incidence of NACE (3.7% vs 5.5%; adjusted odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = .019) and MACE (1.1% vs 1.9%; adjusted OR, 0.35; 95% CI, 0.12-0.99; P = .046), whereas the incidence of major bleeding events was not different between the 2 APT strategies (1.7% vs 2.6%; adjusted OR, 0.61; 95% CI, 0.25-1.50; P = .273). CONCLUSIONS The APT continuation strategy was chosen in a substantial proportion of patients and was associated with the benefit of potentially reducing 30-day NACE and MACE with similar incidence of major bleeding events, compared with APT discontinuation. This study suggests a possible benefit of APT continuation in non-cardiac surgery within 1 year of second-generation drug-eluting stent implantation.
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Affiliation(s)
- Sang-Hyup Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Choongki Kim
- Department of Cardiology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Sanghoon Shin
- Department of Cardiology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hyeongsoo Kim
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong-Kwan Park
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Seung-Jin Oh
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungsoo Cho
- Department of Cardiology, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Oh-Hyun Lee
- Division of Cardiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jae Youn Moon
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hoyoun Won
- Cardiovascular and Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yongsung Suh
- Department of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Yun-Hyeong Cho
- Department of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Jung Rae Cho
- Division of Cardiology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea
| | - Byoung-Kwon Lee
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Joon Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Jun Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Ho Shin
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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5
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[ESC guidelines 2022 on cardiovascular assessment and management of patients undergoing non-cardiac surgery : What is new?]. Herz 2023; 48:31-38. [PMID: 36449042 DOI: 10.1007/s00059-022-05150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 12/03/2022]
Abstract
The new European Society of Cardiology (ESC) guidelines on the cardiovascular assessment and management of patients undergoing non-cardiac surgery were published in August 2022. In the preparation of the new document the previous guidelines published in 2014 were completely revised and the recommendations for action were adapted or renewed. Furthermore, the guidelines have been supplemented with some new chapters. The new and revised recommendations result in significant changes for the clinical practice. This particularly applies to the preoperative risk stratification, the perioperative risk management and the detection and management approaches in cases of perioperative and postoperative complications. Cardiovascular biomarkers play a special role in both the preoperative risk stratification and the detection of postoperative complications in combination with appropriate algorithms for action. The perioperative management of antithrombotic treatment (antiplatelet therapy or oral anticoagulation) is becoming increasingly individualized depending on the risk of ischemia or bleeding of the planned surgery. Particular attention is paid to the early detection of perioperative or postoperative myocardial infarctions based on determination of high-sensitivity (hs) cardiac troponin, not least because its association with high risk of morbidity and mortality. In patients with complex cardiovascular diseases, such as severe coronary artery disease, valvular heart diseases or those with ventricular support systems, the decision in an interdisciplinary team is highly recommended.
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Pavlenko TA, Lebedeva AY, Protsenko DN. Bridging therapy according to new clinical guidelines: A review. CONSILIUM MEDICUM 2022. [DOI: 10.26442/20751753.2022.10.201912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In modern world it is really important to know how to manage patients taking anticoagulant or antiplatelet therapy. There is an increasing number of patients, who have gone through PCI or any other cardiac intervention and who also need another surgery which cannot be postponed till the end of dual antiplatelet therapy. The number of patients who take oral anticoagulant has also increased last years. Algorithms of perioperative bridging therapy and antiplatelet therapy discontinuation can help to decrease both ischemic and hemorrhagic complications. Multidisciplinary risk assessment remains a critical component of perioperative care.
