Preoperative Cardiac Stents Perioperative Management · 2018-03-31 · zMarch 2003-Sirolimus-eluting (Cypher ... Registry. Circulation 2006;113:2803-9. Catastrophic Outcomes ... •

Preoperative Cardiac Preoperative Cardiac StentsStents

Perioperative Perioperative ManagementManagement

Mark A. Taylor, MDMark A. Taylor, MDDepartment of AnesthesiaDepartment of Anesthesia

RevascRevasc prior to NCSprior to NCS

If it offered long term benefitIf it offered long term benefit----made sense made sense to do itto do it11--2 vessel CAD by angiogram, no benefit 2 vessel CAD by angiogram, no benefit to to revascrevasc compared with aggressive med compared with aggressive med managementmanagementPCI with DES increase risk if PCI with DES increase risk if antiplateletantiplatelet is is interrupted for NCS?interrupted for NCS?

Stent TherapyStent TherapyNumber of PCI > CABGNumber of PCI > CABGStents used in majority of Stents used in majority of PCIsPCIs

Increase procedural successIncrease procedural successDecrease Decrease restenosisrestenosis ratesrates

BMS vs. DESBMS vs. DESPrevents Prevents restenosisrestenosisMarch 2003March 2003--SirolimusSirolimus--eluting (eluting (CypherCypher®®))April 2004April 2004--PaclitaxelPaclitaxel--eluting (eluting (TaxusTaxus®®))2005, 85% of stents were DES2005, 85% of stents were DES

Stent ThrombosisStent ThrombosisRisksRisks

SupoptimalSupoptimalangiographic resultangiographic resultHigh risk lesionsHigh risk lesions

•• SmallSmall•• Bifurcated lesionsBifurcated lesions•• Overlapping DESOverlapping DES

DiabetesDiabetesRenal failureRenal failureLow EFLow EF

PreventionPreventionGood Angiographic Good Angiographic resultsresultsDual Dual antiplateletantiplatelettherapytherapyRegional vs. GARegional vs. GA

•• 1993 study of arterial 1993 study of arterial thrombosis (thrombosis (RosenfieldRosenfieldet al. et al. AnesiologyAnesiology))

Stent ThrombosisStent ThrombosisDESDES

Risk between 0.5%Risk between 0.5%--3.5%3.5%Catastrophic outcomesCatastrophic outcomesFatality rate 45%Fatality rate 45%--75%75%MI rates 25%MI rates 25%--65%65%

Degree of endothelial coverageDegree of endothelial coverageIntensity of Intensity of antiplateletantiplatelet therapytherapy

Newsome, LT, etal. Coronary Artery Stents: Part I. Evolution of Percutaneous CoronaryIntervention. Anes & Anal 2008;107 (2):552-569.

Stent evaluationsStent evaluations

BMS BMS Complete Complete endotheliazationendotheliazation by 28 daysby 28 days

DESDESIncomplete healing, fibrin Incomplete healing, fibrin depostiondepostion and and inflammatory cells at 6 monthsinflammatory cells at 6 months

SirolimusSirolimus activates platelets and induces activates platelets and induces aggregationaggregation

Premature DiscontinuationPremature Discontinuation

Greatest Predictor of stent thrombosisGreatest Predictor of stent thrombosisPremier RegistryPremier Registry

500 patients with acute MI with DES500 patients with acute MI with DES7.5% mortality rate among patients who 7.5% mortality rate among patients who prematurely prematurely d/cedd/ced thienopyridinethienopyridine treatmenttreatmentPts who remained on ASA and Pts who remained on ASA and clopidogrelclopidogrelhad a 0.7% mortality ratehad a 0.7% mortality rate

Spertus et al. Prevalence, predictors and outcomes of premature discontinuation of Thienopyridine therapy after drug-eluting stent placement: results from the PREMIERRegistry. Circulation 2006;113:2803-9.

