Pre-Op Risk Assessment - pg 3
Treatment - aRA, Diu, ASA, AC, Cath
a2 Receptor agonists
A meta-analysis pooled 23 randomized trials, in 8,
and non-vascular surgery in 3 cases. Periop
use
of a2 receptor agonists was associated with
subgroup having vascular surgery
, while there
, while there
subgroup was no benefit in
non-vascular surgery.
Diuretics
Hypokalaemia is reported to occur in up to 34% of patients
undergoing surgery (mostly non-cardiac).It is well known to
increase significantly the risk of ventricular tachycardia (VT)
and ventricular fibrillation in cardiac disease
ASA
A large meta-analysis, including 41 studies in 49 590
bleeding risks of ASA, concluded that the risk of bleeding
complications was increased by
1.5 but that aspirin did not
lead to higher severity levels of bleeding
complications.
AntiCoagulation
If INR <1.5, surgery can be performed safely.
A high thromboembolic risk is present in patients with
-Atrial fibrillation
-Mechanical prosthetic heart valves
-Biological prosthetic valves or MV repair <3 months
-VTE<3 mo+ thrombophilia
Treat with i.v. UFHs up until 4 h prior to surgery
Oral anticoagulants should be resumed on day 1
or 2 after surgery at the preop maintenance dose
plus a boost dose of 50% for two days; the
maintenance dose should be administrated after.
LMWH or UFH should be continued until the INR
returns to therapeutic levels.

In low risk surgery such as cataract surgery, no
changes in oral anticoagulation therapy is needed

Protamine Sulfate: 1mg per 100 U of heparin
sodium. If the heparin infusion was stopped for
>30 min but <2 h, then use half the dose.
Revascularization
Data from the CASS registry indicates that patients
who had
CABG within the previous 5 years
can be sent for surgery, if their clinical condition
has remained unchanged since their last exam.

reported in relation to
acute stent thrombosis
at the time of surgery if performed within weeks
after coronary stenting with
discontinuation of
antiplatelet therapy
.

DC dual antiplts 6 weeks(best 3 mo)after BMS
DC dual antiplts 12 mos after DES

In patients who require temporary interruption of
ASA or clopidogrel  before surgery, it is
recommended that this treatment be stopped at
least 5 days and, preferably as much as 10 days,
prior to the procedure.

Therapy can be resumed after 24 h.
Recommendations for Revascularization prior to surgery:
-The CARP trial - compared medical therapy to CABG or PCI
prior to major vascular surgery in patients with stable IHD.
Screened 5859 patients (VA), 510 were randomized.
No
difference
of long term endpoint of mortality at 2.7 years (22
vs 23%), also no difference in peri-op MI (12 vs 14%)
-The
DECREASE-V, 1880 pts were screened for the presence
of: age>70, angina pectoris, previous MI, CHF, DM, CKD, TIA
or CVA. In the presence of >3 risk factors, DSE was performed,
and in the presence of extensive ischemia (>5/16 segments or
>3/6 walls), pts were sent for revascularization. ASA abd BB
were initiated in all pts.
3Vx or LM disease was present in 75% of cases. Also 43% had
EF<35%. There was no difference in all-cause mortality and
non-fatal MI at 30 days (
43% for revascularization vs 33%
for medical)
CABG vs PCI:
undergo CABG or PCI indicated that CABG remains the trt of choice but that PCI is a valuable alternative
Pre-op 1
Testing
Pre-op 3
Treatment
Pre-op 2
Treatment