New 2014 ACC/AHA perioperative cardiac guidelines

[IlDestriero]

HOT OFF THE PRESS

The new 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery was released today.
See below.

“2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery”
http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.07.944


2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary
http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.07.945

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[deleted171991]

Just browsing through the beginning of the Executive Summary, this looks like a major rewrite.

 

[sevoflurane]

They've added DES >30 days but<365 days. If surgical delay risk is > than DES thrombosis then proceed. Hmmm.... I can see a lot of semi- elective vascular procedures being done @ 180 days after DES placement.

I can see this happening: AAA repair for a 5.8cm aneurysm (edit) 180 days after DES.

This is probably reasonable.

 

[deleted171991]

A few notes below. I hate to say it, but IMHO the algorithms in the previous 2 versions were clearer.

1. They redefine urgency and risk. Emergent procedure= threat to life or limb if not in OR < 6 hours, no/very limited/minimal clinical evaluation. Urgent procedure = threat to limb or life if not in the OR in 6-24 hours, time for limited clinical evaluation. Time-sensitive procedure (most oncologic procedures) = a delay of >1-6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome. Elective procedure = could be delayed up to 1 year.

Low risk procedure = risk of major adverse cardiac event (MACE) or MI of <1%.
Elevated risk procedure = risk of MACE > 1%.

2. Clinical Risk Factors: Recommendations

1. Valvular Heart Disease
- If patient has at least moderate valvular stenosis or regurg -> preop echo, if no preop echo within 1 year or change in clinical status or physical exam since last evaluation
- If patient meets standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity, valvular intervention before elective non-cardiac surgery will reduce periop risk.
- Elevated-risk noncardiac surgery with intraop and postop hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS/MR , asymptomatic severe AR with normal LVEF. or asymptomatic severe MS if valve morphology is not favorable for perc mitral balloon commissurotomy.

2. Other clinical risk factors
- Chronic pulmonary vascular targeted therapy should be continued, unless contraindicated/not tolerated, in patients with PHTN for noncardiac surgery.
- Unless the risks of the delay outweigh the potential benefits, preop evaluation by a PHTN specialist before noncardiac surgery can be beneficial, particularly for those with features of increased periop risk

3.2 Stepwise approach to CAD (known or risk factors for):
1. If emergency -> clinical risk stratification (that may influence periop management) and proceed to surgery with appropriate monitoring.
2. If surgery urgent/elective and ACS -> refer for cardiology eval and mgmt according to GDMT (goal-directed medical therapy) according to UA/NSTEMI and STEMI CPGs (clinical practice guidelines)
3. If risk factors for stable CAD -> estimate periop risk of MACE on the basis of the combined clinical/surgical risk. This can use the ACS NSQIP risk calculator (www.surgicalriskcalculator.com) or incorporate the RCRI.
4. If risk of MACE <1% -> proceed to surgery without further testing.
5. If elevated risk of MACE (>1%), determine functional capacity with an objective measure or scale, such as the DASI (Duke Activity Status Index). If moderate/good/excellent (>= 4 METs) functional capacity, proceed to surgery without further eval.
6. If poor (< 4 METs) or unknown functional capacity -> pharmacological stress testing if it will impact patient decision making or periop care. If unknown functional capacity, exercise stress testing reasonable to perform. If stress test abnormal, consider coronary angiography and revascularization; the patient can then proceed to surgery with GDMT, or consider alternative strategies, such as noninvasive treatment for the indication of surgery, or palliation. If stress test is normal, proceed to surgery according to GDMT.
7. If testing will not impact decision making or care, proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment for the indication of surgery or palliation.

4.1 The 12-Lead ECG
- Preop resting ECG is reasonable for patients with known CAD, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except if low-risk surgery.
- Preop resting ECG may be considered for asymptomatic patients without known CAD, except for low-risk surgery.
- Routine preop resting 12-lead ECG not useful for asymptomatic patients undergoing low-risk procedures.

4.2 Assessment of LV function
- Reasonable for patients with dyspnea of unknown origin to undergo preop eval of LV fxn.
- Reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preop eval of LV fxn.
- Reassessment of LV fxn in clinically stable patients with previous LV dysfxn may be considered if previous assessment > 1 year ago.
- Routine preop eval of LV fxn not recommended.

