- also see PreOp Eval
Low-risk patients: (Do Not need noninvasive cardiac testing)
- who are able to walk for 2 blocks OR
- Climb a flight of stairs without stopping to rest .
- If already on a β-blocker
should continue it, but
- Adding one preoperatively may increase risk [DO NOT ADD if pt is not
already on it].
- Stopping aspirin therapy in patients with coronary stents places
them at risk for perioperative cardiac events.
- Surgical bleeding is somewhat increased in patients on aspirin, but
differences in the severity of bleeding events and mortality in surgical
patients on low-dose aspirin versus controls are minimal.
- Plavix (Clopidogrel):
- Stopping clopidogrel in patients who have recently undergone
coronary stent placement markedly increases risk, but there is no
need to start clopidogrel in other patients.
- bare-metal stents: 6 weeks (min: 1 month
- Drug-eluting stents: 1 year (min: 6 months)
- Perioperative statin therapy should be continued for all
patients undergoing surgery.
- For patients undergoing vascular therapy, statins have been
associated with an improvement in postoperative cardiac outcomes.
Source: ITE 2013, Q50
A 63-year-old male presents for a preoperative evaluation prior to total
knee arthroplasty. He underwent coronary artery angioplasty and stent
placement 3 years ago following an episode of angina and an abnormal
exercise stress test. His current medications include aspirin, atorvastatin
(Lipitor), and lisinopril (Prinivil, Zestril). He runs 2 miles three
times/week without difficulty. He has no history of heart failure, diabetes
mellitus, kidney disease, or cerebrovascular disease. An EKG and
preoperative blood tests, including kidney function tests, are normal.
Which one of the following is indicated prior to surgery to decrease this
patient’s perioperative risk?
A) Performing noninvasive cardiac stress testing
B) Continuing his statin therapy
C) Discontinuing aspirin
D) Starting a -blocker
E) Starting clopidogrel (Plavix)
ITE 2014, Q 164.
A 60-year-old male is scheduled for coronary revascularization. Which one of
the following would reduce his cardiovascular risk the most when given
B) Calcium channel blockers
E) Warfarin (Coumadin)
- Statins are the drugs of choice to reduce perioperative
cardiovascular risks (level of evidence 1). In addition to lowering
cholesterol, they also reduce vascular inflammation, improve endothelial
function, and stabilize atherosclerotic plaques. For the most
protection, statins should be started 4 weeks prior to
the procedure and continued after surgery (SOR A).
- Beta-Blockers and aspirin are beneficial, but less so than statins.
Ref: Holt NF: Perioperative cardiac risk reduction. Am Fam Physician