2010, Metzler Helfried

Transcription

1 Perioperative Strategies in Patients on Dual Antiplatelet Drug Therapy: Noncardiac Surgery H. Metzler Department of Anaesthesiology and Intensive Care Medicine Medical University of Graz, Austria

2 What is typical for noncardiac surgery?

3 Risk of bleeding Interdisciplinary plotting by surgeons, cardiologists and anaesthesiologists Risk of thrombosis

4 Event rate Bleeding risk Safe zone for surgery Thrombosis risk high low % Platelet inhibition

5 Any Adverse Event MN Vicenzi et al, Brit J Anaesth 2006; 96:

6 Re-PCI / MI / Death MN Vicenzi et al, Brit J Anaesth 2006; 96:

7 Outcome Patients with events Event-free patients Patients 46 (44.7) 57 (55.3) With multiple events 11 (10.7) Number of events 57 (100) Death (all cardiac) 5 (8.8) MI 12 (21.0) Redo PCI 8 (14.0) CHF 0 (0.0) Sustained VT 1 (1.8) New unstable angina 5 (8.8) Myocardial cell injury 22 (38.6) Bleeding 4 (7.0) Vicenzi MN et al, Br J Anaesth 2006; 96:

8 Days from stenting to surgery MACEs (%) Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention: Nuttall GA et al, Anesthesiology 2008; OR

9 MACE (%) ,5 5,8 5,9 Fig.1 Major adverse cardiac events (MACEs) versus time period between percutaneous coronary intervention (PCI) and surgery Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents: Rabbitts J et al, Anesthesiology 2008; 109: , > 366 Days between PCI and surgery

10 Characteristics Associated with MACEs in Univariate Analysis OR Emergent NCS 4.4 Shock at time of PCI 4.1 Previous history of MI 2.29 Advanced age 1.52 Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents: Rabbitts J et al, Anesthesiology 2008; 109:

11 Patients (%) Single Total bleeding risk Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents: Dual Type of antiplatelet regiment at NCS Van Kuijk JP et al, Am J Cardiol 2009; 104: Severe bleeding

12 Platelet Reactivity Index (%) Means ± S.D. H S C D0 D3 D5 D7 Group H S C D0 D3 D5 D7 Metzler H et al, Eur J Anaesth 2010; 27:

13 Perioperative Thrombosis / Bleeding Risk Influencing Variables Stent specific variables - Type of stent (BMS, DES) - Time of implantation - Number, place and length of stents Patient specific variables - Diabetes mellitus - Renal insufficiency - Poor LV-function Surgery related variables High bleeding risk procedures - Intracranial surgery - Retrolental surgery - Prostatic surgery - AAA-Surgery (rel.) - Others

14 Risk of thrombosis high moderate low Categorization of a Patient with Coronary Stent and Scheduled for Noncardiac Surgery low moderate high Bleeding risk

15 Algorithm for Preoperative Management of Patients after PCI with Dual Antiplatelet Drug Therapy Emergency Proceed to surgery Risik of thrombosis Noncardiac Surgery Semi-elective and urgent Case by case decision Risk of bleeding Continue aspirin + clopidogrel Continue aspirin stop clopidogrel stop aspirin stop clopidogrel Elective Wait until completion of the mandatory dual antiplatelet regime

16 Preoperative Bridging Low molecular weight heparin GP IIb / IIIa Antagonists Nonsteroidal Antiinflammatory Drugs (NSAIDs) Warfarin

17 Bridging with GPIIb/IIIa Antagonists Clopidogrel Aspirin Clopidogrel Aspirin Clopidogrel Aspirin Preop. GPIIb/IIIaAnt GPIIb/IIIaAnt OP Postop.

18 Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents AHA/ACC Science Advisory, Circulation 2007; 115: In patients, who are likely to require surgical procedures within the next 12 months Bare Metal Stents 2. Awareness of healthcare providers of the potentially catastrophic risk of premature discontinuation 3. Elective procedures should be deferred until completion of thienopyridine therapy (12 months after DES) 4. If procedures mandate discontinuation, aspirin should be continued, if at all possible.

19 Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion Fleisher LA et al, Circulation 2007; 116: e418 - e499

20 Recommendations for timing of noncardiac surgery after PCI Balloon angioplasty Bare-metal stent Drug-eluting stent < 14 days 14 days Minimum 6 weeks Postpone non-urgent surgery Proceed to surgery with aspirin Optimally 3 months Previous PCI Poldermans D et al, Eur Heart J 2009; 30: < 6 weeks < 12 months 12 months Postpone non-urgent surgery Proceed to surgery with aspirin

21 The Perioperative Management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008; 133: In patients with a coronary stent who have interruption of antiplatelet therapy before surgery, we suggest against the routine use of bridging therapy with UFH, LMWH, direct thrombin inhibitors, or glycoprotein IIb/IIIa inhibitors (Grade 2C)

22 Recommendations on aspirin Recommendations Class a Level b Continuation of aspirin in patients previously IIa B treated with aspirin should be considered in the perioperative period Discontinuation of aspirin therapy in patients IIa B previously treated with aspirin should be considered only in those in whom haemostasis is difficult to control during surgery a Class of recommendation b Level of evidence Poldermans D et al, Eur Heart J 2009; 30:

23 Preoperative discontinuation of antiplatelet drug therapy ACC / AHA 2007 The risk of stopping antiplatelet therapy should be weighed against the benefit of reduction in bleeding complication from the planned surgery ESC / ESA 2009 Aspirin should only be discontinued if the bleeding risk outweighs the potential cardiac benefit

24 Management of perioperative stent thrombosis Management of perioperative bleeding complications Platelet transfusion Desmopressin Antifibrinolytics NovoSeven Cath lab!

25 Real Life Primary care physicians have to be involved! Coronary stents, dual antiplatelet therapy and the perioperative scenario are an interdisciplinary challenge! The surgeon is the leading player in the perioperative scenario! Surgeons are outstanding individualists! Stent identification card! Surgery of high-risk patients close to interventional cardiologic units!