4.3 Exercise testing
- If elevated risk and >10 METs, reasonable to forgo further exercise testing with cardiac imaging, and proceed to surgery.
- If elevated risk and unknown FC, reasonable to perform exercise testing for FC if it will change management.
- If elevated risk and 4-10 METs, may be reasonable to forgo further exercise testing with cardiac imaging, and proceed to surgery.
- If elevated risk and <4 METs or unknown FC, reasonable to perform exercise testing with cardiac imaging if it will change management.
- Routine screening with noninvasive stress testing not useful for low risk patients.

4.4. Noninvasive Pharmacological Stress Testing Before Noncardiac surgery
- If elevated risk and <4 METs, noninvasive pharmacological stress testing reasonable, if it will change management.
- Routine screening with noninvasive stress testing not useful for low-risk noncardiac surgery.

5.1. Coronary Revascularization Before Noncardiac Surgery
- Recommended if indicated according to existing CPGs (2011 CABG and 2011 PCI CPGs)
- Not recommended routinely before noncardiac surgery exclusively to reduce periop cardiac events.

5.2. Timing of Elective Noncardiac Surgery in Patients With Previous PCI
- Elective noncardiac surgery should be delayed 14 days after balloon angioplasty.
- Elective noncardiac surgery should optimally be delayed 365 days after DES.
- Consensus decision among treating physicians about risks of surgery and antiplatelet therapy.
- Elective noncardiac surgery after DES can be considered after 180 days, if the risk of further delay is greater than the risk of ischemia and stent thrombosis.
- Elective noncardiac surgery should not be performed within 30 days after BMS, or 12 months after DES if dual antiplatelet therapy will need to be discontinued periop.
- Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty if aspirin will need to be discontinued periop.

5.3. Periop Beta-Blocker Therapy
- Should be continued in patients who are on BB chronically.
- Reasonable if intermediate- or high-risk myocardial ischemia noted in preop risk stratification, or if >=3 RCRI risk factors
- Should not be started on the day of surgery.

5.4, 5.5, 5.6.
- Statins should be continued.
- Statins for vascular surgery reasonable to start periop.
- Alpha-2 agonists not recommended for prevention of cardiac events in noncardiac surgery.
- Reasonable to continue ACEI/ARB. If stopped, should be restarted ASAP postop.

5.7. Antiplatelet Agents
- If 4-6 weeks after BMS/DES, dual antiplatelet tx should be continued, unless the relative risk of bleeding outweighs the benefit of prevention of stent thrombosis
- If on P2Y12 platelet receptor-inhibitor, aspirin should be continued and the P2Y12 restarted ASAP postop.
- Management of periop antiplatelet tx by consensus of surgeon, anesthesiologist, cardiologist and patient, risk of bleeding versus prevention of stent thrombosis
- If no previous coronary stenting, reasonable to continue aspirin if risk of cardiac events > risk of increased bleeding.
- If no previous coronary stenting, initiation/continuation of aspirin not beneficial unless risk of ischemic events > risk of surgical bleeding.

5.8. CIEDs
- If preop reprogramming to prevent tachytherapy, patients should be on cardiac monitoring and external defibrillator should be available. CIED should be reprogrammed to active therapy before discontinuation of cardiac monitoring and discharge.

6. Anesthetic Consideration and Intraop Management
- Use of PAC may be considered when underlying medical conditions that significantly affect hemodynamics cannot be corrected before surgery.
- No benefit for routine use of PAC, even in patients with elevated risk.

 

[painstop]

Antiplatelet discontinuation in DES patients at 180 days in the appropriate scenario seem to be the biggest reconsideration in these guidelines.

I cannot remember if this was in the prior guidelines but goes well with the "Death of the PAC" thread...although cardiac surgery can hardly be called routine and these guidelines are meant for non-cardiac surgery:

1. Routine use of pulmonary artery catheterization in patients, even those with elevated risk, is not
recommended (152-154). (Level of Evidence: A)

 

[TaoistDoc]

Great, more ammo for the ABA oral examiner. Just what I needed.

 

[turnupthevapor]

Great Review FFP! Appreciate that.