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 300] [Impact Index Per Article: 150.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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8
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Calderaro D, Bichuette LD, Maciel PC, Cardozo FAM, Ribeiro HB, Gualandro DM, Baracioli LM, Soeiro ADM, Serrano CV, Costa RAD, Caramelli B. Update of the Brazilian Society of Cardiology's Perioperative Cardiovascular Assessment Guideline: Focus on Managing Patients with Percutaneous Coronary Intervention - 2022. Arq Bras Cardiol 2022; 118:536-547. [PMID: 35262593 PMCID: PMC8856674 DOI: 10.36660/abc.20220039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Daniela Calderaro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Dornfeld Bichuette
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Pamela Camara Maciel
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Danielle Menosi Gualandro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel - Suíça
| | - Luciano Moreira Baracioli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Alexandre de Matos Soeiro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital BP Mirante, São Paulo, SP - Brasil
| | - Carlos Vicente Serrano
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Bruno Caramelli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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9
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Thim T, Egholm G, Kristensen SD, Olesen KKW, Madsen M, Jensen SE, Jensen LO, Sørensen HT, Bøtker HE, Maeng M. Risk of Myocardial Infarction and Death After Noncardiac Surgery Performed Within the First Year After Coronary Drug-Eluting Stent Implantation for Acute Coronary Syndrome or Stable Angina Pectoris. Am J Cardiol 2021; 160:14-20. [PMID: 34583812 DOI: 10.1016/j.amjcard.2021.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
This study aimed to examine the 30-day risk of myocardial infarction (MI) and death in patients who underwent noncardiac surgery within 1 year after coronary drug-eluting stent implantation for acute coronary syndrome (ACS) or stable angina pectoris (SAP) and to compare it with the risk in surgical patients without known coronary artery disease. Patients with drug-eluting stent implantation for ACS (n = 2,291) or SAP (n = 1,804) who underwent noncardiac surgery were compared with a cohort from the general population without known coronary artery disease matched on the surgical procedure, hospital contact type, gender, and age. In patients with ACS, the 30-day MI risk was markedly increased when surgery was performed within 1 month after stenting (10% vs 0.8%; adjusted odds ratio [ORadj] 20.1, 95% confidence interval [CI] 8.85 to 45.6), whereas mortality was comparable (10% vs 8%, ORadj 1.17, 95% CI 0.76 to 1.79). When surgery was performed between 1 and 12 months after stenting, the 30-day absolute risk for MI was low but higher than in the comparison cohort (0.6% vs 0.2%, ORadj 2.18, 95% CI 0.89 to 5.38), whereas the mortality risks were similar (2.0% vs 1.8%, ORadj 1.03, 95% CI 0.69 to 1.55). In patients with SAP, the 30-day MI risk was low but higher than in the comparison cohort (0.4% vs 0.2%, ORadj 1.90, 95% CI 0.70 to 5.14), whereas the mortality risks were similar (2.2% vs 2.1%, ORadj 0.91, 95% CI 0.61 to 1.37). In conclusion, patients with ACS and SAP who underwent surgery between 1 and 12 months after stent implantation had a risk for MI and death that was similar to the risk observed in surgical patients without coronary artery disease.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Gro Egholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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10
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Valenti R, Muraca I, Marcucci R, Ciatti F, Berteotti M, Gori AM, Carrabba N, Migliorini A, Marchionni N, Valgimigli M. "Tailored" antiplatelet bridging therapy with cangrelor: moving toward personalized medicine. Platelets 2021; 33:687-691. [PMID: 34672898 DOI: 10.1080/09537104.2021.1983162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the setting of patients with indication to receive dual antiplatelet therapy undergoing surgery or invasive procedures, the risk of perioperative cardiac ischemic events, particularly stent thrombosis, is high, because surgery has a prothrombotic effect and antiplatelet therapy is withdrawn in order to avoid bleeding complications. Cangrelor, an intravenous P2Y12 receptor antagonist, has been tested in a randomized trial as a "bridge" to cardiac surgery from discontinuation of oral P2Y12 receptor antagonists. Thus, a consensus document extended its off-label use in this setting and before non-cardiac surgery. Currently, despite the implementation of a standardized bridging protocol with cangrelor, a residual risk of adverse outcome mainly due to bleeding events, still persist during the perioperative phase.Accordingly, a personalized management driven by platelet reactivity serial measurements and careful assessment of ischemic and bleeding risks has potential to optimize outcomes and costs as compared to a standardized bridging protocol, based on average pharmacodynamic data of oral P2Y12 inhibitors.While specific indications for bridging have been extensively addressed in the aforementioned consensus statement, the aim of the present document is the proposal of a "tailored" clinical decision-making algorithm inspired to the principle of personalized medicine dealing with complex clinical scenarios.