Catastrophic OutcomesCatastrophic OutcomesKaluzaKaluza in 2000 NCS within 6 wks of PCI in 2000 NCS within 6 wks of PCI NCS after PCINCS after PCI----40 patients with BMS40 patients with BMS

7 MI7 MI11 major bleeds11 major bleeds8 deaths8 deaths

PosnerPosnerPCI within 90 days of NCS associated with PCI within 90 days of NCS associated with complication rates similar to patients with CAD complication rates similar to patients with CAD without without revascrevasc

BASKET LATEBASKET LATE

How long to treat with How long to treat with antiplateletantiplatelet agents agents to prevent late eventsto prevent late eventsWhat happens after What happens after antiplateletantiplatelet therapy therapy endsends

neointimalhyperplasia

thrombus


RCT DES RCT DES vsvs BMS (2:1 ratio)BMS (2:1 ratio)Survived 6 months without eventSurvived 6 months without eventStopped Stopped clopidogrelclopidogrelFollowed for an additional 12 monthsFollowed for an additional 12 monthsLate clinical events (7Late clinical events (7--18 18 mthmth))Late stent thrombosis (7Late stent thrombosis (7--18 18 mthmth))

Pfisterer, M. et al. Late Clinical Events After Clopidogrel Discontinuation May Limit Benefit of Drug Eluting Stents. JACC 2006 48:12;2584-91.


Nonfatal MI and cardiac death/MI were higherPfisterer, M. et al. Late Clinical Events After Clopidogrel Discontinuation May Limit B fi f D El i S JACC 2006 48 12 2584 91


Angiographic thrombosis rates the samePfisterer, M. et al. Late Clinical Events After Clopidogrel Discontinuation May Limit


Thrombosis related event much higher risk of bad outcomePfisterer, M. et al. Late Clinical Events After Clopidogrel Discontinuation May Limit

fi f l i


Thrombosis related eventThrombosis related eventMedian time 116 daysMedian time 116 daysRange between 15 days to 362 daysRange between 15 days to 362 days



Benefit of lower rate of Benefit of lower rate of reinterventionsreinterventions vs. vs. late complicationlate complicationLate stent thrombosis after discontinuation Late stent thrombosis after discontinuation of of clopidogrelclopidogrel may limit net clinical benefitmay limit net clinical benefit


BASKET LATEBASKET LATEConclusionsConclusions----ClopidogrelClopidogrel discontinuationdiscontinuation

Late stent thrombosisLate stent thrombosis•• 22--3 times higher in patients with DES3 times higher in patients with DES•• Carried 4 times higher risk of cardiac death or MI Carried 4 times higher risk of cardiac death or MI

vsvs non thrombosis related eventsnon thrombosis related events•• Occurred after 1 year after drug terminationOccurred after 1 year after drug termination•• More frequent in following patientsMore frequent in following patients

Previous MIPrevious MINeed for Need for IIbIIIaIIbIIIa inhibitors initiallyinhibitors initiallyDESDES


BASKET + BASKET LATEBASKET + BASKET LATE

In 100 patientsIn 100 patientsMay avoid 5 major cardiac May avoid 5 major cardiac events/interventions at 6 months but lead to 3 events/interventions at 6 months but lead to 3 patients suffering cardiac death or nonfatal MI patients suffering cardiac death or nonfatal MI during months 7during months 7--1818


CamenzindCamenzind et al 09/06et al 09/06MetaMeta--analysis of all company supported analysis of all company supported RCTRCT----3 yr follow up3 yr follow upSirolimusSirolimus--DES 60% relative increase in DES 60% relative increase in death or MI (P = 0.03)death or MI (P = 0.03)PaclitaxelPaclitaxel-- DES 15% increase (NS)DES 15% increase (NS)““late stent thrombosis and discontinuation late stent thrombosis and discontinuation of of antiplateletantiplatelet therapy caused higher rates therapy caused higher rates of death and MIof death and MI

Camenzind E, et al. Stent thrombosis late after implantation of first-generation drug-elutingStents : a cause for concern. Circulation 2007;115:1440-55.

