Delaying Surgery After Stroke A 63-year-old man suffers an acute - PDF document

Delaying Surgery After Stroke A 63-year-old man suffers an acute stroke that is managed without thrombolysis. Brain MRI incidentally detects a large meningioma. The neurosurgeon wants to resect the tumor Updates and Controversies in in 2 weeks. Because of his stroke, you recommend delaying surgery for: Perioperative Medicine A. 1 month B. 3 months Hugo Quinny Cheng, MD C. 6 months Division of Hospital Medicine University of California, San Francisco D. 9 months E. At least a year Updates and Controversies in Delaying Surgery After Stroke Perioperative Medicine Question: How does time between stroke and surgery How long should we delay surgery: affect the risk of cardiovascular complications? • After ischemic stroke? • After acute myocardial infarction Danish cohort study of all adults undergoing elective • After drug-eluting stent implantation? noncardiac surgery from 2005-2011: Should we bridge patients on anticoagulants? • 7137 patients had prior stroke (1.5% of total cohort) • Outcome: 30-d postop Major Adverse Cardiac Events Postoperative anemia: (MACE): nonfatal MI, ischemic stroke, cardiovascular death • How much evaluation is needed? • Looked at effect of time since stroke on MACE rate • When should patients be transfused? Jorgenson ME et al. JAMA 2014; 312:269-277 1

Delaying Surgery After MI Delaying Surgery After Stroke 20% A 63-year-old man suffers an acute myocardial infarction treated without PCI. He was already scheduled for prostate MACE Incidence CV Death cancer surgery in one month. Because of his recent MI, 15% you recommend delaying surgery for: Ischemic Stroke Acute MI 10% A. 1 month B. 2 months 5% C. 3 months D. 6 months 0% < 3 months 3-6 months 6-12 months > 12 months E. At least a year Time Between Acute Stroke & Surgery Delaying Surgery After Acute MI How Long to Wait after CVA? Question: How does time between acute MI and Conclusions: surgery affect the risk of postoperative MI? • Surgery after CVA associated with high CV risk • Risk falls over 9 months, biggest drop after first 3 months 563,842 patients (1999-2004) discharged after hip surgery, colectomy, cholecystectomy, AAA repair, or Caveats: lower extremity amputation: • Nonrandomized, observational study • 2.9% of cohort had experienced acute MI in prior year My take-away: • Outcome: 30-day postoperative MI • Delay elective surgery for at least 3 months (up to 9 months) if possible Livhits M et al. Annals of Surgery 2011; 253:857-63 2

Surgery After Drug Eluting Stent Delaying Surgery after Acute MI A 75-y.o. man sustains an unstable cervical spine fracture. He had a drug-eluting stent placed 6 35% months ago for stable angina. The spine surgeon 30% 30-Day Postop MI wants to operate, but putting him in a halo vest is 25% a less desirable alternative approach. 20% 15% What do you recommend? 10% 1. Operate now; 6 months is fine 5% 0% 2. Wait 9 months after DES placed < 30 31-60 61-90 91-180 181-365 3. Wait 12 months after DES placed Time (days) Between Acute MI & Surgery How Long to Wait after MI? ACC/AHA Guidelines for PCI Conclusions: • Indications for PCI are same as for nonsurgical patients • Surgery within one year of acute MI associated with high • Avoid PCI if antiplatelet drugs will need to be held prematurely risk of postoperative MI • Delay elective surgery after elective PCI: • Risk falls over time; most of the reduction within 2 months Bare metal stent: 30 days • Trend is similar when only elective surgery considered Drug eluting stent: 6 months (optimal) Caveats: 3 months (if harm in delay) • Nonrandomized, observational study • Continue or restart antiplatelet agents (especially ASA) as soon as possible, unless bleeding risk precludes ACC/AHA Guidelines: • Delay elective surgery for at least 2 months 3

BRIDGE Trial Managing Perioperative Anticoagulation Two patients on warfarin therapy are scheduled for elective hip Patients: arthropasty. You’re asked whether they should receive • 1884 patients on warfarin for atrial fib or flutter perioperative bridging anticoagulation (with enoxaparin): • CHADS-2 score > 1 One patient has atrial fibrillation due to hypertension • • Excluded patients with mechanical valve or stroke within The other patient has a mechanical AVR • 12 weeks and cardiac & neurologic surgery Neither has any other relevant comorbidity • Intervention: 1. Heparin bridge for AVR only • Randomized to bridging with LMWH or placebo 2. Heparin bridge for AF only Outcome: 3. Heparin bridge for both • 30-day risk of arterial thromboembolism & bleeding 4. Heparin bridge for neither Douketis JD et al. NEJM, 2015; 373:823-33 BRIDGE Trial Benefits & Harm of Bridging Perioperative Anticoagulation Bridged No Bridge Death or disability from Death or disability from thromboembolism perioperative bleeding Embolic Event 0.3% 0.4% Non-inferior averted by bridging caused by bridging Major Bleeding 3.2% 1.3% NNH = 53 Minor Bleeding 21% 12% NNH = 12 Douketis JD et al. NEJM, 2015; 373:823-33 4