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Affiliation(s)
- Renato Valenti
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Iacopo Muraca
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Rossella Marcucci
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesca Ciatti
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Martina Berteotti
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Anna Maria Gori
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Nazario Carrabba
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Angela Migliorini
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Marco Valgimigli
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (Eoc), Lugano, Switzerland; Department of Cardiology, University of Bern, Bern, Switzerland
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11
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Cao D, Levin MA, Sartori S, Claessen B, Roumeliotis A, Zhang Z, Nicolas J, Chandiramani R, Bedekar R, Waseem Z, Goel R, Chiarito M, Lupo B, Jhang J, Dangas GD, Baber U, Bhatt DL, Sharma SK, Kini AS, Mehran R. Perioperative risk and antiplatelet management in patients undergoing non-cardiac surgery within 1 year of PCI. J Thromb Thrombolysis 2021; 53:380-389. [PMID: 34386899 DOI: 10.1007/s11239-021-02539-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, especially in patients with recent percutaneous coronary intervention (PCI). We aimed to illustrate the types and timing of different surgeries occurring after PCI, and to evaluate the risk of thrombotic and bleeding events according to the perioperative antiplatelet management. Patients undergoing urgent or elective non-cardiac surgery within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, or stent thrombosis) at 30 days. Perioperative bleeding was defined as ≥ 2 units of blood transfusion. A total of 1092 surgeries corresponding to 747 patients were classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones, and were associated with an increased risk of both MACE and bleeding. Preoperative interruption of antiplatelet therapy (of any kind) occurred in 44.6% of all NCS and was more likely for procedures occurring later post-PCI and at intermediate risk. There was no significant association between interruption of antiplatelet therapy and adverse cardiac events. Among patients undergoing NCS within 1 year of PCI, perioperative ischemic and bleeding events primarily depend on the estimated surgical risk and urgency of the procedure, which are increased early after PCI. Preoperative antiplatelet interruption was not associated with an increased risk of cardiac events.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bimmer Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anastasios Roumeliotis
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rashi Bedekar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zaha Waseem
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy, and Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Bonnie Lupo
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Jhang
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- The University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annapoorna S Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA.
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12
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Milder DA, Kam PC. Perioperative implications of newer generation drug-eluting coronary stents: A narrative review. Anaesth Intensive Care 2021; 49:338-348. [PMID: 34134534 DOI: 10.1177/0310057x20984792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Newer generation drug-eluting stents are the most commonly inserted stent in the setting of percutaneous coronary intervention. This narrative review focuses on the evidence underpinning the perioperative management of patients with newer generation drug-eluting stents undergoing non-cardiac surgery. Six studies reported the incidence of major adverse cardiovascular events according to the time interval from percutaneous coronary intervention to non-cardiac surgery, and the comparative risks of newer and first generation drug-eluting stents. No study demonstrated an increased risk of major adverse cardiovascular events once three months had elapsed between stent implantation and non-cardiac surgery. Only one study included patients with third and fourth generation drug-eluting stents. Seven studies analysed the relationship between antiplatelet therapy, major adverse cardiovascular events and perioperative bleeding. The risks of major adverse cardiovascular events do not appear to be increased if antiplatelet therapy is ceased for less than seven days but are increased if it is discontinued for more than seven days. Most studies reported no differences in the incidence of major bleeding associated with antiplatelet therapy. The risk of perioperative major adverse cardiovascular events in non-cardiac surgery does not appear to be increased after three months following implantation with newer generation drug-eluting stents. However, the possibility of increased risk cannot be excluded as most studies were inadequately powered. The thrombotic risk is substantially reduced in patients with fourth (polymer free) generation drug-eluting stents, and urgent non-cardiac surgery can be considered one month after percutaneous coronary intervention. Larger multicentre studies are needed to define the optimal window for non-cardiac surgery after percutaneous coronary intervention and provide definitive perioperative strategies for patients presenting for non-cardiac surgery after the implantation of newer generation drug-eluting stents.
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Affiliation(s)
- David A Milder
- Department of Anaesthesia, Concord Repatriation General Hospital, Concord, Australia
| | - Peter Ca Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia.,Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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13
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Zheleva-Kyuchukova I, Gelev V. Antiplatelet therapy after PCI in patients with high risk of bleeding. PHARMACIA 2020. [DOI: 10.3897/pharmacia.67.e52737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The progress of percutaneous coronary interventions (PCI) over the last few decades facilitated treatment of increasingly complex patient populations. The introduction of drug-eluting stents (DESs) led to need of stronger and prolonged inhibition of platelets which in turn increased the incidence of bleeding complications. The identification and management of patients at high bleeding risk (HBR) during and after percutaneous coronary interventions (PCI) is still problematic in everyday clinical practice.
