Optimal medical management around the time of surgery

Due to technical advancement and improved life expectancy, the surgical patient population is increasing in age and level of comorbidities. In an effort to decrease postoperative cardiac complications and death, optimal medical management is essential. Undergoing surgery has an accelerating effect on coronary atherosclerosis, increases inflammation, and induces a state of hypercoagulability in patients. Therefore, cardioprotective measures should be taken, especially in patients with a high risk of cardiac complications after surgery. Furthermore, increasing numbers of patients scheduled for surgery are treated with antiplatelet and/or anticoagulant therapy. These agents require strict management around the time of surgery, due to their ability to cause haemorrhage on the one hand and increased cardiac risks of withdrawal on the other. As planning for surgery begins, cardioprotective measures are best initiated. Optimally, 30 days before surgery both b-blockade and statin therapy are recommended to start. Especially in high cardiac risk patients, these medications have proven to be beneficial in the perioperative period and in long term follow-up. Additionally, the use of antiplatelet therapy should be assessed. A cardiologist and an anaesthetist should be consulted if the planned procedure has such a high bleeding risk that withdrawal from antiplatelet therapy is considered by the surgeon. Antiplatelet - especially clopidogrel - withdrawal is often hazardous to the patient, and surgery should therefore be postponed until clopidogrel therapy has stopped, if possible. Patients with current anticoagulant treatment should discontinue their therapy 5 days before most types of surgery. This will reduce the risk of bleeding during surgery, but it will increase the risk for thrombosis. In general, LMWH will be used as bridging therapy to reduce the perioperative thrombotic risk. LMWH therapy should commence 1 day after acenocoumarol or 2 days after warfarin, and be continued until 12 h before surgery. One or two days, and certainly no less than 12 h after surgery, LMWH bridging therapy can be continued. One or 2 days after surgery, anticoagulant therapy should be restarted at 150% of the preoperative daily dose for 2 days, and then continued at the preoperative daily dose. Heparin is discontinued when the INR reaches the therapeutic range. This paper provides a comprehensive outline of the optimal perioperative medical management concerning cardiac risk in any surgical population, based on recent guidelines. We emphasise that knowledge of, and adherence to, current guidelines is essential for optimal care and safety of surgical patients.

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