FIRESTORM 2007FIRESTORM 2007--20082008

Redefined definitions of stent thrombosisRedefined definitions of stent thrombosisReanalysis of data setsReanalysis of data sets

MauriMauri NEJM 2007NEJM 2007----no difference yet small no difference yet small studystudyStone NEJM 2007Stone NEJM 2007----small yet significant small yet significant increase with DES over 1increase with DES over 1--4 yrs4 yrsSpaulding NEJM 2007Spaulding NEJM 2007----increase in death and increase in death and MI with DES, better outcomes with BMS in MI with DES, better outcomes with BMS in diabeticsdiabetics

ACC/AHA RecommendationsACC/AHA Recommendations

ASA 325 mg non enteric indefinitelyASA 325 mg non enteric indefinitelyMinimum 3 months Minimum 3 months clopidogrelclopidogrel for for sirolimussirolimus--coated (coated (CypherCypher®®) stents) stentsMinimum 6 months Minimum 6 months clopidogrelclopidogrel for for paclitaxelpaclitaxel--coated (coated (TaxusTaxus®®) stents) stents12 months 12 months clopidogrelclopidogrel optimumoptimum12 months minimum?12 months minimum?

ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention-Summary Article. Circulation 2006;113:156-175.

DES vs. BMSDES vs. BMSImpair healingImpair healingLower in stent Lower in stent stenosisstenosisDelay Delay endotheliazationendotheliazation““thrombogenicthrombogenicsurfacesurface””Low risk Low risk vsvs high risk high risk lesionslesionsAccelerated Accelerated periopperiop

ClopidogrelClopidogrel and DESand DESLong term outcomeLong term outcome

Landmark analysis techniqueLandmark analysis technique6 month 6 month clopidogrelclopidogrel use (yes or no)use (yes or no)12 month 12 month clopidogrelclopidogrel use (yes or no)use (yes or no)4666 patients4666 patients•• 3165 with BMS3165 with BMS•• 1501 with DES1501 with DES

Eisenstein, EL, et.al. Clodipogrel Use and Long-term Clinical Outcomes AfterDrug-Eluting Stent Implantation. JAMA 2007;297:159-168.

ClopidogrelClopidogrel and DESand DESLong term outcomeLong term outcome

Patients with long term Patients with long term clopidogrelclopidogrel with with DES significantly improved prognosisDES significantly improved prognosis

Significantly lower death and death or MI Significantly lower death and death or MI compared with patients with DES not compared with patients with DES not receiving the medicationreceiving the medication

Continued Continued clopidogrelclopidogrel therapy conveys therapy conveys important prognostic benefit for patients important prognostic benefit for patients with DES although not seen for BMSwith DES although not seen for BMS

Eisenstein, EL, et.al. Clodipogrel Use and Long-term Clinical Outcomes AfterDrug-Eluting Stent Implantation. JAMA 2007;297:159-168.

PerioperativePerioperative

HypercoagulableHypercoagulablePlatelet activationPlatelet activationReduced Reduced FibrinolyticFibrinolytic activityactivityProcoagulantProcoagulant clotting factors increaseclotting factors increase

InflammatoryInflammatoryHemodynamic changesHemodynamic changesPlatelet transfusions?Platelet transfusions?

NCS and Cardiac NCS and Cardiac StentingStenting

Retrospective reviewRetrospective review--PCI up to 2 yr prior PCI up to 2 yr prior to NCSto NCS

Surgical procedureSurgical procedure30 day CV outcome30 day CV outcomeNo No periopperiop antiplateletantiplatelet therapy protocoltherapy protocol•• Some received through procedureSome received through procedure•• Some stopped 1 week prior to ORSome stopped 1 week prior to OR

Schouten, O, et al. Noncardiac Surgery after Coronary Stenting: Early Surgery and Interruption of Antiplatelet Therapy are Associated with an Increase in Major AdverseEvents. JACC 2007 49:1;122-125.

