9/21/2015 Perioperative Medical Therapy: Beta Blockers, Statins, ACE-Inhibitors, ARB – Effects on Mortality Art Wallace, MD, PhD SF VAMC Chief of Anethesia and Vice Chair of Anesthesia and Perioperative Care UCSF Disclosures No financial interests to disclose. Worked in field for many years and have opinions. 1
9/21/2015 Goals & Objectives: How should you do a preop assessment in 2015? Does perioperative beta blockade reduce risk? What does CARP say? What about Poldermans? What about statins? What about PCI, Aspirin, Plavix? What about the POISE Data? What do I do now? 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Fleisher, LA, et. al. I know you memorized all 54 pages. ECHO: Patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation. (Class 1) Monitor patients with severe AS, MR, AR, MR (Class 2A) ECG for Known CAD (Class 2) ECHO for CHF without prior evaluation or change in condition (Class 2) Stress Test: In elevated risk patients only if it will change management. Coronary angiography: Not recommended (Class 3) CABG prior to non-cardiac surgery: Not recommended (Class 3) PCI with DES: Delay non-cardiac surgery 365 days PCI with BMS: Delay 30 days, Balloon 14 days. 2
9/21/2015 Recommendations for Beta-Blocker Medical Therapy Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically. (I) ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Recommendations for Beta-Blocker Medical Therapy It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started. (IIa) Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor. (IIb) Beta blockers are probably recommended for patients in whom preoperative assessment identifies coronary heart disease or high cardiac risk as defined by the presence of more than 1 clincial risk factor, who are undergoing intermediate risk or vascular surgery. (IIb) ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 3
9/21/2015 Recommendations for Beta-Blocker Medical Therapy It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started. (IIa) In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers. (IIb) In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, coronary artery disease, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery. (IIb) In patients with a compelling long-term indication for beta-blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit. In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before – surgery. (IIb) Beta-blocker therapy should not be started on the day of surgery. (III) ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Recommendations for Statin Therapy Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery. (I) Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery. (IIa) Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures. (IIb) ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 4
9/21/2015 Recommendations for Alpha-2 Agonists Class III (Changed) Alpha-2 agonists for prevention of cardiac events are not recommended in patients who are undergoing noncardiac surgery. ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery ACE-I and ARB Continuation of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers perioperatively is reasonable.(IIa) If angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively. (IIa) ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 5
9/21/2015 Anti-Platelet Agents Continue Dual Anti-Platelet Therapy (DAPT) in patients undergoing urgent non-cardiac surgery during the first 4-6 weeks after BMS or DES implantation, unless the risks of bleeding outweighs the benefit of stent thrombosis prevention. In patients where surgery requires discontinuation of P2Y inhibitors, continue aspirin and restart P2Y platelet inhibitor as soon as possible. In patients undergoing nonemergency/nonurgent non-cardiac surgery without prior coronary stenting, it may be reasonable to continue aspirin when the risk of CAD outweighs risk of bleeding. Initiation of ASA is not beneficial in patients undergoing elective noncardiac surgery who have not had previous coronary stenting. ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery CARP TRIAL (McFalls et al. N Engl J Med. 2004 ) Coronary Artery Revascularization Prophylaxis Trial. Multi-centered, randomized, prospective, controlled trial sponsored by the Department of Veterans Affairs. Patients with significant CAD who are undergoing operations for peripheral arterial disease are randomized to myocardial revascularization versus best medical care Can 3.2 + 1.5 < 3.0 ? NO 6
9/21/2015 Overall Survival in the Two Years after Noncardiac Surgery among 192 Patients in the Atenolol and Placebo Groups who Survived to Hospital Discharge. 6 month survival 100% vs 92% p < 0.001, 1 year survival 97% vs 86% p =0.005, 2 year survival 90% vs 79% p=0.019, Mangano et. al. NEJM 335:23: 1713-1720, 1996. Kaplan-Meir Estimate of Cumulative Percentage of Patients who Died of Cardiac Causes or had a Non Fatal Myocardial Infarction during the Perioperative Period Poldermans et. al. NEJM 341:24:1789-1840, 1999. 7
9/21/2015 Wallace A.W., et. al. Effect of Clonidine on Cardiovascular Morbidity and Mortality after Non-Cardiac Surgery Anesthesiology 101(2) 284- 293, 2004 1.0 Clonidine 0.9 0.8 0.7 Survival P lacebo 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 200 400 600 Days after S urgery Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leão P, Caramelli B. J Vasc Surg. 2004 May;39(5):967-75 Prospective, randomized, placebo-controlled, double- blind clinical trial was performed to analyze the effect of atorvastatin compared with placebo on the occurrence of a 6-month composite of cardiovascular events after vascular surgery. Cardiovascular complications are the most important cause of perioperative morbidity and mortality among patients undergoing vascular surgery. Statin therapy may reduce perioperative cardiac events through stabilization of coronary plaques. METHODS: One hundred patients were randomly assigned to receive 20 mg atorvastatin or placebo once a day for 45 days, irrespective of their serum cholesterol concentration. Vascular surgery was performed on average 30 days after randomization, and patients were prospectively followed up over 6 months. The cardiovascular events studied were death from cardiac cause, nonfatal myocardial infarction, unstable angina, and stroke. RESULTS: Fifty patients received atorvastatin, and 50 received placebo. During the 6-month follow-up primary end points occurred in 17 patients, 4 in the atorvastatin group and 13 in the placebo group. The incidence of cardiac events was more than three times higher with placebo (26.0%) compared with atorvastatin (8.0%; P =0.031). The risk for an event was compared between the groups with the Kaplan-Meier method, as event-free survival after vascular surgery. Patients given atorvastatin exhibited a significant decrease in the rate of cardiac events, compared with the placebo group, within 6 months after vascular surgery (P =0.018). 8
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