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ESC 2022: Manual provides guidelines to reduce surgical risks to be passed on to the patient in preoperative assessment

ESC 2022: Manual provides guidelines to reduce surgical risks to be passed on to the patient in preoperative assessment

during a conference European Society of Cardiology (ESC 2022), guidelines for preoperative assessments were introduced, which provided, among other things, guidance to be passed on to the patient to reduce surgical risks.urgent. Related to tobacco consumption and drug use. See below what the how-to guide says.

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Quit Smoking

Smoking cessation at least four weeks prior to surgery reduces events in theaThe s-operative period should always be recommended. As well as controlling the risk factors of high blood pressure, diabetes and dyslipidemia.

Use of medicine

– Beta-blockers: It is one of the most tested drugs in the context of non-cardiac surgeries with very controversial results. Currently the recommendation is that it can be started before surgery when the patient knows coronary artery disease, myocardial ischemia, or two or more cardiovascular risk factors. Patients already using the medication should keep it as usual.

statins: Patients already using the drug should keep it perioperatively and we can consider starting it if the patient has an indication for its use.

Renin-angiotensin-aldosterone system inhibitors: Studies evaluating this class of drugs in the perioperative period are inconclusive, but hypotension caused by continued use of these drugs appears to be more harmful than hypertension by discontinuation. Therefore, current recommendations are that we can maintain ACE inhibitors and angiotensin receptor blockers in patients with stable HF; In patients without HF, we can consider suspending the dose on the day of surgery, in order to avoid hypotension and its complications. There are two main studies in progress that will give us answers on this topic.

Calcium channel blockers: There are few studies of this class of drugs and the current recommendation is to retain them in patients who are already using them, especially if the cause is vascular angina pectoris, taking care not to overdose on the day of surgery. Avoid low blood pressure.

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– Diuretics: if their use is due to high blood pressure, they should be kept until the day of surgery and returned as soon as possible. In cases of HF, the dose should be adjusted before surgery, in order to avoid hypervolemia and dehydration. It is recommended that attention be paid to electrolytes, the need for replacement, and an appropriate volume assessment.

SGLT2 Inhibitors: This drug has been associated with a rare but very serious complication, hypoglycemic ketoacidosis, with reports of it occurring after non-cardiac surgery related to in-hospital medication change, diet change, and intervention. Therefore, the FDA recommends suspending it 3 to 4 days before the procedure and if possible symptoms of ketoacidosis develop, dose ketones. European guidelines also recommend suspension in cases of moderate or high-risk surgery.

Anticoagulant drugs

We should always assess the risk of bleeding associated with the procedure and the risk of developing a blood clot. The most dangerous surgeries for hemorrhage are intracranial, spinal and vitreous.

Combination of antiplatelet agents with aspirin

If aspirin use is for primary prevention, it should be discontinued seven days prior to the procedure and, after the procedure, re-evaluated if the medication is really indicated.

In cases of secondary prevention, the risk of ischemia must be weighed against the risk of bleeding, and if there is no risk of severe bleeding, it is preferable to keep aspirin. If the indication for aspirin after TAVI and the risk of surgery-related bleeding is high, the drug should be discontinued.

Antiplatelet combination with clopidogrel

Currently, there are some recommendations for the use of clopidogrel in monotherapy, including post-AMI with angioplasty, and the decision on what to do in the perioperative context should be made based on the risk of bleeding and ischemic risk: keep the medication, switch to aspirin or Pause for a short period or make a bridge around the surgery, depending on each case.

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Dual antiplatelet pool

The ideal situation is to postpone the procedure until the ideal time to resist aggregation has been reached (6 months for elective angioplasty, 12 months after acute coronary syndrome). However, several studies have shown that this time can be safely reduced, and in cases of surgery that cannot be postponed, such as oncological surgeries, it can be as little as 1 month in patients with low to moderate ischemic risk and 3 months in patients in great danger. The P2Y12 inhibitor is stopped three to seven days before the operation, depending on the medication, and the patient remains on aspirin.

Ideally, the return of antiplatelet drugs should be as short as possible, in the first 48 hours after surgery.

Vitamin K antagonists

We must also balance the risk of thrombotic events with the risk of bleeding. Warfarin is the main representative of this class and, if used due to a metal prosthesis, should be maintained in the case of small procedures and easy bleeding control, with an INR close to the therapeutic minimum.

In the case of major procedures, heparin bypass may be considered when the risk of thrombosis is high (mitral or tricuspid valve, aortic prosthesis associated with another risk factor for thrombosis or older model) or not perform bypass when the risk of thrombosis is lower, such as in cases of valve Mechanical aortic without atrial fibrillation.

In cases of atrial fibrillation or deep vein thrombosis, a heparin bridge should be considered if coronary arteritis istwoDStwo– VASc greater than 6, in case of cardiac arrest of less than 3 months or high risk of recurrence of thromboembolism.

The medication should be reinstated 12 to 24 hours after surgery if the bleeding is well controlled and the patient is able to take the medication. The recommended dose is the patient’s usual dose plus 50% for the first two days. If bridging was performed with heparin, it should be restarted within 24 hours and maintained until the target INR is reached. If the surgery involves a high risk of bleeding, anticoagulant therapy should begin 48 to 72 hours later.

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New anticoagulants (NOAC)

There are currently four: rivaroxaban, apixaban, dabigatran, and edoxaban. Each drug has a half-life and all interfere with kidney function. Where suspension is indicated, the suspension time varies from 24 to 96 hours depending on glomerular filtration rate (GFR) and medication.

As with warfarin, simple procedures with a low risk of bleeding can be performed without warfarin, and heparin, on the contrary, is not recommended in almost any situation. It can usually be restarted within the first 24 hours.

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