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Revascularization

Guiding Question:
In the perioperative period does revascularization have an effect similar to what it does in ACS or similar to what it does in chronic stable angina?

 

Patients undergoing vascular surgery have a high prevalence of CAD and are at high risk of perioperative cardiac complications. Similarly, patients undergoing nonvascular surgery with high Gupta or RCRI scores are also at increased risk of perioperative cardiac complications. Preoperative coronary revascularization can ameliorate severe coronary stenoses.  But does it prevent perioperative MI?

Patients with coronary stents commonly need noncardiac surgery. How long should they wait before undergoing elective noncardiac surgery? How should their antithrombotic therapy be managed?

 

Learning Objectives:

  • Appropriately refer patients for revascularization (R2, R3)
  • Appropriately manage post-PCI patients in the perioperative period (R3)

 

Review cases 5 and 6  for this section of the module.

 

Learning Resources:
Readings:

  1. 2014 ACC Guidelines pgs 39-42
  2. UpToDate chapter on Management of Cardiac Risk for Noncardiac Surgery (Read section on Revascularization versus Medical Therapy up to Beta-blockers)
  3. Coronary artery revascularization before elective major vascular surgery. McFalls et al. NEJM 2004 (Landmark RCT on revascularization)
  4. UpToDate chapter on Elective Noncardiac Surgery After Percutaneous Coronary Intervention.
  5. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. Hawn et al. JAMA 2013 (Study looking at timing and type of stents in relation to MACE)

Videos: (Total viewing time 11:34)

  1. Reducing Perioperative Cardiac Risk: Does Revascularization Work? (4:03)
  2. Managing Patients Needing Noncardiac Surgery After PCI (7:31)

Annotated PowerPoint Slides (Note: To download the slides click “Save” at the top of the presentation. After downloading, click on “View” tab and view as “Notes Page”)

  1. Reducing Perioperative Cardiac Risk: Does Revascularization Work? (6 slides)
  2. Noncardiac Surgery After PCI (9 slides)