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Abstract
IMPORTANCE Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. OBSERVATIONS Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose β-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without β-blocker use; P = .005) and mortality (3.1% vs 2.3% without β-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. CONCLUSIONS AND RELEVANCE Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.
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Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
- Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, New York
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
- Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, New York
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Abstract
PURPOSE OF REVIEW Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. RECENT FINDINGS Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. SUMMARY Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.
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Smith BB, Warner MA, Warner NS, Hanson AC, Smith MM, Rihal CS, Gulati R, Bell MR, Nuttall GA. Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents. Anesth Analg 2019; 128:621-628. [PMID: 30169404 DOI: 10.1213/ane.0000000000003408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Second-generation drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0-90, 91-180, 181-365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0-90 days and 3.4 (0.8 to 15.3) at 91-180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT.
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Affiliation(s)
- Bradford B Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Matthew A Warner
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - Mark M Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Charanjit S Rihal
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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18
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Smilowitz NR, Lorin J, Berger JS. Risks of noncardiac surgery early after percutaneous coronary intervention. Am Heart J 2019; 217:64-71. [PMID: 31514076 DOI: 10.1016/j.ahj.2019.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Prior registry data suggest that 4%-20% of patients require noncardiac surgery (NCS) within 2 years of percutaneous coronary intervention (PCI). Contemporary data on NCS after PCI in the United States among women and men are limited. We determined the rate of early hospital readmission for NCS and associated outcomes in a large cohort of patients who underwent PCI in the United States. METHODS Adults undergoing PCI between January 1 and June 30, 2014, were identified from the Nationwide Readmission Database. Patients readmitted for NCS within 6 months of PCI were identified. Outcomes of interest were in-hospital death, myocardial infarction (MI), and bleeding defined by International Classification of Diseases, Ninth Revision, codes. RESULTS Among 221,379 patients who underwent PCI and survived to hospital discharge, 3.5% (n = 7,696) were readmitted for NCS within 6 months post-PCI, and 41% of these hospitalizations were elective. Early NCS was complicated by MI in 4.7% of cases, and 21% of perioperative MIs were fatal. Bleeding was recorded in 32.0% of patients. All-cause mortality occurred in 4.4% of patients (n = 339) readmitted for surgery. The risk of death or MI was greatest when NCS was performed within the first month after PCI. CONCLUSIONS Despite clear guidelines to avoid surgery early after PCI, NCS was performed in 1 of every 29 patients with recent PCI, corresponding to as many as ~30,000 patients each year nationwide. Surgical mortality and perioperative MI were high in this setting. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.
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Perioperative kardiovaskuläre Morbidität und Letalität bei nichtherzchirurgischen Eingriffen. Anaesthesist 2019; 68:653-664. [DOI: 10.1007/s00101-019-0616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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20
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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Zhao SG, Xu JJ, Xu L, Zheng JF, Zhou ZC, Jiang LQ. Ileal perforation caused by a fish bone shortly after drug-eluting stent implantation for acute myocardial infarction. J Int Med Res 2019; 47:2709-2715. [PMID: 31014143 PMCID: PMC6567709 DOI: 10.1177/0300060519842778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
During the past century, the incidence of myocardial infarction has markedly increased worldwide. Percutaneous coronary intervention with stent implantation is often considered as the first-choice treatment, especially in emergency cases. Current guidelines recommend delayed elective noncardiac surgery for such vulnerable patients. However, few suggestions are available regarding the exact treatment strategy for patients who have already undergone percutaneous coronary intervention but suddenly need emergent noncardiac surgery for an unrelated reason. We herein present a case involving a patient with acute myocardial infarction who had undergone implantation of a drug-eluting stent and developed an ileal perforation due to fish bone ingestion 3 days postoperatively. After carefully balancing the risks of stent thrombosis and uncontrollable bleeding, dual antiplatelet therapy and low-molecular-weight heparin were given with close monitoring. Emergency laparotomy and partial small bowel resection surgery were then performed, after which the patient eventually recovered. This case indicates a possible management strategy for patients with acute myocardial infarction complicated by emergency noncardiac surgery.
