who do you do troponin post op ?
basically patient who undergo urgent or emergency surgery above hte age of 65 or above the age of 45-64 with cvd
what does the trops timing post op look like and what else ?
trops 48-72
PACU EKG
major/significant CVD in preop context means what
CAD
PAD
CHF
CVD
obst cardiac
pulmo htn ( sevee)
bnp threshold
300
the RCRI elements ( 6 )
- high risk surgery
- ischemic heart diseasE
- CHF HX
- HX stroke
- t2dm ( on insulin)
- preop creat >177
what is bnp predictive of ?
postop adverse cardiac events
MINS & asymptomatic MIs vs other symptomatic myocardial infarction - what are they associated with
basically a similar increased irks of 30 day mortality as symptomatic myocardidac infarction.
in what cardiac surgery do you hold p2yi . timeline to hold
if patient going on pump
- clopido 2-7
- tica 2-3 ( vs 5-7 for others)
class 1 indication for AVR
severe AS w/ sx
severen AS, asx, ef<50%
severe AS going for other cardiac sx ( i.e. CABG)
so let’s say, echo shows moderate AS. but you are symptomatic and ef is less than 50 .. what do you do next ?
dobutamine stress echo
okay now same .. modeterate AS on echo , but you;’re symptomatic . now ef >50% . what do you do ?
AVR if teh expert things this is AS causing the symptoms.
POAF thought to be what type of afib. valve or nonvalv
nonvalv
what dd the poise 1 say about metoprolol study . why is problematic ?
starting 100 mg metoprolol xr 2-4 hrs preop led to more dea th, more stroke, less mi ( most of which were mins)
- bcs blunts adrenergic response to stress= more adv reaction
what did the poise 2 trial say about ASA
equal rate of death and MI for those we stopped aspirin
but those who continued had more bleeding
- long story short.. no benefit on MI rate, but more bleeding
but then what did poise 2 subgroup ASA analysis show
those with prior PCI who continued their ASA had less post op MI
what’s recent stent that would propt you to continue ASA ?
- DES : 3-12M
- BMS : 6 weeks
p2y12i timeline to hold for periop
tica & clopi : 5-7 d
prasu : 7-10d
per acc/aha 2024, when do you consider continuing acei ?
in hfref
poise 3 says what about acei to be held
continung acei to avoid hypertesnion vs holding it to avoid hypotension -= no divffference in vasc outcomes OR AKI !!!!
what does the bridge trial state ( nejm 2015)
bridging with warfarin was non inferior to preventing art thromboembolism with out briging and decreased risk of bleeding
high risk bleeding with which anticoagulant?
dabigatran
in elective surgery : doacs including dabigatran , what’s the holding time and when do you resume it
- doacs ( apix, edox, rivarox) : hold it 24hrs pre surgery and resume 24hrs post sugery
- dabigatran : hold 48hrs pre surugery and resume 48-72hours post
what about warfarin, when do you hold pre surgery given you will not be bridiging. do you test for inr
hold it 5 days pre . day -1 you test for INR
when do you resume warfarin post op
resume 12 hrs post op