So are the lee revised index out the window for determining if a pt w poor exercise tolerance needs a noninvasive work up (dm w insulin, cr>2, CVA, CAD, CHF)

 

[deleted171991]

Great Review FFP! Appreciate that.

So are the lee revised index out the window for determining if a pt w poor exercise tolerance needs a noninvasive work up (dm w insulin, cr>2, CVA, CAD, CHF)

It seems so, except for deciding whether a patient needs beta-blockers.

Otherwise, this is the new algorithm to know:

I still function according to the old one I can actually remember: if less than 4 METs, I get further workup if the procedure is high-risk, or if it's intermediate risk and the workup will change my management (especially the latter).

 

[Colba55o]

More about timing of PCI and elective NCS, there is no mention of low vs elevated risk procedures in these guidelines. If patient is undergoing a low risk risk procedure is it still recommended to wait 30d for BMS and 180 for DES? Is it ok to do cataracts, endos, foot surgeries a month out from a DES?
I wish they would have specified this.

 

[deleted171991]

To me it's crystal clear: no elective surgeries within 30 days for BMS or 12 months for DES (if dual antiplatelet therapy needs to be stopped), except if the risks of delay outweigh the risks of doing the procedure early.

Especially with no safe harbor laws, I would be very careful in approving early procedures. You cannot rely on the guidelines in case of a bad outcome.

I have to cancel about 5-6 surgeries/year, for being too early after DES (the last wanted a cataract 2 months out), and I don't feel bad about them at all. They can go have an MI on somebody else's watch.

 

[chmd]

To me it's crystal clear: no elective surgeries within 30 days for BMS or 12 months for DES (if dual antiplatelet therapy needs to be stopped), except if the risks of delay outweigh the risks of doing the procedure early.

Especially with no safe harbor laws, I would be very careful in approving early procedures. You cannot rely on the guidelines in case of a bad outcome.

I have to cancel about 5-6 surgeries/year, for being too early after DES (the last wanted a cataract 2 months out), and I don't feel bad about them at all. They can go have an MI on somebody else's watch.

No elective surgeries less than 12 months out even if Plavix is continued, right? But what's purely elective in private practice? Probably not a whole lot.

 

[deleted171991]

No elective surgeries less than 12 months out even if Plavix is continued, right? But what's purely elective in private practice? Probably not a whole lot.

Almost all that's outpatient surgery is elective by definition.

 

[chmd]

Almost all that's outpatient surgery is elective by definition.

What I mean to say is that there is wiggle room.

 

[BLADEMDA]

Real life case:

76 year old male shows up to get his left total knee replacement; he had a DES placed 7 months ago by his Cardiologist. Cath report, Echo report and note from Cardiologist is on his chart "clearing him" for surgery. Patient discontinued his Plavix 5 days ago and is on aspirin. Are you going to cancel this case? If so, what will you tell the Ortho surgeon and the patient? Legally, the Board Certified Cardiologist has written a very clear note and provided all the information not to mention the fact that the Plavix has already been stopped.

More than one Cardiologist has cleared patients for ELECTIVE SURGERY 6 months after a DES.
Should I cancel all these cases despite the fact the evidence strongly supports the safety of doing elective surgery 6 months post DES placement combined with the Cardiology Clearance?

For me, the plan is simple: do the case

 

[chmd]

If the evidence is clear then why are the guidelines clearly opposed? I have postponed these cases. Well, spine cases. Cards cleared but surgeon refused to claim that it was anything but elective.

Should I start doing cases that don't meet npo guidelines because there is no good evidence to support all of them?

 

[BLADEMDA]

https://books.google.com/books?id=L...ery 6 months after drug eluting stent&f=false

Read pages 1184 and 1185.

 

[BLADEMDA]

If the evidence is clear then why are the guidelines clearly opposed? I have postponed these cases. Well, spine cases. Cards cleared but surgeon refused to claim that it was anything but elective.

Should I start doing cases that don't meet npo guidelines because there is no good evidence to support all of them?

Correct. I follow NPO of 6 hours most of the time and have for over a decade. I'm NOT going to cancel a case based on guidelines not backed by solid, peer reviewed evidence especially when the patient has already stopped his plavix per his Cardiologist's recommendation.