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Affiliation(s)
- Sheng-Gang Zhao
- 1 Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
| | - Jian-Jiang Xu
- 1 Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
| | - Li Xu
- 2 Department of Radiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
| | - Ji-Feng Zheng
- 1 Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
| | - Zhong-Cheng Zhou
- 3 Department of General Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
| | - Li-Qin Jiang
- 1 Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, ZheJiang Province, China
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Cinnella G, Pavesi M, De Gasperi A, Ranucci M, Mirabella L. Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Minerva Anestesiol 2019; 85:635-664. [PMID: 30762323 DOI: 10.23736/s0375-9393.19.12151-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.
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Affiliation(s)
- Gilda Cinnella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco Pavesi
- Division of Multispecialty Anesthesia Service of Polispecialistic Anesthesia, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Andrea De Gasperi
- Division of Anesthesia and Resuscitation, Niguarda Hospital, Milan, Italy
| | - Marco Ranucci
- Division of Anesthesia and Cardio-Thoraco-Vascular Therapy, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Lucia Mirabella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy -
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Thim T, Egholm G, Olesen KKW, Madsen M, Jensen SE, Jensen LO, Bøtker HE, Kristensen SD, Maeng M. Coronary stent implantation and adverse cardiac events after surgery. Eur J Clin Invest 2018; 48:e13030. [PMID: 30246381 DOI: 10.1111/eci.13030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/19/2018] [Accepted: 09/19/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the risk assessment of patients considered for non-cardiac surgery and with recent coronary stent implantation, coronary drug-eluting stent implantation procedure characteristics may be taken into account. We aimed to evaluate associations between coronary drug-eluting stent implantation procedure characteristics and the risk of myocardial infarction and all-cause death within 30 days after non-cardiac surgery. DESIGN Patients with coronary drug-eluting stents were identified using the Western Denmark Heart Registry. Surgical procedures performed after stent implantation were detected using the Danish National Patient Registry. We used registry-based detection of myocardial infarction and all-cause death. RESULTS Of 22 590 patients treated with drug-eluting stents between 2005 and 2012, 4046 underwent non-cardiac surgery within 1 and 12 months after stent implantation. We found no significant association between the risk of myocardial infarction or all-cause death within 30 days after surgery and number of arteries treated (1 [reference] vs more), number of lesions treated (1 [reference] vs more), segments treated (left main and proximal left anterior descending artery vs other [reference]), total stent length (<20 mm [reference] vs ≥20 mm), number of stents (1 [reference] vs >1) and largest balloon diameter (≥3 mm [reference] vs <3 mm). All-cause death, but not myocardial infarction, risk was lower among patients treated with first-generation vs second-generation stents (odds ratio 0.58). CONCLUSIONS We identified no significant associations between stent implantation procedure characteristics and risk of myocardial infarction or all-cause death among patients undergoing non-cardiac surgery. All-cause death was lower with first- vs second-generation drug-eluting stents.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gro Egholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Borioni R, Tomai F, De Persio G, Fratticci L, Tesori MC, Paciotti C, Garofalo M. Safety of carotid endarterectomy early after percutaneous coronary interventions. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2018. [DOI: 10.23736/s1824-4777.18.01371-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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Graham MM, Sessler DI, Parlow JL, Biccard BM, Guyatt G, Leslie K, Chan MTV, Meyhoff CS, Xavier D, Sigamani A, Kumar PA, Mrkobrada M, Cook DJ, Tandon V, Alvarez-Garcia J, Villar JC, Painter TW, Landoni G, Fleischmann E, Lamy A, Whitlock R, Le Manach Y, Aphang-Lam M, Cata JP, Gao P, Terblanche NCS, Ramana PV, Jamieson KA, Bessissow A, Mendoza GR, Ramirez S, Diemunsch PA, Yusuf S, Devereaux PJ. Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery. Ann Intern Med 2018; 168:237-244. [PMID: 29132159 DOI: 10.7326/m17-2341] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. OBJECTIVE To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. DESIGN Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874). SETTING 135 centers in 23 countries. PATIENTS Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery. INTERVENTION Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up. MEASUREMENTS The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome. RESULTS In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, -2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50). LIMITATION Nonprespecified subgroup analysis with small sample. CONCLUSION Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Michelle M Graham
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada (M.M.G.)
