PERIOPERATIVE USE OF CARDIAC MEDICATION IN HIGH RISK PATIENTS

INTRODUCTION

Perioperative period is a stressful condition where a number of physiological changes take place which
can result in a change in drug requirement.

May be due to altered hepatic or renal function or neuro hormonal changes. It is estimated that one
fourth of all patients undergoing a surgical procedure are taking long- term medications

The issues surrounding the decision to discontinue such medications before surgery and when to
reinstitute them are complex

In the preoperative period, it is important to avoid the use of medications that may negatively interacts
with anesthetic agents.

Antihypertensive medications may cause cardiovascular complications, such as hypotension or

myocardial ischemia.

Psychoactive medications may cause prolonged sedation and withdrawal symptoms may develop

Antithrombotic agents may increase the risks of bleeding during surgery

Postoperatively, the concern shifts towards avoiding withdrawal symptoms that may develop and
possible progression of the underlying disease if the medications are not restarted in a timely fashion

Cardiac medication used for disease

 Coronary Artery Disease

 Hypertension

 Heart Failure
  Cardiomyopathy

 Valvular Heart Diseases

 Arrythmias and Conduction Defects

Implanted Pacemakers

 B-blockers

 Calcium channel blockers

 ACE inhibitors/AR antagonists

 Diuretics

 Nitrates

 Digitalis

 Amiodarone

 Anti platelet drugs

 statins

BETA BLOCKERs

MECHANISM OF ACTION:

 Decrease oxygen consumption

 Improve myocardial metabolism

 Block the action of catecholamines

 Decrease sympathetic outflow

 Shift ODC to right leading to increased oxygen supply

 Suppress dysrrhymias

 LV remodelling
RECOMMENDATION

 Perioperative betablocker therapy to be instituted before CABG if LVEF > 30% and preop
status allows it.

 Pt already on BB should take on morning of surgery and renew it immediate past op

 In pt with COPD/reactive airway disease, preferable to use cardio selective agents

 Beta blockers should be continued in patients undergoing surgery who are receiving beta
blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the
drugs

 Beta blockers titrated to heart rate and blood pressure are probably recommended for
patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery
disease or the finding of cardiac ischemia on preoperative testing (4, 5).

Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence
of > 1 clinical risk factor

Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the
presence of > 1 clinical risk factor,* who are undergoing intermediate-risk surgery.

NO CHANGE

The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk
procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk
factor in the absence of coronary artery disease
The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical
risk factors who are not currently taking beta blockers.

Beta blockers should not be given to patients undergoing surgery who have absolute
contraindications to beta blockade

Routine administration of high-dose beta blockers in the absence of dose titration is not useful and
may be harmful to patients not New currently taking beta blockers who are undergoing noncardiac
surgery.

ANAESTHETIC IMPLICATIONS

 Decrease in HR, decrease in BP and myocardial depressant effects of BB and GA agents

appear to be additive

 Severe decrease in HR and block may occur with drugs like fentanyl, vecuronium and
propofol.

 Intubation, incision and extubation occur during periop period result in a surge in
endogenous catecholamines.

 ISIS-I study (International study of infarct survival)

 MIAMI study (Metoprolol in AMI)

 MAPHY study (Metoprolol Vs Thiazide diuretics in HT)

 ASIST study (Atenolol ischaemia study)

-have shown that BB is effective in reducing cardiac complications and could be safely used in the
periop period.

CCB – ADVANTAGES

 Well tolerated and do not alter exercise tolerance like BB’s

 Do not cause fluid retention although ankle edema is a well known side effect.

 Control dysrhythmias

 Prevent coronary artery spasm

 Anti-HT effect

 Negative inotropic, chronotropic and dromotropic

CCB – DISADVANTAGES

 Low response to inotropes and vasopressors

 AV node conduction block

 Peripheral vasodilation after CPB

 Profound brady cardia and low BP when given in presence of BB

Perioperative Calcium Channel Blockers

 Calcium channel blockers significantly reduce

1. Myocardial ischemia

2. Supraventricular tachycardia

3. Morbidity/mortality.

*Large scale trial needed to define the value of these agents.

RECOMMENDATIONS

 Preferable to continue CCB upto the time of surgery, including an oral dose on the morning of
surgery

ANAESTHETIC IMPLICATIONS

 CCB can also enhance the action of muscle relaxants and lowers MAC of inhaled agents

 CCB being vasodilators and myocardial depressants are similar to volatile gents – synergistic
role

 CCB must be administered with caution to patient with impaired LV function or hypovolemia

ACEI/ARA

 Renin-AT system plays a significant role in maintaining intraop BP

 Inhibitors of this system exaggerate the hypotensive effects of anaesthesia, can cause
refractory hypotension and reduced organ perfusion
  Patients treated chronically with ACEI will have significant reduction in MAP,CI,PCWP,SVR
and HR in periop period

 Increased incidence of low BP at induction requiring vasopressors after induction

