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Cardiopulmonary risk
Risk reducing interventions
Perioperative anticoagulation in patients on VKA or those with
coronary stents
Patient
A.Yes
B.No
Class I
Vascular surgery patients with 1 risk factor*
Known CAD, PVD, CVD going for intermediate risk
surgery
Class IIa
Ischemic heart disease
Heart failure
Vascular surgery Diabetes
Renal impairment
Class IIb
Cerebrovascular disease
Intermediate risk surgery
with 1 risk factor*
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Factors Leading to Cumulative Risk for
Perioperative Cardiac Events
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Case 2
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
As the medical consultant, what is the MOST APPROPRIATE next
step?
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Tailoring the Perioperative Evaluation
Based on the Urgency of Surgery
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
As the medical consultant, what is the MOST APPROPRIATE
next step?
1.Complete a full preoperative evaluation, including a
stress test, because she will need a vascular
procedure.
2.Ask the patient about her physical activity so you can
calculate her metabolic equivalents because she
will have an intermediate-risk surgery.
3.Evaluate her postoperatively for signs and symptoms
of a myocardial infarction (MI).
4.Ask for surgery to be delayed for 2 days until a β
blocker lowers her heart rate to between 55 and 65
bpm slowly.
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Cardiovascular Risk Assessment
Is surgery emergent?
Yes Operating Room
Is surgery emergent?
Yes Operating Room
No
Active cardiac condition?
Yes Evaluate and Treat
Cardiac condition
Decompensated HF
Significant arrhythmias
Is surgery emergent?
Yes Operating Room
No
Active cardiac condition?
Yes Evaluate and Treat
Cardiac condition
No
Low-risk surgery?
Is surgery emergent?
Yes Operating Room
No
Active cardiac condition?
Yes Evaluate and Treat
Cardiac condition
No
Low-risk surgery?
Yes Operating Room
Is surgery emergent?
No
Active cardiac condition?
No
Low-risk surgery?
Yes Operating Room
•Endoscopic procedures
•Superficial procedure
•Cataract
•Breast
Fleisher LA et al. JACC
2007
Is surgery emergent?
Yes Operating Room
No
Active cardiac condition?
Yes Evaluate and Treat
Cardiac condition
No
Low-risk surgery?
Yes Operating Room
No
Good (>4 METs) Yes Operating Room
Functional capacity?
Fleisher LA et al. JACC
2007
Perioperative Pearls l Alraies l May 17, 2010
Cardiovascular Risk Assessment
Is surgery emergent?
Low-risk surgery?
No
Good (>4 METs) Yes Operating Room
Functional capacity?
Fleisher LA et al. JACC
2007
Perioperative Pearls l Alraies l May 17, 2010
Cardiovascular Risk Assessment
Good (>4 METs) Yes Operating Room
Functional capacity?
No
Orthopedic Surgery
Breast
Yes
Vascular Intermediate Vascular
surgery Risk surgery surgery
Operating Room
Coronary
Assessment Operating Room with heart rate control or
noninvasive testing if it will change management
Fleisher LA et al. JACC 2007
Yes
Vascular Intermediate Vascular
B surgery Risk surgery B surgery
B B Operating Room
Coronary
Assessment Operating Room with heart rate control or
noninvasive testing if it will change management
Fleisher LA et al. JACC 2007
Yes
Intermediate
Risk surgery
>2 weeks <2 weeks
Operating Room
B preop preop
B
Operating Room with heart rate Noninvasive testing
control or noninvasive testing if it will change management
Michota FA. Ohio ACP 2009
Delay for elective Proceed to surgery Delay for elective Proceed to surgery
or nonurgent surgery on aspirin or nonurgent surgery on aspirin
A.Preoperative spirometry
E.Chest radiography
A.Preoperative spirometry
E.Chest radiography
Consensus
Lung Resection
CABG
Incentive spirometry
Smetana GW et al. N Engl J Med 1999
Qaseem A et al. Ann Intern Med 2006
B.Stop warfarin 5 days before, use SC full dose LMWH starting 3 days before surgery;
resume full dose LMWH with warfarin post-operatively until the INR is
between 2 - 3
C.Use FFP and IV Vitamin K to reverse the effect of warfarin in the AM of surgery and
then proceed with surgery
D.Stop warfarin 5 days before, start IV UFH the same day; resume IV UFH with
warfarin post-operatively until the INR is between 2 - 3
7.
B.Stop warfarin 5 days before, use SC full dose LMWH starting 3 days before surgery;
resume full dose LMWH with warfarin post-operatively until the INR is
between 2 - 3
C.Use FFP and IV Vitamin K to reverse the effect of warfarin in the AM of surgery and
then proceed with surgery
D.Stop warfarin 5 days before, start IV UFH the same day; resume IV UFH with
warfarin post-operatively until the INR is between 2 - 3
7.
procedure
Post-procedural “window” of thrombosis risk
Expert opinion
Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Anticoagulation and Surgery
Bleeding Thrombosis
surgery
Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Communication
Consultant
Surgeon
Anesthesia
Nursing staff
Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Thrombosis Risk “Window”
Days -5 0 1 5
INR INR
1.5-2.0 1.5-2.0
Procedure
Perioperative Pearls l Alraies l May 17, 2010
CHADS2 Score:
1.Recent CHF =1
2.Age ≥ 75 years
=1
3.Diabetes mellitus Kearon C et al. N Eng J Med 1997
=1 Gage J et al. JAMA 2001
4.Prior stroke or TIA
=2 Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
UFH Bridge Protocol
OAC stopped OAC started
Days -5 0 1 5
INR>2.0 INR>2.0
Days -5 0 1 5
INR>2.0 INR>2.0
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Thank you
Chadi Alraies, MD
Alraies@hotmail.com
www.chadialraies.blogspot.com