During the congress of European Society of Cardiology (ESC 2022), the guideline for preoperative assessments was presented, which brought, among other matters, guidelines to be passed on to the patient to reduce surgical risk.urgic. They concern the consumption of tobacco and the use of medication. See below what the guideline points out.
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Quitting smoking at least four weeks before surgery reduces events in the pOs-operative period and should always be recommended. As well as the control of risk factors hypertension, diabetes and dyslipidemia.
– Beta blockers: this is one of the most tested medications in the context of non-cardiac surgeries with very controversial results. Currently, the recommendation is that it can be started preoperatively when the patient has known coronary artery disease or myocardial ischemia or two or more cardiovascular risk factors. Patients who already use the medication should keep it as usual.
– Statins: patients who already use the medication should keep it in the perioperative period and we can consider starting it if the patient has an indication of use.
– Renin-angiotensin aldosterone system inhibitors: studies that evaluated this class of medications in the perioperative period are inconclusive, but it seems that hypotension resulting from maintenance of these medications is more harmful than hypertension resulting from their discontinuation. Therefore, current recommendations are that we can maintain ACE inhibitors and ARBs in patients with stable HF; in patients without HF, we can consider suspending the dose on the day of surgery, in order to avoid hypotension and its complications. There are two major studies underway that will give us answers on this subject.
– Calcium channel blockers: there are few studies with this class of medication and the current recommendation is to keep them in patients who already use them, especially if the reason is vasospastic angina, taking care not to take the dose on the day of surgery to avoid hypotension.
– Diuretics: if the use is due to hypertension, they should be kept until the day of surgery and returned as soon as possible. In cases of HF, the dose must be adjusted before surgery, in order to avoid hypervolemia and dehydration. Attention to electrolytes and the need for replacement and adequate volume assessment is recommended.
– SGLT2 inhibitors: this medication is associated with a rare but very serious complication, euglycemic ketoacidosis, with reports of occurrence after non-cardiac surgery related to in-hospital medication change, diet change and intercurrences. Therefore, the FDA recommends its suspension 3 to 4 days before the procedure and in the occurrence of possible symptoms of ketoacidosis, the dosage of ketones. The European guideline also recommends suspension in cases of intermediate or high risk surgeries.
We should always assess the risk of procedure-related bleeding and the risk of thrombosis. The surgeries with the highest risk of bleeding are intracranial, spinal and vitreoretinal.
– Antiplatelet aggregation with aspirin
If the use of aspirin is for primary prevention, it should be discontinued seven days before the procedure and, after the procedure, it should be reassessed if the medication is really indicated.
In cases of secondary prevention, the ischemic risk and bleeding risk must be weighed and if there is no risk of high bleeding, the ideal is to keep aspirin. If the indication for aspirin is post-TAVI and the risk of surgery-related bleeding is high, the medication should be discontinued.
– Antiplatelet aggregation with clopidogrel
Currently, there are some recommendations for the use of clopidogrel in monotherapy, including post-AMI with angioplasty, and the decision regarding what to do in the perioperative context should be made based on risk of bleeding and ischemic risk: keep the medication or switch to aspirin or discontinue for short period or perform a perioperative bridge, depending on each case.
– Dual antiplatelet aggregation
The ideal is to postpone the procedure until the ideal time for antiaggregation is reached (6 months for elective angioplasty, 12 months after acute coronary syndrome). However, several studies have shown that this time can be safely reduced and, in cases of surgery that cannot be postponed, such as oncological ones, it can be as little as 1 month in patients with low to moderate ischemic risk and 3 months in patients at high risk. The P2Y12 inhibitor is stopped 3 to 7 days before the procedure, depending on the medication, and the patient remains on aspirin.
Ideally, the return of antiplatelet medication should be as brief as possible, in the first 48 hours after surgery.
– Vitamin K antagonists
We must also weigh the risk of thrombotic events and risk of bleeding. Warfarin is the main representative of this class and, if used due to the presence of a metallic prosthesis, it should be maintained in case of small procedures and with easy bleeding control, with an INR close to the lower therapeutic limit.
In case of major procedures, heparin bypass can be considered when the thrombotic risk is high (mitral or tricuspid prosthesis, aortic prosthesis associated with another risk factor for thrombosis or an older model) or not performing the bypass when the thrombotic risk is smaller, as in cases of mechanical aortic valve without atrial fibrillation.
In cases of atrial fibrillation or deep vein thrombosis, heparin bridging should be considered if the CHAtwoDStwo-VASc is greater than 6, in the event of a cardioembolic stroke for less than 3 months or a high risk of recurrence of a thromboembolic event.
Medication should be restarted 12 to 24 hours after surgery if bleeding is well controlled and the patient is able to take the medication. The recommended dose is the patient’s usual dose plus 50% for the first two days. If bridging with heparin was performed, it should be restarted within 24 hours and maintained until the target INR is reached. If the surgery was a high risk of bleeding, anticoagulant treatment should be started after 48 to 72 hours.
– New anticoagulants (NOAC)
There are currently four: rivaroxaban, apixaban, dabigatran and edoxaban. Each drug has a half-life and all interfere with kidney function. When its suspension is indicated, the suspension time varies from 24 to 96 hours depending on the GFR and medication.
As with warfarin, minor procedures with a low risk of bleeding can be performed without warfarin and, conversely, bridging with heparin is not recommended in virtually any situation. It can usually be restarted within the first 24 hours.
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