 

[BLADEMDA]

I agree that we should wait 45 days after a BMS or 12 months after a DES before doing elective surgery. But, there is "wiggle room" and with Cardiology clearance 6 months post DES is perfectly reasonable for elective surgery. Without Cardiology clearance I follow the guidelines which state 12 months post DES.

 

[BLADEMDA]

Waiting six months after receiving a drug-eluting stent may be just enough time to undergo an operation with very low risk of complications.


https://www.cardiosmart.org/News-and-Events/2013/10/Is-Surgery-Safe-for-Stent-Patients

 

[chmd]

Guidelines exist because each physician doesn't have the time or expertise to conduct their own lit review.

Clearance means to me that cardiology or medicine doesn't plan any interventions or further testing prior to a case. It's not a waiver of responsibility.

 

[deleted171991]

https://books.google.com/books?id=L2ckBQAAQBAJ&pg=PA1184&lpg=PA1184&dq=elective surgery 6 months after drug eluting stent&source=bl&ots=j9JWgn7oOC&sig=DpQqvYDgiJQCHPt7nUk1zG96GDw&hl=en&sa=X&ei=56M5Vc_DE6-1sAS7xYDoDw&ved=0CEwQ6AEwBTgK#v=onepage&q=elective surgery 6 months after drug eluting stent&f=false

Read pages 1184 and 1185.

The algorithm on page 1185 is the one from the ACC/AHA guidelines. Is DES between 30-365 days old? Yes. Is the risk of delaying surgery higher than the risk of stent thrombosis? If No (which is for every single elective surgery), delay until 365 days have passed since the DES (class I recommendation).

Those are guidelines written by 2 cardiologist organizations, so I can't tell you how little I care about a particular cardiologist's clearance. Chmd is correct in requiring the surgeon to explain why the surgery is not elective (i.e. can't wait).

 

[chmd]

I agree that we should wait 45 days after a BMS or 12 months after a DES before doing elective surgery. But, there is "wiggle room" and with Cardiology clearance 6 months post DES is perfectly reasonable for elective surgery. Without Cardiology clearance I follow the guidelines which state 12 months post DES.

To be clear, I'm not arguing that it isn't "safe" to have elective surgery 6 months after a DES, just that a cardiologists clearance doesn't change the AHA/ACC guidelines.

 

[BLADEMDA]

To be clear, I'm not arguing that it isn't "safe" to have elective surgery 6 months after a DES, just that a cardiologists clearance doesn't change the AHA/ACC guidelines.

The guidelines are just that...guidelines and the literature seems supportive of the Cardiologist's decision to clear the patient for surgery 6 months after a DES placement. Cancelling the surgery is unwarranted.

 

[BLADEMDA]

whereas timing of surgery more than 6 months after the stent procedure was not significantly associated with MACE


http://www.aahs.org/medstaff/wp-content/uploads/NoncardiacSuJAMA2013.pdf

 

[chmd]

The guidelines are just that...guidelines and the literature seems supportive of the Cardiologist's decision to clear the patient for surgery 6 months after a DES placement. Cancelling the surgery is unwarranted.

I wouldn't fault a colleague for taking your approach, though if there were a complication I'm sure a jury would.

 

[BLADEMDA]

Guidelines exist because each physician doesn't have the time or expertise to conduct their own lit review.

Clearance means to me that cardiology or medicine doesn't plan any interventions or further testing prior to a case. It's not a waiver of responsibility.

Nor is it an excuse to cancel a case because you won't read the literature. The general guidelines are just that ...general guidelines and the Cardiologist has input to the patient's care as well.

 

[deleted171991]

The guidelines are just that...guidelines and the literature seems supportive of the Cardiologist's decision to clear the patient for surgery 6 months after a DES placement. Cancelling the surgery is unwarranted.

The one patient out of 100 who will get that periop stent thrombosis will change your opinion. It's a class I recommendation, while proceeding with surgery after 180 days in certain cases is class IIb.

This is not a discussion about probabilities; we would all bet our money that a full stomach patient won't aspirate on rapid-sequence induction in 90+ cases out of 100, yet we still don't do elective surgeries on non-NPO patients. This is a discussion about assuming the risk of a life-threatening complication, when there is no clear benefit of rushing on the surgical side, except that the surgeon will have a higher income this month.

