Perioperative Cardiovascular Medication Management in Noncardiac Surgery: Common Questions

 

Am Fam Physician. 2017 May 15;95(10):645-650.

Author disclosure: No relevant financial affiliations.

Several medications have been used perioperatively in patients undergoing noncardiac surgery in an attempt to improve outcomes. Antiplatelet therapy for primary prevention of cardiovascular events should generally be discontinued seven to 10 days before surgery to avoid increasing the risk of bleeding, unless the risk of a major adverse cardiac event exceeds the risk of bleeding. Antiplatelet therapy for secondary prevention should be continued perioperatively, except before procedures with very high bleeding risk, such as intracranial procedures. Antiplatelet drugs should be continued and surgery delayed, if possible, for at least 14 days after percutaneous coronary intervention without stent placement, 30 days after percutaneous coronary intervention with bare-metal stent placement, and six to 12 months after percutaneous coronary intervention with drug-eluting stent placement. Perioperative beta blockers are recommended for patients already receiving these agents, and it is reasonable to consider starting therapy in patients with known or strongly suspected coronary artery disease or who are at high risk of perioperative cardiac events and are undergoing procedures with a high risk of cardiovascular complications. Long-term statin therapy should be continued perioperatively or started in patients with clinical indications who are not already receiving statins. Clonidine should not be started perioperatively, but long-term clonidine regimens may be continued. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers generally can be continued perioperatively if patients are hemodynamically stable and have good renal function and normal electrolyte levels.

The prevention of perioperative cardiovascular complications is an important element of general medical care.1 Perioperative practices vary and often are contrary to the best evidence. This article answers common questions about perioperative cardiovascular medication management for noncardiac surgical procedures.

WHAT IS NEW ON THIS TOPIC: PERIOPERATIVE MEDICINE

A 2014 multicenter randomized controlled trial of more than 10,000 noncardiac surgical patients found that clonidine did not reduce rates of mortality or myocardial infarction compared with placebo, and it increased the risk of clinically significant hypotension and nonfatal cardiac arrest.

Overall, trials demonstrate that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers increase the risk of hypotension, but have no significant adverse effects on other perioperative cardiovascular outcomes.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Antiplatelet therapy for primary prevention should be discontinued seven to 10 days before noncardiac surgery unless the patient is at high risk of a major cardiac event. Antiplatelet therapy for secondary prevention should be continued perioperatively unless the patient is undergoing a procedure with a high risk of bleeding (e.g., intracranial surgery).

A

1, 2, 7, 8

Perioperative beta blockers are recommended if a patient is already receiving long-term beta-blocker therapy. They are a reasonable option if a patient has known or strongly suspected clinically significant coronary disease, or if a patient has three or more risk factors for a perioperative major adverse cardiac event plus a planned high-risk procedure.

B

1, 1014

Perioperative statins should be continued in patients already receiving long-term statin therapy. They should be started in patients with clinical indications who are undergoing high-risk noncardiac procedures.

A

1, 1520

Prophylactic clonidine should not be initiated perioperatively. Long-term regimens can be continued perioperatively if the patient is stable.

B

1, 21

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers generally can be continued perioperatively if patients are hemodynamically stable and have good renal function and normal electrolyte levels. If they are withheld preoperatively, they should be restarted as soon as feasible postoperatively.

C

1, 2227


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Antiplatelet therapy for primary prevention should be discontinued seven to 10 days before noncardiac surgery unless the patient is at high risk of a major cardiac event. Antiplatelet therapy for secondary prevention should be continued perioperatively unless the patient is undergoing a procedure with a high risk of bleeding (e.g., intracranial surgery).

A

1, 2, 7, 8

Perioperative beta blockers are recommended

The Authors

show all author info

MICHAEL A. MIKHAIL, MD, is an assistant professor of medicine in the Division of General Internal Medicine at the Mayo Clinic College of Medicine, Rochester, Minn....

ARYA B. MOHABBAT, MD, is an assistant professor of medicine in the Division of General Internal Medicine at the Mayo Clinic College of Medicine.

AMIT K. GHOSH, MD, is a professor of medicine in the Division of General Internal Medicine at the Mayo Clinic College of Medicine.

Address correspondence to Michael A. Mikhail, MD, Mayo Clinic, 200 First St. SW, Rochester, MN 55905 (e-mail: mikhail.michael@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215–2245....

2. Devereaux PJ, Mrkobrada M, Sessler DI, et al.; POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494–1503.

3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians evidence-based clinical practice guidelines [published correction appears in Chest. 2012;141(4):1129]. Chest. 2012;141(suppl 2):e326S–e350S.

4. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–1049.

5. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–387.

6. Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth. 2010;104(3):305–312.

7. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667–2674.

8. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med. 2005;257(5):399–414.

9. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2016;134(10):e192–e194]. Circulation. 2016;134(10):e123–e155.

10. POISE Study Group. Effect of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–1847.

11. Mushtaq M, Cohn SL. Perioperative beta-blockers in noncardiac surgery: the evidence continues to evolve. Cleve Clin J Med. 2014;81(8):501–512.

12. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major non-cardiac surgery. N Engl J Med. 2005;353(4):349–361.

13. Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective beta-blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med. 2002;137(9):715–725.

14. Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011;342d2549.

15. Poldermans D, Bax JJ, Kertai MD, et al. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation. 2003;107(14):1848–1851.

16. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA. 2004;291(17):2092–2099.

17. Kertai MD, Boersma E, Westerhout CM, et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med. 2004;116(2):96–103.

18. Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39(5):967–975.

19. Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B. Improved postoperative outcomes associated with preoperative statin therapy. Anesthesiology. 2006;105(6):1260–1272.

20. Schouten O, Boersma E, Hoeks SE, et al.; Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361(10):980–989.

21. Devereaux PJ, Sessler DI, Leslie K, et al.; POISE-2 Investigators. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1504–1513.

22. Coriat P, Richer C, Douraki T, et al. Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Anesthesiology. 1994;81(2):299–307.

23. Bertrand M, Godet G, Meersschaert K, Brun L, Salcedo E, Coriat P. Should the angiotensin II antagonists be discontinued before surgery? Anesth Analg. 2001;92(1):26–30.

24. Kheterpal S, Khodaparast O, Shanks A, O’Reilly M, Tremper KK. Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery. J Cardiothorac Vasc Anesth. 2008;22(2):180–186.

25. Rosenman DJ, McDonald FS, Ebbert JO, Erwin PJ, LaBella M, Montori VM. Clinical consequences of withholding versus administering renin-angiotensin-aldosterone system antagonists in the preoperative period. J Hosp Med. 2008;3(4):319–325.

26. Turan A, You J, Shiba A, Kurz A, Saager L, Sessler DI. Angiotensin converting enzyme inhibitors are not associated with respiratory complications or mortality after noncardiac surgery. Anesth Analg. 2012;114(3):552–560.

27. Vijay A, Grover A, Coulson TG, Myles PS. Perioperative management of patients treated with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: a quality improvement audit. Anaesth Intensive Care. 2016;44(3):346–352.

28. Chassot PG, Marcucci C, Delabays A, Spahn DR. Perioperative antiplatelet therapy. Am Fam Physician. 2010;82(12):1484–1489.

29. Holt NF. Perioperative cardiac risk reduction. Am Fam Physician. 2012;85(3):239–246.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


Aug 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article