Download Supplemental Content

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts

Drug-eluting stent wikipedia , lookup

Transcript
From the Publishers of
An MI, a Stent, Bleeding, and Surgery!
What Do I Do?
COPYRIGHT © 2016, ALL RIGHTS RESERVED
Terms of Use
The Consult Guys® slide sets are owned and copyrighted by the American College
of Physicians (ACP). All text, graphics, trademarks, and other intellectual property
incorporated into the slide sets remain the sole and exclusive property of ACP.
The slide sets may be used only by the person who downloads or purchases them
and only for the purpose of presenting them during not-for-profit educational
activities. Users may incorporate the entire slide set or selected individual slides
into their own teaching presentations but may not alter the content of the slides in
any way or remove the ACP copyright notice.
Users may make print copies for use as hand-outs for the audience the user is
personally addressing but may not otherwise reproduce or distribute the slides by
any means or media, including but not limited to sending them as e-mail
attachments, posting them on Internet or Intranet sites, publishing them in meeting
proceedings, or making them available for sale or distribution in any unauthorized
form, without the express written permission of the ACP. Unauthorized use of the
Consult Guys® slide sets constitutes copyright infringement.
Copyright © 2016
Copyright © 2016
Patient
Copyright © 2016
Patient
Copyright © 2016
Cardiac cath post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
Copyright © 2016
PTCA post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
Copyright © 2016
Clear for Surgery?
Our Concerns:

Perioperative Risk

Antiplatelet management in the perioperative
period
Copyright © 2016
How to Determine Risk of MACE
 Low risk (<1%)
 Increased risk ( > 1%)
Copyright © 2016
211,410 + 257,385 = 468,795 patients
*Gupta PK et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery.
Circulation. 2011;124:381-387, published online before print July 5 2011, doi:10.1161/CIRCULATIONAHA.110.015701
Patient
 Age: 85
 Cr: > 1.5
 ASA Class: III (severe systemic disease)
 Functional: Independent
 Surgery: Intestinal
 Risk probability for perioperative MI or cardiac
arrest: 2.3%
Copyright © 2016
Risk predictors
4315 + 1422 = 5737 patients
High risk OR
Hx CAD
Hx CHF
Cerebrovasc dx
Diabetic insulin
Cr > 2
*Lee TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery.
Circulation. 1999;100:1043-1049, doi:10.1161/01.CIR.100.10.1043
Revised Cardiac Index
 High risk surgery: intraperitoneal
 CAD: prior MI
 CHF: No
 Cerebrovascular disease: No
 Diabetes on insulin: Yes
 Serum creatinine > 2mg/dl: Yes
 Risk of MI, pulmonary edema, ventricular
fibrillation, cardiac arrest, complete heart block:
> 11%
Copyright © 2016
Perioperative Risk
 Risk of major cardiac event or death: 2.3 - > 11%
 Risk of not performing the surgery:



Continued GI bleed
Cancer growth
Bowel obstruction
Copyright © 2016
Stent
 Bleeding risk vs stent thrombosis
 Second generation DES since 2008

Less stent thrombosis
Copyright © 2016
ACC AHA 2014 Guideline
Delay elective surgery after stent
 Balloon angioplasty without stent: 14 days
 Bare metal stent: 30 days
 Drug eluting stent: 365 days
 Drug eluting stent: 180 days

If risk of delaying surgery is greater than the risk of stent
thrombosis – myocardial ischemia consider NCS after
180 days
*Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation
and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137.
doi:10.1016/j.jacc.2014.07.944.
European Society of Cardiology 2014 Guideline
Delay elective surgery after stent
 Bare metal stent: 4 week minimum, 3 months ideal
 Drug eluting stent (new generation): 6 months
A
minimum of 3 months might be acceptable
*The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC)
and the European Association for Cardio-Thoracic Surgery (EACTS). 2014 ESC/EACTS
Guidelines on myocardial Revascularization. European Heart Journal (2014) 35, 2541–2619.
NCS during the 2 years following stent
Risk of MI or need for coronary revascularization
 VA retrospective – older men
 Stents placed 2000 - 2010
 Risk highest (3.5%) immediately after stent
 Risk stabilizes (1.0%) at 6 months post stent
 Especially true for drug eluting stent
*Holcomb CN, Graham LA, Richman JS, et al. The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following
Coronary Stenting. J Am Coll Cardiol. 2014;64(25):2730-2739. doi:10.1016/j.jacc.2014.09.072.
Perioperative Cardiovascular Risk
 NSQIP database
 Mayo Clinic
 1120 patients with stents then NCS
2006 to 2011
 Risk of major adverse cardiac event and bleeding elevated
for 1 year post stent

*Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation
Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2016;67(9):1038-1049.
doi:10.1016/j.jacc.2015.11.063.
Time to stent thrombosis
Stop ASA, stop
thienopyridine
Median 7 days
Continue ASA, stop
thienopyridine
Median 122 days (6% within
10 d)
*Eisenberg MJ et al. Safety of Short-Term Discontinuation of Antiplatelet Therapy in Patients With Drug-Eluting Stents.
Circulation. 2009; 119: 1634-1642 .
85-year-old man
right colectomy
 Continue aspirin
 Discontinue clopidogrel 5 days preop
 Resume clopidogrel asap postop
 Loading dose 300mg
 Heightened surveillance for postop stent
thrombosis
Copyright © 2016
85-year-old man
right colectomy
 Don’t forget other agents to decrease risk
 Statin
 Continue
beta blocker
 His anemia at time of NSTEMI should have raised
concern about drug eluting stent committing him to
long term asa + clopidogrel
Copyright © 2016
Produced by
and
Copyright © 2016
COPYRIGHT © 2016, ALL RIGHTS RESERVED