| | | | - Joel L Parlow
- Queen's University, Kingston, Ontario, Canada (J.L.P.)
| | - Bruce M Biccard
- Groote Schuur Hospital and University of Cape Town, Western Cape, South Africa (B.M.B.)
| | - Gordon Guyatt
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Kate Leslie
- Royal Melbourne Hospital, Melbourne Medical School, University of Melbourne, and Monash University, Melbourne, Victoria, Australia (K.L.)
| | | | - Christian S Meyhoff
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark (C.S.M.)
| | - Denis Xavier
- St. John's Medical College and Research Institute, Bangalore, India (D.X.)
| | | | - Priya A Kumar
- University of North Carolina, Chapel Hill, North Carolina (P.A.K.)
| | - Marko Mrkobrada
- Schulich School of Medicine & Dentistry at Western University, London, Ontario, Canada (M.M.)
| | - Deborah J Cook
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Vikas Tandon
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Jesus Alvarez-Garcia
- Sant Pau Hospital and Biomedical Research Institute, Autonomous University of Barcelona, Research Center of Cardiovascular Diseases (CIBERCV), Barcelona, Spain (J.A.)
| | - Juan Carlos Villar
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia, and Department of Medicine, Universidad Autónoma de Bucaramanga, Santander, Colombia (J.C.V.)
| | - Thomas W Painter
- University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia (T.W.P.)
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy (G.L.)
| | | | - Andre Lamy
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Richard Whitlock
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Yannick Le Manach
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - Meylin Aphang-Lam
- Hospital Arzobispo Loayza, Universidad Peruana Cayetano Heredia, Lima, Peru (M.A.)
| | - Juan P Cata
- The University of Texas MD Anderson Cancer Center, Houston, Texas (J.P.C.)
| | - Peggy Gao
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | | | | | | | - Amal Bessissow
- McGill University Health Centre, Montréal, Québec, Canada (A.B.)
| | | | - Silvia Ramirez
- Hospital Universitario Fundación Hospital Alcorcon, Madrid, Spain (S.R.)
| | - Pierre A Diemunsch
- Centre Hospitalier Universitaire de Hautepierre, Strasbourg, France (P.A.D.)
| | - Salim Yusuf
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
| | - P J Devereaux
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (G.G., D.J.C., V.T., A.L., R.W., Y.L., P.G., S.Y., P.D.)
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Abstract
PURPOSE OF REVIEW Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.
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Affiliation(s)
- Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA.
| | - Sibu P Saha
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA
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28
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Zwart B, Godschalk TC, Kelder JC, Ten Berg JM. High risk of stent thrombosis in the first 6 months after coronary stenting: Do not discontinue clopidogrel early after ACS. J Interv Cardiol 2017; 30:421-426. [PMID: 28836297 DOI: 10.1111/joic.12413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the incidence of stent thrombosis (ST) after early discontinuation of clopidogrel. BACKGROUND Premature discontinuation of clopidogrel is the strongest risk factor for ST. In contrast, recent studies suggest that shorter dual antiplatelet therapy (DAPT) can be discontinued as soon as 3 months after stenting. However, these studies included very few ACS patients and were not powered for ST. Hence, little is known about the occurrence of ST in high-risk populations when DAPT is discontinued early. METHODS This is a subanalysis of The Dutch ST Registry 437 ST cases (mainly first-generation DES and BMS). Acute coronary syndrome was the indication for index-PCI in 74% of the patients. Clopidogrel discontinuation rates in ST patients and matched controls were used to calculate the absolute incidence of ST after early clopidogrel discontinuation. RESULTS The overall rate of ST after cessation of clopidogrel was 4.6% (95%CI: 3.9-5.4%), as compared to 1.7% (95%CI: 1.5-1.9%) in patients who did not discontinue clopidogrel. The incidence of ST was 35.4% when clopidogrel was discontinued in the first 30 days after index-PCI declining to 11.7% when clopidogrel was discontinued in the first 180 days. CONCLUSIONS This dedicated ST registry shows that ST rates were very high when clopidogrel was discontinued before 6 months after index-PCI and therefore suggests that clopidogrel discontinuation in the first 6 months after ACS should be avoided.