 

[urge]

To be clear, I'm not arguing that it isn't "safe" to have elective surgery 6 months after a DES, just that a cardiologists clearance doesn't change the AHA/ACC guidelines.

With latest generation DES 6 month is accepted. I would do any elective case if their cardiologist is on board.

 

[BLADEMDA]

I wouldn't fault a colleague for taking your approach, though if there were a complication I'm sure a jury would.

No they would not. The literature is clear that the Cardiologist has the final say on this matter as he/she is the heart specialist. You don't need to agree with the decision just that the decision is reasonable which it is.

 

[deleted171991]

No they would not. The literature is clear that the Cardiologist has the final say on this matter as he/she is the heart specialist. You don't need to agree with the decision just that the decision is reasonable which it is.

I disagree. Most cardiologists have about the same level of understanding about what happens in the operating room as a layperson. Hence you get the idiotic "cleared for surgery under sedation".

The cardiologist is a consultant. Since I am the one performing anesthesia, the decision is ultimately mine.

 

[BLADEMDA]

The one patient out of 100 who will get that periop stent thrombosis will change your opinion. It's a class I recommendation, while proceeding with surgery after 180 days in certain cases is class IIb.

This is not a discussion about probabilities: we would all bet our money that a full stomach patient won't aspirate on induction in 90+ cases out of 100, yet we still don't do elective surgeries on non-NPO patients. This is a discussion about assuming the risk of a life-threatening complication, when there is no clear benefit of rushing on the surgical side, except that the surgeon will have a higher income this month.

What about the fact that the patient already stopped his Plavix? hasn't the patient already incurred some risk by following the advice of his Cardiologist? Should I feel

The one patient out of 100 who will get that periop stent thrombosis will change your opinion. It's a class I recommendation, while proceeding with surgery after 180 days in certain cases is class IIb.

This is not a discussion about probabilities; we would all bet our money that a full stomach patient won't aspirate on rapid-sequence induction in 90+ cases out of 100, yet we still don't do elective surgeries on non-NPO patients. This is a discussion about assuming the risk of a life-threatening complication, when there is no clear benefit of rushing on the surgical side, except that the surgeon will have a higher income this month.

Patient, Cardiologist and Surgeon have all planned this surgery. If you cancel this case then I'm sure another Anesthesiologist like myself will step up to the plate and do it based on the published literature.

 

[chmd]

With latest generation DES 6 month is accepted. I would do any elective case if their cardiologist is on board.

If it's so clearly safe then I'm sure the guidelines will change soon but Cardiologists I've spoken to don't disagree that's "it's probably a little bit safer" to wait the full 365. Is that an extra 0.1%? What's acceptable to improve sometimes quality of life w a TKA?

Also, Malpractice cases can be very expensive even if they aren't legitimate cases of malpractice.

 

[BLADEMDA]

I disagree. Most cardiologists have about the same level of understanding about what happens in the operating room as a layperson. Hence you get the idiotic "cleared for surgery under sedation".

The Cardiologist, who I personally know, feels the same way about your knowledge of Cardiology and DES placement.

 

[BLADEMDA]

If it's so clearly safe then I'm sure the guidelines will change soon but Cardiologists I've spoken to don't disagree that's "it's probably a little bit safer" to wait the full 365. Is that an extra 0.1%? What's acceptable to improve sometimes quality of life w a TKA?

Also, Malpractice cases can be very expensive even if they aren't legitimate cases of malpractice.

When the airway goes bad who do they sue? I've been there and it isn't the Orthopedic Surgeon or Urologist. If the patient has a MACE with documentation from his/her Cardiologist it's a tough sell to sue the Attending Anesthesiologist especially when the literature is anything but certain on the timing.

 

[deleted171991]

The Cardiologist, who I personally know, feels the same way about your knowledge of Cardiology and DES placement.

To this type of BS, I usually respond with: why is the patient still on dual antiplatelet therapy (outside of the periop period), doctor, if there is no risk of thrombosis anymore?

 

[chmd]

No they would not. The literature is clear that the Cardiologist has the final say on this matter as he/she is the heart specialist. You don't need to agree with the decision just that the decision is reasonable which it is.

That's news to me. I'm the one doing the anesthetic and I am personally responsible for the outcome -- as is the surgeon. I'm sure the cardiologist would also be screwed.

