handling co-medication in your cardiac risk patient

8/13/2019 Handling Co-medication in Your Cardiac Risk Patient

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4RC2 LEHOT

Handling co-medication in your cardiac risk patient

Jean-Jacques Lehot, Lionel Bapteste, Fabien Reverdy

Fdration Hospitalo-Universitaire dAnesthsie-Ranimation, Hpital Neurologique Pierre Wertheimer

59, Bd Pinel, 69677 Lyon-Bron cedex, France. Universit Claude Bernard Lyon 1, France

Most cardiac patients take cardiac or antithrombotic drugs. When preparing patients for surgery it is

important to know which medication should be administered right up to the time of surgery, which

should be withdrawn beforehand and, if a medicine has been discontinued, when it can be safely

restarted after anaesthesia. Less commonly, some cardiac drug treatments should be initiated before

anaesthesia in order to decrease the perioperative cardiovascular risk. In this refresher course article

the more recent European recommendations will be discussed.

1,2

These guidelines are also availableonline at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/perioperative-cardiac-

care.aspx. The class and the level of these recommendations have been highlighted.1

In some instances

the recent French guidelines for ischaemic heart disease will be discussed.3

What patients are at cardiac risk?

The risk of perioperative cardiac death, myocardial infarction, severe arrhythmia and acute cardiac

failure depends on the preoperative cardiac status and on the type of surgery. The revised cardiac risk

index4 is commonly used because it is easy to interpret (Table 1, one point per risk factor) and is

applicable to all patients.

Table 1: Lee index (cross for clinical risk factors; one point per cross; after Ref. 4): MI=myocardial infarction;

IHD=ischaemic heart disease.

Renal dysfunction is defined when serum creatinine concentration is greater than 177 mol.l-1

. The

clinical risk factors do not take into account the surgical risk. The incidence of cardiac complications in

patients older than 50 years of age undergoing elective surgery is 0.4, 0.9, 7 and 11% respectively when

the score is 0, 1, 2 or 3. Risk also depends on the type of surgery including the potential invasiveness

and haemodynamic changes associated with the procedure. Arterial surgery and especially aortic

surgery presents the highest risk (Table 2).


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Table 2:Cardiac risks according on surgery (Ref. 1): MI=myocardial infarction.

Cardiovascular medications

The balance between the benefit and the risk of the treatment should be assessed for each patient. A

randomised study comparing coronary artery revascularisation with medical treatment before elective

major arterial surgery showed no long term difference in mortality.5

Therefore optimal pharmacological

treatment seems effective in patients with stable ischaemic heart disease. In contrast, withdrawal of

beta-blockers, statins or aspirin prior to anaesthesia may worsen the condition of the patient. Finally,

when the anaesthesiologist or the cardiologist starts a treatment preoperatively, it is important to re-

evaluate the necessity of this treatment postoperatively.

Beta-blockers

Beta-blockers (BB) decrease myocardial oxygen consumption, protect against the destabilization ofcoronary plaques during adrenergic discharges and increase the threshold for arrhythmias. Weaning of

BB may induce unwelcome sympathetic activity perioperatively. Selective beta-1 receptor-blockers such

as atenolol, metoprolol and bisoprolol have been extensively studied perioperatively as a method of

reducing myocardial ischaemia. In randomized studies BB are beneficial in high risk surgery, mainly

arterial surgery.

In the POISE study metoprolol succinate 200 mg administered 2 to 4 hours as a standard dose before

surgery reduced the incidence of myocardial infarction but favoured hypotension, bradycardia and a

lower cardiac output leading to a higher incidence of perioperative strokes.6 Therefore BB therapy

should start at least one week and ideally one month before surgery (Table 3). Heart rate should be

adjusted to 60 to 70 beats per minute by titration but without the occurrence of hypotension. Patients

with chronic cardiac failure should only receive a low dose. Heart rate and blood pressure should be


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monitored carefully with an excessive fall in either being corrected immediately. Moreover, heart rate

control with short-acting drugs such as esmolol during surgery in addition to chronic BB therapy needs

further assessment.

Table 3: ESA/ESC recommendations on beta-blockers (Ref. 1): IHD=ischaemic heart disease;a class of

recommendation;blevel of evidence.

Statins

Beside their lipid-lowering effects, statins induce coronary plaque stabilization and may prevent plaque

rupture and subsequent myocardial infarction in the perioperative period. Therefore, despite the

potential risk of myopathy and rhabdomyolysis, statins should be continued perioperatively or started

in high risk surgery patients, optimally between 30 days and at least one week before surgery (Table 4).

Statins with a long half-life, rosuvastatin, atorvastatin, fluvastatin, or extended-release formulations are

recommended to bridge the period immediately after surgery when oral intake is not feasible. However

the optimal perioperative statin dose is unknown.


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Table 4:ESA/ESC recommendations on statins (Ref. 1):

a

class of recommendation;

b

level of evidence.

Nitrates

Nitrates are vasodilators. They decrease myocardial oxygen demand but may induce hypotension.

Therefore they are usually not recommended preoperatively except in case of left ventricular failure

and hypertension (Table 5).