RECOMMENDATIONS

 Preferable not to continue ACEI/ARA upto day of surgery

 OMIT on the morning of surgery

 If continued, it is mandatory to maintain an adequate volume load and BP with vasopressor,

if necessary

 Discontinue ACEI preop (12 hours preop if captopril (or) 24 hours preop if enalapril) and
substitute shorter acting IV anti-HT drugs

 ACEI may increase insulin sensitivity and hypoglycemia- concern in DM patients

DIURETICS

 Cause significant dyselectrolytemia and fluid imbalance

 Should be discontinued preop

 Efficacy comes down with decrease in GFR

NITRATES

 Weightman etal found nitrates to be independent predictors of mortality after CABG surgery

 This may be due to tolerance to nitrates which in turn decreases the effectiveness of nitrates
causing decreased vasodilatation of IMA graft, decreased inhibition of platelets, decreased
ischaemic preconditioning, decreased sensitivity to vasoconstrictors

 Preop discontinuation results in rebound coronary vasoconstriction and worsening of

myocardial ischaemia

RECOMMENDATIONS

 Regarding patients on therapeutic and prophylactic NTG, this agent should be continued until
and perhaps beyond induction of anaesthesia, especially in patients who were preop on
nitrates for angina

DIGITALIS

INDICATIONS

 Prevents post operative arrhythmias after lung surgery

 Controls ventricular rate in patients with atrial fibrillation

 Improves cardiac contractility in patients with congestive cardiac failure

DISADVANTAGES

 Narrow margin of safety

 Exacerbation of hypokalemic risk –K+ concentration can fluctuate widely during anaesthesia
due to fluid shifts,ventilatory acid- base dearrangements and adjuvant treatments

 Intraoperative arrhythmia due to digitalis may be difficult to differentiate from those having
other sources

 Digitalis toxicity can present with such diverse cardiac arrhythymais on junctional escape
rhythm,PVC Ventricular bigeminy or trigeminy,Junctional Tachycardia, PAT with/without,
sinus arrest, Mobitz type I and II block or VT

 Prophylactic digitalization to prevent arrhythmias after lung surgery has proven ineffective in
a number of Randomized controlled studies

RECOMMENDATION

 As digitalis has a long blood half-life(36 Hrs),pre-op discontinuation on the day of surgery
should not result in a significant decrease in blood levels.

 As intravenous preparation is available,the drug can be supplemented if required.

 Moreover heart rate can be effectively controlled with b-blockers and cardiac contractility
can be increased with inotropes.pre-op discontinuation of digitalis is recommended

AMIODARONE

 Antiarrhythmic agent

 Used to treat recurrent SVT & VT

 It causes a significant reduction in the incidence of post-op atrial fibrillation and duration of
hospitilization

 Side effects

Pulmonary infiltrates

Hypo/Hyperthyroidism Peripheral neuropathy Deranged LFT Prolonged QT interval

 Increase quinidine, procainamide, digoxin levels

 Prolongation of Prothrombin time causing bleeding in patient on warfarin

 Amiodarone increase phenytoin levels and phenytoin enhance the conversion of amiodarone

Synergism with BB

RECOMMENDATIONS

 As amiodarone has a long T1/2 (29 days), and pharmacologic of effects may persists for over
45 days after its discontinuation, effective preoperatively discontinuation is not feasible
  Omit morning dose as IV form is available and is fact acting

 Risk of discontinuation increases reappearance of life threatening ventricular arrhythmias

 Amiodarone has to be started 7 days preop

 This is both inconvenient and costly

ANTIPLATELET DRUGS

RECOMMENDATIONS

 To discontinue, aspirin, clopidogrel & Ticlopidine atleast 5-7 days before surgery to reduce
the risk of periop bleeding & reinstitute them when the bleeding risk is diminished.

Recommendations for Statin Therapy

For patients currently taking statins and scheduled for noncardiac surgery, statins should be
continued.

For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable.

For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures,

statins may be considered.

Alpha-2 agonists for perioperative control of hypertension may be considered for patients with
known CAD or at least 1 clinical risk factor who are undergoing surgery.

Alpha-2 agonists should not be given to patients undergoing surgery who have contraindications to
this medication.

Perioperative arrhythmias & conduction disturbances

 In patients with documented hemodynamically significant or symptomatic arrhythmias,

acute treatment is indicated.
  (1) supraventricular arrhythmias:

 Beta blockers (most effective)

 CCB

 Digoxin (least effective)

 (2) Ventricular arrhythmias:

 PVC

 Complex ventricular ectopy therapy

 Nonsustained tachycardia

 Sustained/symptomatic ventricular tachycardia

 🢝 Lidocaine

 🢝 Procainamide

 🢝 Amiodarone

Successful perioperative evaluation and management of high risk cardiac patients undergoing
noncardiac surgery requires careful teamwork and communication between surgeon,
anaesthesiologist and the patient’s primary caregiver.

 The decision to withhold and restart medications

should be based on the

pharmacokinetics and

pharmacodynamics of the agent, available clinical data and

expert opinion

 Anaesthetists should exercise diligence in obtaining an accurate medication history on all

preoperative patients and in reviewing the medications in the post operative orders