Please show me the evidence that would absolve me. Actually don't, that would make me feel like the cardiologist's nurse.

 

[deleted171991]

When the airway goes bad who do they sue? I've been there and it isn't the Orthopedic Surgeon or Urologist. If the patient has a MACE with documentation from his/her Cardiologist it's a tough sell to sue the Attending Anesthesiologist especially when the literature is anything but certain on the timing.

The guidelines are very certain. Class I recommendation is as certain as one can be.

As I said: the risk of thrombosis is probably in the low percentiles, I just don't want to find out the exact number in my OR. I personally don't perform elective surgeries before 1 year has passed, unless the cardiologist states that the patient does not need DAPT anymore, both preop and postop.

 

[BLADEMDA]

That's news to me. I'm the one doing the anesthetic and I am personally responsible for the outcome -- as is the surgeon. I'm sure the cardiologist would also be screwed.

Please show me the evidence that would absolve me. Actually don't, that would make me feel like the cardiologist's nurse.

Just like the Ortho Surgeon is responsible for the airway if you can't intubate or ventilate the patient. Sorry, that's NOT his field of expertise and he isn't responsible for the outcome.

You won't let the patient's specialist do his/her job because you are micromanaging based on general guidelines then delaying the surgery while a more senior Anesthesiologist steps up to the plate. The time to cancel the case is PRIOR to the patient's stopping his Plavix. Yes, the Surgery itself is prothrombotic but the patient has already incurred some risk.

 

[urge]

If it's so clearly safe then I'm sure the guidelines will change soon but Cardiologists I've spoken to don't disagree that's "it's probably a little bit safer" to wait the full 365. Is that an extra 0.1%? What's acceptable to improve sometimes quality of life w a TKA?

Also, Malpractice cases can be very expensive even if they aren't legitimate cases of malpractice.

If it makes you feel better, the original recommendation of 1 yr of dual antiplatelet therapy after DES was totally made up with no data behind it.

As long as the cardiologist who is managing the pt thinks that stopping the plavix is not dangerous during the periooperative period, I'm happy to provide the anesthesia.

 

[chmd]

What about the fact that the patient already stopped his Plavix? hasn't the patient already incurred some risk by following the advice of his Cardiologist?

So you agree there is increased risk? Obviously if there is risk to stopping Plavix then there is increased risk to having surgery on top of stopping Plavix.

Do you think the evidence wasn't fully reviewed by the cardiologists and anesthesiologists who wrote the guidelines?

 

[deleted171991]

If it makes you feel better, the original recommendation of 1 yr of dual antiplatelet therapy after DES was totally made up with no data behind it.

And yet most cardiologists don't have the guts to stop DAPT before 1 year, proof or no proof.

I'll say it again: I will happily perform anesthesia on a patient with a new generation stent, if the cardiologist states that the patient does not need DAPT anymore (hence he considers the stent epithelialized).

 

[urge]

And yet most cardiologists don't have the guts to stop DAPT before 1 year, proof or no proof.

I'll say it again: I will happily perform anesthesia on a patient with a new generation stent, if the cardiologist states that the patient does not need DAPT anymore (hence he considers the stent epithelialized).

I would take DAPT for life if I had CAD. Why not? What is good for the goose, is good for the gander.

Doesn't mean my surgeries should be postponed because of the anesthesiologists not wanting to deal with low likelyhood complications.

 

[deleted171991]

I would take DAPT for life if I had CAD. Why not? What is good for the goose, is good for the gander.

Doesn't mean my surgeries should be postponed because of the anesthesiologists not wanting to deal with low likelyhood complications.

There is no proof that you need DAPT after 1 year. Which would make me pretty comfortable about administering you anesthesia after 1 year, DAPT or not.

Anyway, we get back to my original opinion about this kind of decisions: as long as the US is a malpractice nanny-state, where not even the patient can assume the risks of his own decisions (and basically waive his right to suing for malpractice), I really don't care who else thinks that the patient is safe from having a bad outcome, if the guidelines say the opposite.

And I remembered my favorite type of cardiology clearance: the patient is cleared for surgery, but will need a stress-test post-op for his abnormal EKG. I see about 2-3 of these every year.

