Peri‐operative cardiac protection for non‐cardiac surgery

Abstract

Summary Cardiovascular complications are an important cause of morbidity and mortality after non‐cardiac surgery. Pre‐operative identification of high‐risk individuals and appropriate peri‐operative management can reduce cardiovascular risk. It is important to continue chronic beta‐blocker and statin therapy. Statins are relatively safe and peri‐operative initiation may be beneficial in high‐risk patients and those scheduled for vascular surgery. The pre‐operative introduction of beta‐blockers reduces myocardial injury but increases rates of stroke and mortality, possibly due to hypotension. They should only be considered in high‐risk patients and the dose should be titrated to heart rate. Alpha‐2 agonists may also contribute to hypotension. Aspirin continuation can increase the risk of major bleeding and offset the benefit of reduced myocardial risk. Contrary to the initial ENIGMA study, nitrous oxide does not seem to increase the risk of myocardial injury. Volatile anaesthetic agents and opioids have been shown to be cardioprotective in animal laboratory studies but these effects have, so far, not been conclusively reproduced clinically.

Lesão Miocárdica após Cirurgia Não Cardíaca – Estado da Arte

“…58 A cirurgia de revascularização do miocárdio e a intervenção coronária percutânea são procedimentos associados com um risco significativo. 59 Pacientes com stents coronários após a intervenção coronária percutânea estão em risco de trombose de stent durante a cirurgia, especialmente em caso de interrupção no uso de agentes antiplaquetários no período perioperatório. A revascularização antes da cirurgia não cardíaca é recomendada apenas para pacientes a quem a revascularização é indicada independentemente de cirurgia.…”

Post-operative Management

“…Beta-blocker use should be continued during the perioperative phase, while it is no longer recommended for use in naïve patients, as was suggested by earlier studies. Preoperative introduction of betablockers can reduce myocardial complications, but may increase the rate of stroke and mortality, possibly due to hypotension [29]. The preoperative pharmaceutical review may also contribute to preventing the intra-operative blood pressure fall that has been found to increase the risk of death within 5 days after surgery [30].…”

Current Concepts in the Prevention of Perioperative Myocardial Injury

“…If a stent has been inserted recently, there is an ongoing risk of stent thrombosis and antiplatelet therapy should be continued throughout the perioperative period [29]. Chronic statin and beta blocker therapy should be continued because their withdrawal has been associated with an increased rate of adverse events [68]. The lack of efficacy of preoperative revascularization and the success of techniques that control perioperative tachycardia by blunting the stress response to surgery have led to reduction in the number of preoperative coronary angiographies that are being performed in asymptomatic patients.…”