Drug Topics - January 28, 2008 - (Page H2) 2 HSE DRUG TOPICS JANUARY 28, 2008 www.drugtopics.com > > > Clinical Practice New guide targets heart patients undergoing noncardiac surgery Heidi Belden, Pharm.D. tatin therapy should be continued throughout noncardiac surgery. So says a new update from both the American College of Cardiology and American Heart Association (ACC/AHA). The ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery has been issued as a revision to the 2002 guidelines. Although it was previously unclear what to do about cholesterol-lowering statins in patients with heart disease who were about to undergo noncardiac surgery, new clinical trial evidence shows a protective effect of perioperative statin use on cardiac complications during surgery. Therefore, statins should not be discontinued before surgery, according to the new guide. “The cardiovascular benefits of statins are well known and decrease “Statins decrease both cardiovascular morcardiovascular morbidity bidity and mortality in patients who have heart and mortality in patients disease and those with who have heart disease risk factors for heart disease,” said Michael A, and risk factors Militello, Pharm.D., a for heart disease.” cardiology clinical specialist at the Cleveland Michael A. Militello, Pharm.D. Cleveland Clinic Clinic. Discontinuation prior to surgery could lead to increased incidence of cardiovascular events, he said. Also, it is now reasonable to use statins in patients undergoing vascular surgery and in patients with at least one cardiovascular risk factor undergoing an intermediate-risk procedure such as orthopedic, prostate, or head and neck surgery, he explained. The updated guidelines also advocate stopping antiplatelet therapy for as short a time as possible after stent placement. This is a significant change from the previous guidelines that called for discontinuation of antiplatelet meds before surgery to reduce the risks for excessive bleeding associated with any surgical procedure. The antiplatelet therapy duration varies for patients who have undergone percutaneous coronary intervention (PCI) and who need elective noncardiac surgery, according to Militello, and depends on the modality of PCI performed. Specifically, for patients who have had PCI with placement of a bare metal stent (BMS), dual S anitplatelet therapy should be continued for four to six weeks after PCI and noncardiac surgery delayed until that time. “The thienopyridine should be discontinued one week prior to any noncardiac surgery to allow for adequate washout of antiplatelet effect,” he explained. However, “if a noncardiac surgery needs to be performed prior to four weeks after BMS placement, then the dual therapy should be continued since the risk of stent thrombosis is significant,” he added. Since late stent thrombosis risk is significant for drugeluting stents (DES), and premature discontinuation of therapy significantly increases the risk of cardiovascular events including death and myocardial infarction, the minimum duration of dual antiplatelet therapy is 12 months after DES implantation. “Any elective surgery or procedure with a significant risk of bleeding should be delayed,” Militello said. However, patients with a DES who must undergo urgent noncardiac surgery that requires discontinuing thienopyridine therapy should continue aspirin if possible, and the antiplatelet agent restarted as soon as possible. Beta-blockers should be continued in patients undergoing surgery who are receiving them to treat angina, symptomatic arrythmias, and hypertension, according to ACC and AHA. “The new guidelines consider vascular surgery as the highest risk for post-operative cardiovascular events and recommend that patients with coronary artery disease (CAD) or those at high risk of CAD should initiate beta-blocker therapy,” Militello explained. He went on to say that institution of betablockers is also reasonable in patients undergoing intermediate-risk surgery if they have CAD or high cardiac risk (more than one risk factor). Finally, the use of betablockers in patients undergoing low- or intermediaterisk procedures in patients without cardiac risk factors is not necessary, he explained. The new guide does not include any Class 1 recommendations for the use of alpha-2 agonists, but says they may be considered in the treatment of perioperative hypertension in patients with known CAD or in those who have at least one clinical risk factor and are undergoing surgery. The update also addresses the use of volatile anesthetic agents as well as prophylactic intraoperative nitroglycerin. The report is available at www.circ.ahajournals.org/cgi/ content/full/116/17/e418. DT http://www.drugtopics.com http://www.circ.ahajournals.org/cgi/content/full/116/17/e418 http://www.circ.ahajournals.org/cgi/content/full/116/17/e418
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