Table 5:ESA/ESC recommendations on nitrates (Ref. 1):aclass of recommendation;

blevel of evidence.

Angiotensin converting enzyme-inhibitors and angiotensin receptor-blockers

Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor-blockers (ARB) decrease

blood pressure and preserve organ function. ACE inhibitors, or ARB in patients intolerant of ACE

inhibitors, are administered chronically to treat hypertension and left ventricular (LV) dysfunction.

Hypotension is less frequent when ACE inhibitors are discontinued the day before surgery. ACE

inhibitors and ARB withdrawal may be considered 24 hours before surgery when they are prescribed for

hypertension but are not stopped when they are prescribed for LV dysfunction (Table 6). ACE inhibitors

are contraindicated in case of angioedema.7


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Table 6: ESA/ESC recommendations on ACE-inhibitor and angiotensin receptor-blocker (Ref. 1):a class of

recommendation;blevel of evidence.

Calcium channel-blockers

Calcium channel-blockers (CCB) are direct vasodilators, particularly in coronary arteries. Therefore they

are continued in patients with Prinzmetal angina pectoris. Heart-rate reducing CCB, in particular

diltiazem, may be considered in patients who have contra-indications to BB. By contrast

dihydropyridine CCBs may induce reflex tachycardia and short acting dihydropyridines such as

nifedipine capsules should be avoided (Table 7).


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Table 7: ESA/ESC recommendations on calcium channel-blockers (Ref. 1):a class of recommendation;

b level of

evidence.

Ivabradine

Ivabradine is an Ifcurrent channel-blocker. It is a specific inhibitor of the pacemaker in the sino-atrial

node. It does not affect blood pressure and contractility, and may reduce myocardial ischaemia. More

studies are needed to recommend ivabradine before anaesthesia.

Alpha 2 receptor-agonists

Alpha 2 receptor-agonists include clonidine and dexmedetomidine. They reduce post-ganglionic

noradrenaline output and therefore may reduce the catecholamine surge during surgery. They

potentiate depth of anaesthesia and reduce postoperative shivering. They may be considered to reduce

the risk of cardiovascular complications associated with arterial surgery (Table 8).

Table 8:ESA/ESC recommendations on alpha 2 receptor-agonists (Ref. 1):a class of recommendation;

b level of

evidence.


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Diuretics

In heart failure, diuretics are often used in high doses. In general, diuretics which are required to

control heart failure should be continued up to the day of anaesthesia, continued intravenously

perioperatively and orally when possible. In patients with hypertension, diuretics are usually not

recommended on the day of surgery (Table 9). In the perioperative period, volume, potassium and

magnesium status should be monitored carefully.

Table 9:ESA/ESC recommendations on diuretics (Ref. 1): aclass of recommendation; blevel of evidence.

Digoxin

Digoxin is part of treatment for chronic cardiac failure. It increases myocardial contractility and slows

down atrioventricular conduction, leading to decreased ventricular rate in patients with sinus rhythm or

atrial fibrillation. Overdose is facilitated by renal dysfunction and can lead to ventricular arrhythmia

especially in the presence of hypokalaemia and myocardial ischaemia. Before elective procedures the

digoxin plasma concentration may be checked (normal range: 0.6-2.6 nmol.l-1

).


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Antiarrhythmic medications

Continuation of oral anti-arrhythmic drugs before anaesthesia is recommended when the

cardiovascular status is stable, including amiodarone or BB (Tables 10 and 11).

Table 10: ESA/ESC recommendations on supraventricular arrhythmias (Ref. 1): AF=atrial fibrillation;

supraventricular tachycardia (SVT);aclass of recommendation;

blevel of evidence.

Table 11: ESA/ESC recommendations on ventricular arrhythmias (Ref. 1): VT=ventricular tachycardia;

VPBs=ventricular premature beats;aclass of recommendation;

blevel of evidence.


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Antiplatelet therapy

Low dose aspirin has antiplatelet properties. Aspirin is indicated in patients undergoing carotid

endarterectomy to prevent stroke and in patients undergoing arterial surgery to prevent serious

cardiovascular events (Table 12). Aspirin withdrawal is associated with a 3-fold increase in major

adverse cardiac events and aspirin should be discontinued only if the bleeding risk outweighs the

potential cardiac benefit (Table 13). Considering that aspirin and clopidogrel antiplatelet effects last 10

days, a 5-day withdrawal is often selected in non-cardiac surgery except in neurosurgery when total

reversal of their effect is required. Anticoagulant drugs such as heparin are not efficient as a bridge

after withdrawal of antiplatelet therapy.

Table 12: ESA/ESC recommendations on stroke/transient ischaemic attack (Ref. 1):a class of recommendation;

b

level of evidence.

Table 13:ESA/ESC recommendations on aspirin (Ref. 1):aclass of recommendation;

blevel of evidence.

In order to prevent coronary stent thrombosis, the duration of combined therapy with aspirin and

clopidogrel is at least 6 weeks after bare-metal stent insertion, and 12 months after drug-eluting stent

insertion (Figure 1).