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Affiliation(s)
- Bastiaan Zwart
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thea C Godschalk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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29
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Abstract
Up to 15-23% of the patients with percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation need a surgical procedure <12 months from PCI. Perioperative risk stratification in these patients is challenging and should take into account many individual clinical and anatomic variables, along with the intrinsic surgical risk for ischemic and bleeding events. The presence of DES has always been considered as a harbinger of doom. In fact, DES are associated with delayed vascular healing and require longer dual antiplatelet treatment. Perioperative pharmacologic management in those patients is intricate because of the tradeoff between the increased thrombotic risk associated with premature DAPT discontinuation and the increased risk of bleeding in the presence of antithrombotics. Whilst most of the studies agree upon the inverse relationship between time from stenting to surgery and cardiac risk, more recent data challenge the previous belief that surgery should be deferred at least 12 months after DES implantation and this safety window could be shortened to <6 months or even less with new-generation DES. The aim of this brief commentary is to critically review available data about cardiac risk associated with surgery in patients with coronary drug-eluting stents.
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Affiliation(s)
- Francesco Saia
- Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
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30
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Dalal A. Organ transplantation and drug eluting stents: Perioperative challenges. World J Transplant 2016; 6:620-631. [PMID: 28058211 PMCID: PMC5175219 DOI: 10.5500/wjt.v6.i4.620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/18/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Patients listed for organ transplant frequently have severe coronary artery disease (CAD), which may be treated with drug eluting stents (DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis (ST) in the perioperative period. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyNow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.
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31
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Egholm G, Kristensen SD, Thim T, Olesen KK, Madsen M, Jensen SE, Jensen LO, Sørensen HT, Bøtker HE, Maeng M. Risk Associated With Surgery Within 12 Months After Coronary Drug-Eluting Stent Implantation. J Am Coll Cardiol 2016; 68:2622-2632. [DOI: 10.1016/j.jacc.2016.09.967] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/28/2016] [Accepted: 09/27/2016] [Indexed: 12/30/2022]
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Barra ME, Fanikos J, Gerhard-Herman MD, Bhatt DL. Bridging Experience With Eptifibatide After Stent Implantation. Crit Pathw Cardiol 2016; 15:82-88. [PMID: 27465001 DOI: 10.1097/hpc.0000000000000084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Patients who have undergone intracoronary stent implantation often require surgery within the first year after the procedure. Planned or emergent surgical intervention requires interruption of antiplatelet therapy and is associated with an increased risk of stent thrombosis. Eptifibatide, an intravenous glycoprotein IIb/IIIa inhibitor (GPIIb/IIIa), can be considered for antiplatelet bridging of high-risk patients in the periprocedural period. OBJECTIVES The aim of this report is to describe the management of antiplatelet therapy and outcomes of patients who were bridged with eptifibatide perioperatively within 1 year of intracoronary stent implantation. METHODS We performed a retrospective analysis of patients identified through the hospital's computer system consecutively from January 1, 2011 to December 31, 2014. We included 18 patients who were bridged from an oral P2Y12-receptor antagonist with eptifibatide before surgery. Outcome measures were the incidence of thromboembolic events or stent thrombosis within 30 days of surgery and death within 90 days of hospital discharge. Safety measures were the incidence of thrombolysis in myocardial infarction major, minor, or minimal bleeding. RESULTS Of the 18 patients assessed, no patients experienced thromboembolic events or stent thrombosis. There was one major bleeding event and one minimal bleeding event postoperatively. Antiplatelet therapy management was highly variable in the perioperative period with 72.2% receiving the recommended GPIIb/IIIa loading dose, 50% of patients not continuing aspirin throughout the surgery, 27.8% of patients stopping antiplatelet therapy less than 5 days before surgery, and 50% not receiving a loading dose of an oral P2Y12-receptor antagonist postoperatively. CONCLUSIONS Within a limited sample size, bridging with an intravenous GPIIb/IIIa inhibitor appeared feasible. Further study is needed on the optimal strategy to manage patients with recent stenting who need surgical procedures.
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Affiliation(s)
- Megan E Barra
- From the Department of Pharmacy and Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA
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