NCS and Cardiac NCS and Cardiac StentingStenting

30 day MACE30 day MACENonfatal MINonfatal MICardiac deathCardiac death

192 patients surgery within 2 yrs192 patients surgery within 2 yrsEarly surgery (Early surgery (clopidogrelclopidogrel required 1/3/6 required 1/3/6 mthsmthsfrom trial studiesfrom trial studiesLate surgeryLate surgery


NCS and Cardiac NCS and Cardiac StentingStentingFirst 30 daysFirst 30 days--5 MACE all fatal5 MACE all fatal

Early surgery group 4 MACE (13.3%)Early surgery group 4 MACE (13.3%)All these patients discontinued their All these patients discontinued their antiplateletantiplatelet agents (31%)agents (31%)No MACE in patients who continued therapyNo MACE in patients who continued therapyLate surgery group 1 MACE (0.6%)Late surgery group 1 MACE (0.6%)

No difference in blood transfusion in those No difference in blood transfusion in those who discontinued who discontinued antipltantiplt therapytherapy


NCS and Cardiac NCS and Cardiac StentingStentingConclusionsConclusions

““Association between early NCS after Association between early NCS after Cardiac Cardiac stentingstenting and perioperative and perioperative adverse cardiovascular eventsadverse cardiovascular events””

““discontinuation of discontinuation of antiplateletantiplatelet therapy therapy during the perioperative period may be a during the perioperative period may be a major case of the increase in MACE.major case of the increase in MACE.””““antiplateletantiplatelet therapy throughouttherapy throughout””

Schouten, O, et al. Noncardiac Surgery after Coronary Stenting: Early Surgery and Interruption of Antiplatelet Therapy are Associated with an Increase in Major AdverseEvents JACC 2007 49:1;122 125

AHA/ACC/SCAI/ACS/ADAAHA/ACC/SCAI/ACS/ADA

Prevention of Premature Discontinuation Prevention of Premature Discontinuation of Dual of Dual AntiplateletAntiplatelet Therapy in Patients Therapy in Patients with Coronary Artery Stentswith Coronary Artery Stents

12 months of dual therapy12 months of dual therapyEducationEducationCollaborationCollaboration

Grines, CL, et al. AHA/ACC/SCAI/ACS/ADA Science Advisory, Prevention of Premature Antiplatelet Therapy in Patients with Coronary Artery Stents. Circulation2007;115:813-818


Premature discontinuationPremature discontinuation--non surgical non surgical patientspatients

Catastrophic stent thrombosisCatastrophic stent thrombosisOccurs between 8%Occurs between 8%--30% of patients30% of patientsPooled analysis 6 trialsPooled analysis 6 trials•• Incidence of MI or death 64.4%Incidence of MI or death 64.4%

““doubling the rates of MI and deathdoubling the rates of MI and death””



Surgical patientsSurgical patientsKaluzaKaluza 2000 40 patients2000 40 patients

7 MI, 6 fatal, 5 off meds7 MI, 6 fatal, 5 off medsSharma 2004 47 patientsSharma 2004 47 patients

6 of 7 deaths in manner 6 of 7 deaths in manner c/wc/w stent thrombosisstent thrombosisPatients infarct in OR Patients infarct in OR oror PACUPACU



Stent thrombosis 29% of patients who Stent thrombosis 29% of patients who discontinue discontinue antiplateletantiplatelet therapy earlytherapy early

Mortality rate for stent thrombosis is 20Mortality rate for stent thrombosis is 20--45%45%

Early discontinuation of Early discontinuation of antiplateletantiplatelet is is greatest predictorgreatest predictor


Factors to discontinue drugsFactors to discontinue drugsPatientsPatients•• CostCost•• EducationEducation•• ElderlyElderly•• Lack of followLack of follow--up/cardiac rehabup/cardiac rehab