 

[urge]

There is no proof that you need DAPT after 1 year. Which would make me pretty comfortable about administering you anesthesia after 1 year, DAPT or not.

Send me your cancellations. I'll be happy to take care of them.

 

[chmd]

I would take DAPT for life if I had CAD. Why not? What is good for the goose, is good for the gander.

Doesn't mean my surgeries should be postponed because of the anesthesiologists not wanting to deal with low likelyhood complications.

If someone puts a teaspoon of cream in their coffee before a cataract I'm still going to postpone their phaco even if the risk is probably close to zero, and I would do so because of the clear guidelines which are based on less than perfect evidence.

I wouldn't change my mind based on what a GI doc said either, even if he had a great paper to support his position. I would reconsider when the guidelines changed, or when it became common practice at academic centers across the nation.

 

[deleted171991]

Send me your cancellations. I'll be happy to take care of them.

I'd be happy to. We all have different level of risk tolerance, based on our own experience. The same way I use an LMA for stuff that others wouldn't even consider without an ETT etc.

I am not ashamed to be conservative in certain things, and liberal in others. If that makes me less popular with the cool kids crowd, so be it. I just don't shoot from the hip, except at targets I am sure I always hit.

 

[deleted171991]

Mar 19, 2015 UpToDate article is full of warnings about discontinuing DAPT before 12 months (including elective surgery), despite some trials recommending only 6 months:

http://www.uptodate.com/contents/antiplatelet-therapy-after-coronary-artery-stenting

Another article:

http://www.uptodate.com/contents/el...gery-after-percutaneous-coronary-intervention

Elective noncardiac surgery in stented patients — In order to minimize adverse cardiovascular events, we suggest that elective noncardiac surgery be deferred until after the minimal recommended duration of DAPT for each type of stent. For patients treated with either BMS or DES who are not at high risk of bleeding, we suggest one year of DAPT. In patients at high risk of bleeding, our recommended duration of therapy is one and six months, respectively. (See "Antiplatelet therapy after coronary artery stenting", section on 'Noncardiac surgery or GI endoscopy'.)

While the optimal duration of DAPT for stented patients is not known, we are concerned that the proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT if a significant percent of struts are not endothelialized. In addition, one cannot predict the possibility that DAPT might have to be stopped due to unexpected major bleeding. Thus, we recommend caution in performing elective noncardiac surgery prior to the minimal recommended duration of such therapy.

 

[urge]

I'd be happy to. We all have different level of risk tolerance, based on our own experience. The same way I use an LMA for stuff that others wouldn't even consider without an ETT etc.

I am not ashamed to be conservative in certain things, and liberal in others. If that makes me less popular with the cool kids crowd, so be it. I just don't shoot from the hip, except at targets I am sure I always hit.

A few weeks ago we were arguing about getting an echo on a pt with HOCM diagnosed years ago. Most people said go to OR wuth traditional HOCM management, while I wanted an echo. Different strokes for different folks.

Discussion is good to keep the mind sharp.

 

[Arch Guillotti]

Patient, Cardiologist and Surgeon have all planned this surgery. If you cancel this case then I'm sure another Anesthesiologist like myself will step up to the plate and do it based on the published literature.

Would you step in and do a case that one of your partners refused to?

 

[Mman]

I disagree. Most cardiologists have about the same level of understanding about what happens in the operating room as a layperson. Hence you get the idiotic "cleared for surgery under sedation".

The cardiologist is a consultant. Since I am the one performing anesthesia, the decision is ultimately mine.

Fortunately for the cardiologist, in the case of when to perform surgery with the new stent, they aren't performing anesthesia or telling you how to do your job. They are merely telling you their expert opinion on the stent and risk of cardiac complications.

Fortunately for you, the risk of postop MI commented on by the cardiologist isn't related to how you perform your anesthetic.


If the patient and their cardiologist and the surgeon are all comfortable with the risk of the surgery and their heart, then it's not my place to try to change that. All I can do is tailor my anesthetic to the patient's needs and do the best I can.

But if a patient comes in with a questionable situation and they haven't had a detailed discussion with their cardiologist, I have a very long conversation with the patient about risks of postop MI and they usually decide they'd rather go talk to their cardiologist than have surgery today.