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Fig. 1: ESA/ESC recommendations on patients treated by percutaneous coronary intervention (PCI)

(Ref.1)

Anticoagulant therapy

When the risk of perioperative bleeding or thrombosis is low, vitamin K antagonists are maintained or

modified in order to obtain an international normalized ratio (INR) less than 1.5 during surgery. In other

circumstances vitamin K antagonists are substituted by heparin.1Low molecular weight heparin should

not be used in severe renal failure. No official recommendations exist concerning the perioperative

management of new oral direct anticoagulants (dabigatran and rivaroxaban) used in atrial fibrillation.

Prophylaxis of infective endocarditis

In patients with valvular heart disease and those with prosthetic valves who are undergoing surgery at

risk of bacteraemia, antibiotic prophylaxis should be initiated.8,9

Renal failure

For patients at risk of developing contrast medium nephropathy, hydration with isotonic sodium

chloride without oral N-acetylcysteine is recommended prior to injection of contrast-medium.10

Insulin

Postoperative control of hyperglycaemia with intensive insulin therapy to maintain glucose

concentrations below 10 mmol.l-1, is recommended after high-risk surgery or complicated major surgery

requiring admission to ICU.

Practical issues

A multidisciplinary discussion including consultation with the cardiologist and the surgeon may allow

better assessment of the risk, reducing the invasiveness of the intervention where possible, and

optimisation of perioperative monitoring.3 In patients with ischaemic heart disease undergoing

intermediate to high risk surgery, the benefit of introducing BB, aspirin and statin treatment should be

discussed several weeks before an elective procedure. This period permits optimal titration of BB

therapy. In patients with a left ventricle ejection fraction less than 40%, ACE inhibitors may be

introduced (Table 14).


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Surgery Beta-blockers(titration)

ACE-inhibitors or

ARBs

in patients with

LV ejection

fraction 5%)I B I C IIb C I B

Table 14: ESA/ESC recommendation gradation on medications in stable patients with moderate or poor functional

capacity (< 4 metabolic equivalents) undergoing elective surgery (after Ref. 1): ACE=angiotensin converting-enzyme;

ARBs=angiotensin receptor-blockers.

Conclusion

Pre and post operative cardiac drug therapy requires careful cardiac assessment and a detailed

knowledge of both pharmacology and surgical considerations.

Key learning points

Patients receiving beta-blockers or statins should continue this treatment perioperatively. Aspirin should be continued if the potential cardiac benefit outweighs the risk of bleeding. In patients with ischaemic heart disease undergoing high-risk surgery, the introduction of beta-

blockers, aspirin or statins may be contemplated at least one week before an elective

procedure. Earlier introduction is required to titrate beta-blocker therapy.

In patients with a left ventricle ejection fraction less than 40%, ACE inhibitors may beintroduced.

A multidisciplinary approach including cardiologist, surgeon and anaesthesiologist oftenensures the best perioperative management.


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References

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Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of

Anaesthesiology (ESA). Eur J Anaesthesiol2010; 27: 92-137.

2. De Hert S, Imberger G, Carlisle J et al.Task Force on Preoperative Evaluation of the Adult Noncardiac Surgery Patient of theEuropean Society of Anaesthesiology.Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines

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3. Derumeaux G, Piriou V, Marret E et al. Socit franaise d'anesthsie et de ranimation (Sfar); Socit franaise de cardiologie(SFC). [Perioperative assessment of cardiac risk patient in non-cardiac surgery]. Annales Franaises dAnesthsie Ranimation

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4. Lee TH,Marcantonio ER, Mangione CM et al. Derivation and prospective validation of a simple index for prediction of cardiac riskof major noncardiac surgery.Circulation 1999; 7: 1043-9.

5. McFalls EO, Ward HB, Moritz TE et al.Coronary-artery revascularization before elective major vascular surgery. NEJM2004; 351:2795-2804.

6. POISE Study Group, Devereaux PJ, Yang H, Yusuf S et al. Effects of extended-release metoprolol succinate in patients undergoingnon-cardiac surgery (POISE trial): a randomised controlled trial. Lancet2008; 371:1839-1847.

7. Stojiljkovic L. Renin-angiotensin system inhibitors and angioedema: anesthetic implications. Current Opinion in Anaesthesiology2012; 25: 356-362.

8. Habib G, Hoen B, Tornos P et al. ESC Committee for Practice Guidelines.Guidelines on the prevention, diagnosis, and treatment ofinfective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of

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(ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009; 30: 2369-2413.

9. Wilson W, Taubert KA, Gewitz M et al.; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki DiseaseCommittee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on

Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes

Research Interdisciplinary Working Group.Prevention of infective endocarditis: guidelines from the American Heart Association: aguideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on

Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia,

and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation2007; 116: 736-754.

10. O'Sullivan S,Healy DA, Moloney MC, Grace PA, Walsh SR.The role of N-acetylcysteine in the prevention of contrast-inducednephropathy in patients undergoing peripheral angiography: a structured review and meta-analysis. Angiology 2012 Nov 27.

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handling co-medication in your cardiac risk patient

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