Health care providersHealth care providers•• Misguided concerns about bleedingMisguided concerns about bleeding•• Lump all Lump all anticoagsanticoags togethertogether

AHA/ACC/SCAI/ACS/ADAAHA/ACC/SCAI/ACS/ADARecommendationsRecommendations

Educate and avoid in non compliant Educate and avoid in non compliant patientspatientsAvoid if surgical procedure planned within Avoid if surgical procedure planned within next 12 monthsnext 12 monthsEducation prior to discharge importance Education prior to discharge importance and significance of early discontinuationand significance of early discontinuationContact cardiologist if going to stop or Contact cardiologist if going to stop or instructed to stop by other health care instructed to stop by other health care providerprovider


ProceduralistProceduralist must know risk, must know risk, communicate with cardiologistcommunicate with cardiologistDelay elective proceduresDelay elective procedures----12 months 12 months DES, 1 month minimum for BMSDES, 1 month minimum for BMSDES and procedures and DES and procedures and d/cd/c clopidogrelclopidogrel, , continue ASA and restart continue ASA and restart clopidogrelclopidogrelASAPASAP

ClopidogrelClopidogrel ForeverForever

Everyone with DES?Everyone with DES?Acute coronary syndromeAcute coronary syndromeLong stentsLong stentsMultiple stentsMultiple stentsOverlapping stentsOverlapping stentsDiabetesDiabetesRenal failureRenal failure

Newsome PerspectiveNewsome PerspectiveWake ForestWake Forest

No elective surgeryNo elective surgery12 months DES12 months DES3 months BMS3 months BMS

Urgent procedure and anyone on team Urgent procedure and anyone on team wants to stop wants to stop antiplateletantiplatelet therapytherapy----patientpatient’’s cardiology consults cardiology consultNever stop ASANever stop ASA--if held, resume and wait 2 if held, resume and wait 2 hours before ORhours before OR

Bridging TherapyBridging Therapy

IntegrillinIntegrillin----GP GP IIbIIIaIIbIIIa inhibitorinhibitorPrevent activation and aggregationPrevent activation and aggregation

HeparinHeparinPrevent thrombin formationPrevent thrombin formation

IV therapyIV therapyHold 6 hours Hold 6 hours preoppreop

Newsome, LT, et al. A Protocol for the Perioperative Management of PatientsWith Intracoronary Drug-Eluting Stents. APSF;Winter Newsletter 2007.


Only if Only if clopidogrelclopidogrel must stopmust stopCardiologist documentsCardiologist documents

Type of DES placed and dateType of DES placed and dateCoronary complexitiesCoronary complexitiesComorbiditiesComorbidities (CRF, DM, low EF)(CRF, DM, low EF)

ClopidogrelClopidogrel held 5 days held 5 days preoppreop (cardiologist (cardiologist must approve)must approve)



ASA throughoutASA throughoutAdmit patient 2 days Admit patient 2 days preoppreop to surgical to surgical serviceserviceStart Bridge therapyStart Bridge therapy

Normal renal functionNormal renal function 180 mcg/kg IV load180 mcg/kg IV load 2.0 mcg/kg/min CI2.0 mcg/kg/min CICr > 2.0, Cr > 2.0, ClcrClcr < 50< 50 180 mcg/kg IV load180 mcg/kg IV load 1.0 mcg/kg/min CI1.0 mcg/kg/min CI

IV Heparin to keep PTT 70IV Heparin to keep PTT 70--9090



Hold infusions 6 hour Hold infusions 6 hour preoppreopCardiology and surgeryCardiology and surgery

Resume Resume clopidogrelclopidogrel or or integrellinintegrellin ASAP (post ASAP (post op night)op night)ClopidogrelClopidogrel load 600 mg load 600 mg p.op.o..ClopidogrelClopidogrel maintainancemaintainance 75 mg 75 mg p.op.o. daily. daily

ororIntegrellinIntegrellin protocolprotocol



Small studies/reportsSmall studies/reportsNot testedNot testedNot accepted as standardNot accepted as standard