Effect of Mechanical Valve Location & BRIDGE Trial for Atrial Fibrillation Design on Thromboembolic Risk Conclusions: Valve Location: • Bridging did not reduce risk of embolism Aortic RR = 1.0 • Bridging increases bleeding risk Mitral RR = 1.8 Caveats: Valve Design: • Few patients with high CHADS-2 score (mean = 2.3) Caged Ball RR = 1.0 My take-away: Tilting Disk RR = 0.7 • Don’t bridge majority of atrial fibrillation Bi-leaflet RR = 0.6 • Carefully consider bridging if stroke risk is very high (CHADS-2 score 5 or 6, rheumatic atrial fibrillation) Cannegieter, et al. Circulation , 1994 Perioperative Anticoagulation: What About Mechanical Valves? 2012 ACCP Guidelines (9 th Edition) 7% Atrial Fib. Mechanical Valve Recommendation Thromboembolic 6% Atrial Fibrillation Risk (annual) CHADS 2 = 5-6; Any MVR; older (caged- Bridge with heparin 5% Mechanical Valve recent CVA; ball or tilting disc) AVR; 4% rheumatic AF recent CVA 3% CHADS 2 = 3-4 Bileaflet AVR plus other ??? 2% stroke risk factor(s) 1% CHADS 2 = 0-2 Bileaflet AVR without AF or No heparin bridge 0% other stroke risk factor Without Anticoagulation With Warfarin Ansell J. Chest. 2004;126:204S-233S. Cannegieter, et al. Circulation , 1994 5

Perioperative Anticoagulation: How About Venous Clots? My Approach after BRIDGE Retrospective cohort study • 1178 patients on warfarin for DVT or PE Atrial Fib. Mechanical Valve Recommendation • Outcome: 30-day recurrent clotting & significant bleeding CHADS 2 = 5-6; Any MVR; older (caged- Consider recent CVA; ball or tilting disc) AVR; Bridged No Bridge Hazard bridging rheumatic AF recent CVA Ratio CHADS 2 = 3-4 Bileaflet AVR plus other Recurrent VTE 0% 0.2% ns stroke risk factor(s) No bridge Bleeding 2.7% 0.2% 17 (4-75) CHADS 2 = 0-2 Bileaflet AVR without AF or other stroke risk factor Clark NP et al. JAMA Int Med , 2015; 175:1163 What About Venous Clots? Venous Clots: 2012 ACCP Guideline Risk of Recurrent VTE Risk of Recurrent VTE Recommendation High Risk: Bridge VTE < 3 months ago; Severe thrombophilia Medium Risk: Case-by-case VTE 3-12 months ago; recurrent VTE; decision VTE with cancer other thrombophilia Low: No bridge Single VTE > 12 months ago Time Since Venous Thromboembolic Event 6

Venous Clots: My Approach Estimated & Actual Blood Loss Risk of Recurrent VTE Recommendation Estimated Blood Loss (EBL): • Based on suctioned blood and weight of sponges High Risk: Consider bridging • Poor repeatability and inter-observer variability VTE < 3 months ago; or IVC filter Severe thrombophilia Actual Blood Loss (ABL): Medium Risk: • Calculated value based on patient’s estimated blood VTE 3-12 months ago; recurrent VTE; volume and change in hemoglobin level VTE with cancer other thrombophilia No bridge ABL = Estimated Blood Volume x ∆ Hct Low: (Initial Hct + Final Hct)/2 Single VTE > 12 months ago EBL versus ABL Postoperative Anemia You visit a 79-year-old woman on postoperative day #1 after Procedure Estimated Actual hip fracture repair. You notice her hemoglobin dropped from Blood Loss Blood Loss 11.6 g/dL on admission to 8.5 g/dL today. The operative Total Hip Arthoplasty 362 mL 1383 mL note reports an EBL (estimated blood loss) of 300 mL. Which of the following actions is most likely to be useful? Total Knee Arthroplasty 159 1067 Posterior Spinal Fusion 975 1606 1. Order labs to rule out coagulopathy 2. Order labs to rule out hemolysis Retropubic Prostatectomy 1300 1794 3. Recheck CBC; the results are wrong 4. No work-up; the EBL is wrong Table courtesy Barbara Slawski, MD (Medical College of Wisconsin) 7