Perioperative Management of Perioperative Management of Patients with Coronary StentsPatients with Coronary Stents

PreventionPreventionAvoid Avoid preoppreop revascularizationrevascularizationRevascularizeRevascularize without stentswithout stentsAppropriate stent selectionAppropriate stent selectionDelay surgery after stent placementDelay surgery after stent placementContinue Continue antiplateletantiplatelet therapytherapyImprove awareness of all MDs caring for Improve awareness of all MDs caring for these patientsthese patients

Avoid Revascularization Avoid Revascularization PreopPreop

Corn Art Corn Art RevascRevasc Prophylaxis (CARP)Prophylaxis (CARP)510 patients undergoing vascular surgery510 patients undergoing vascular surgery•• 33% AAA, 67% lower extremity 33% AAA, 67% lower extremity revascrevasc•• Excluded LM disease, unstable angina, CMExcluded LM disease, unstable angina, CM•• 41% CABG 41% CABG vsvs 59% PCI59% PCI

RevascRevasc vsvs No No revascrevasc preoppreop•• No difference in postop AMI (8.4% both groups)No difference in postop AMI (8.4% both groups)•• Median survival 27 months (78%)Median survival 27 months (78%)

McFalls EO, et al. Coronary-artery revascularization before elective major vascular Surgery. NEJM 2004;351:2795-2804.

RevascRevasc without stentwithout stent350 patients NCS within 2 350 patients NCS within 2 mthsmths of balloon only of balloon only PCIPCI

1 death, 2 1 death, 2 MisMis

Acceptable resultsAcceptable resultsMay be alternative if surgery is needed (within 4 May be alternative if surgery is needed (within 4 to 6 weeks)to 6 weeks)Gray zone Gray zone

To early risk for sub acute or acute thrombosisTo early risk for sub acute or acute thrombosisTo late risk for To late risk for restenosisrestenosis

Brilakis ES, et.al. Outcome of patients undergoing balloon angioplasty in the two months priorTo NCS. Am J Cardiol 2005;96:512-514

Stent Selection Stent Selection PreoperativelyPreoperatively

Surgery needed within 12 Surgery needed within 12 mthsmthsBMSBMS

Surgery can waitSurgery can waitDESDES----1 year vs. forever at risk?1 year vs. forever at risk?If DES is neededIf DES is needed•• Prefer Prefer sirolimussirolimus stent (CYPHER) 3 stent (CYPHER) 3 mthmth rulerule

Delay SurgeryDelay Surgery

BMSBMS4 to 6 week minimum4 to 6 week minimum

DESDES12 month minimum12 month minimum

Continue Continue AntiplateletAntiplatelet TherapyTherapy

Optimal length of dual Optimal length of dual antiplateletantiplatelettreatment unknowntreatment unknownContinue both agentsContinue both agents----risk of bleedingrisk of bleeding

SafeSafe UnsafeUnsafe•• Dental extractionsDental extractions NeurosurgeryNeurosurgery•• Cataract surgeryCataract surgery•• Routine dermatologic surgeryRoutine dermatologic surgery

Higher bleeding riskHigher bleeding risk•• Risk of Risk of thrombosis,MIthrombosis,MI and death > bleedingand death > bleeding

Stop and BridgeStop and Bridge

Does not offer complete protectionDoes not offer complete protectionMust be continued into the post op period as Must be continued into the post op period as this is the greatest risk periodthis is the greatest risk periodExpensiveExpensiveLogistically difficultLogistically difficultUnprovenUnproven

Stop and GoStop and Go

Only used when absolutely necessary Only used when absolutely necessary secondary to bleeding risksecondary to bleeding risk

Neurosurgical casesNeurosurgical casesReload with 600 mgReload with 600 mg

Takes effect within 2Takes effect within 2--4 hours4 hoursPrevents Prevents hyporesponsivenesshyporesponsiveness

EducationEducation

Anesthesiologist surveyAnesthesiologist survey63% unaware of current recommendations63% unaware of current recommendations33% recommended no delay, or a delay of 133% recommended no delay, or a delay of 1--2 2 weeks following weeks following ““stentstent”” placementplacement

Patterson L. et.al. Appropriate waiting time for noncardiac surgery following coronaryStent insertion: views of Canadian anesthesiologist. Can J Anaesth 2005;52:440-441

Preoperative PlanningPreoperative Planning

Stent type (BMS, SES, PES)Stent type (BMS, SES, PES)Stent locationStent locationDate of implantationDate of implantationConsult interventional as well as patientConsult interventional as well as patient’’s s cardiologistcardiologist

Brilakis, ES, etal. Perioperative Management of Patients with Coronary Stents. JACC, 2007;49:2145-2150.

Preoperative PlanningPreoperative Planning

Joint decision with input from anesthesia, Joint decision with input from anesthesia, cardiologist and surgeon cardiologist and surgeon

Timing of surgeryTiming of surgeryAppropriate Appropriate antiplateletantiplatelet managementmanagement

Perform surgery in centers with 24 hour Perform surgery in centers with 24 hour interventional cardiology coverage interventional cardiology coverage available to treat stent thrombosis with available to treat stent thrombosis with immediate PCIimmediate PCI

Brilakis, ES, etal. Perioperative Management of Patients with Coronary Stents. JACC, 2007;49:2145-2150.

Stent Thrombosis TreatmentStent Thrombosis Treatment

ST elevation acute MIST elevation acute MITreatment early reperfusionTreatment early reperfusion

ThrombolyticsThrombolytics contraindicatedcontraindicatedPrimary PCI treatment of choicePrimary PCI treatment of choice•• ASAASA•• Single dose of heparin or Single dose of heparin or bivalirudinbivalirudin

Stent Thrombosis TreatmentStent Thrombosis TreatmentOutcomesOutcomes

RetrospecitveRetrospecitve analysis 2001analysis 200148 patients with MI within 1 week of NCS48 patients with MI within 1 week of NCS•• Heparin and ASAHeparin and ASA•• 65% survival with 65% survival with ““early invasive strategyearly invasive strategy””•• High frequency of High frequency of cardiogeniccardiogenic shock and arrestshock and arrest•• 1 patient with significant operative site bleeding 1 patient with significant operative site bleeding

(TKA)(TKA)•• Included Included intrathoracicintrathoracic and neurosurgical casesand neurosurgical cases

Berger, PB.etal. An Immediate Invasive Strategy for the Treatment of Acute MyocardialInfarction Early after NCS. Am J Cardiol 2001;87:1100-1102.

Real WorldReal WorldPatient in ASCPatient in ASC--outpatient surgeryoutpatient surgeryOff both agents because Off both agents because ““told to stoptold to stop””Now whatNow what

ASAASA----325 mg325 mgCancel case reschedule in 3Cancel case reschedule in 3--5 days to allow 5 days to allow ASA to work and get more informationASA to work and get more informationDo later in day after 2Do later in day after 2--4 hours4 hoursIf surgeon wants to proceed, must know rates If surgeon wants to proceed, must know rates of stent thrombosis and mortalityof stent thrombosis and mortality

Real WorldReal World

Avoid platelet transfusion unless Avoid platelet transfusion unless absolutely necessaryabsolutely necessary

Increase activity and aggregation without Increase activity and aggregation without increase countincrease countSympathetic activation and cytokinesSympathetic activation and cytokinesEnhances Enhances prothromboticprothrombotic statestate

Documents

Preoperative Cardiac Stents Perioperative Management · 2018-03-31 · zMarch 2003-Sirolimus-eluting (Cypher ... Registry. Circulation 2006;113:2803-9. Catastrophic Outcomes ... •