Guias de preoperatorio de la ESC enfoque para anestesistas #cardiologia #anestesia #preoperatorio

1. Rafael Vidal Pérez
Servicio de Cardiología
@rafavidalperez Hospital Universitario Lucus Augusti

3. La magnitud del problema
• Anualmente se estima que:
– 5,7 millones de procedimientos en Europa a pacientes
con riesgo aumentado para complicaciones
cardiovasculares.
– En el mundo entero, la cirugía no cardíaca se asocia
con una tasa media de complicaciones totales del 7–
11% y una tasa de mortalidad del 0,8–1,5%,
dependiendo de las precauciones de seguridad.
– Para países de la UE: Al menos ocurren 167000
complicaciones cardíacas debido a procedimientos
quirúrgicos no cardíacos, de los cuales 19000 pueden
amenazar supervivencia.
Data only available at a national level in 23 European countries (41%)

4. Razones para unas nuevas guías de la ESC/ESA
• Alta incidencia de morbilidad y mortalidad
cardíaca peri-operatoria
• Impacto de las enfermedades y comorbilidades
vasculares en el resultado postoperatorio
• Impacto de estrategias de disminución del riesgo
– Medicaciones: Beta-Bloqueantes, estatinas, IECA,
antiagregantes y anticoagulantes orales
– Revascularización coronaria: Stents y duración de la
DAG
• Cambios en las técnicas quirúrgicas
• Tipo de anestesia

5. >115 experts have been involved
including 24 Task Force members, 26
members of the Committee for
Practice Guidelines, 36 National
Cardiac Society reviewers, 24 expert
peer reviewers, and a number of ESC
and ESA Board members.
279 referencias bibliográficas
CPG Coordinator

6. Objetivos de estas guías
• Describir como valorar el riesgo cardíaco
perioperatorio empleando los factores de riesgo
clínicos y el tipo de procedimiento quirúrgico
• Describir una aproximación por pasos para la
valoración del riesgo cardíaco preoperatorio
• Comprender el impacto de las distintas
comorbilidades sobre el riesgo perioperatorio
• Describir como reducir el riesgo cardíaco
• Ser fáciles de usar por los médicos

7. Summary of key findings of the Dutch Echocardiographic Cardiac Risk Evaluation Applying
Stress Echocardiography (DECREASE) series of studies:
DECREASE I: In high-risk patients undergoing non-cardiac surgery, perioperative beta-blockade with
bisoprolol significantly reduces cardiac death and MI in the short- and long-term
DECREASE II: Patients identified as intermediate risk on the basis of a simple clinical assessment do not
need pre-operative echocardiographic cardiac stress testing, provided that they receive bisoprolol to maintain
resting heart rate at 60–65 b.p.m.
DECREASE III: In high-risk patients undergoing major vascular surgery, fluvastatin XL significantly reduces
myocardial ischaemia and the combined endpoint of cardiovascular death and MI
DECREASE IV: In intermediate-risk patients, bisoprolol significantly reduces cardiac death and MI, with a
non-significant trend towards a beneficial effect of fluvastatin XL
DECREASE V: In high-risk patients with extensive stress-induced ischaemia, coronary revascularization
(added to tight heart rate control with bisoprolol) does not produce any additional reduction in death and MI
and delays surgery.

8. The committee found “several serious errors
and protocol violations” in the DECREASE II
and DECREASE VI studies and raised the
possibility that the blind may have been
broken in the DECREASE II, IV, and VI
studies. For the DECREASE II and VI
studies the committee determined that there
was no independent endpoint evaluation.
For DECREASE VI the committee found
evidence of data fabrication in submitted
abstracts for the study (the trial has not been
published).

10. ¿Qué hay de nuevo en estas guías?
• Un equipo experto multidisciplinar debería ser consultado para la
evaluación preoperatoria de pacientes con enfermedad cardíaca
conocida o con alto riesgo de sufrirla cuando vayan a ser sometidos
a cirugía de alto riesgo no cardíaca
• La valoración del riesgo quirúrgico, que depende del tipo de
procedimiento, ha sido actualizada.
• La valoración del riesgo del paciente ahora incluye no solo el score
de Lee sino también otras escalas de riesgo validados tales como
NSQIP y recomendaciones sobre biomarcadores (BNP &
Troponinas)
• El inicio preoperatorio de beta-bloqueantes no se recomienda en
todos los pacientes pero se debería considerar en los apcientes
programados para cirugía de alto riesgo y que tengan factores de
riesgo clínicos, o en aquellos que tengan enfermedad coronaria
conocida o isquemia miocárdica

11. ¿Qué hay de nuevo en estas guías?
• Las recomendaciones sobre el uso de aspirina e inhibidores
P2Y12 en pacientes que se van a someter a cirugía no
cardíaca se han actualizado.
• Se ha incluido una sección sobre el manejo de los nuevos
anticoagulantes orales en pacientes que se van someter a
cirugía no cardíaca.
• Se han actualizado las recomendaciones al respecto del
momento de la cirugía no cardíaca tras una
revascularización.
• La sección sobre enfermedades concomitantes se ha
actualizado
• La sección sobre monitorización perioperatoria se ha
actualizado y expandido con la ayuda de anestesistas
expertos

15. Surgical risk estimate is a broad approximation
of 30-day risk of cardiovascular death and
myocardial infarction that takes into account
only the specific surgical intervention, without
considering the patient’s comorbidities

16. LLeeee SSccoorree
To predict post-operative
myocardial infarction, pulmonary
oedema, ventricular fibrillation or
cardiac arrest, and complete heart
block
http://www.mdcalc.com/revised-cardiac-riskindex-for-pre-operative-risk/

17. NNSSQQIIPP
To assess the risk of intra-operative/
post-operative myocardial
infarction or cardiac arrest, using the
American College of Surgeons National
Surgical Quality Improvement Program
(NSQIP) database
http://www.surgicalriskcalculator.com/miorcardiacarrest

18. Therefore, the NSQIP and Lee risk index
models provide complementary prognostic
perspectives and can help the clinician in
the decision-making process.
Risk models do not dictate management
decisions but should be regarded as one
piece of the puzzle to be evaluated, in
concert with the more traditional
information at the physician’s disposal
Based on the existing data, assessment of
serum biomarkers for patients undergoing
non-cardiac surgery cannot be proposed
for routine use, but may be considered in
high-risk patients (METs ≤4 or with a
revised cardiac risk index value >1 for
vascular surgery and >2 for non-vascular
surgery).

37. Va a ser raro que ya
no estuviera tomando

38. Aspirin should be discontinued if the bleeding risk outweighs the potential
cardiovascular benefit.121,123–125 For patients undergoing spinal surgery or certain
neurosurgical or ophthalmological operations, it is recommended that aspirin be
discontinued for at least seven days

41. Doble antiagregación
• 5-25% de los pacientes con stents requieren cirugía no cardíaca en los 5
años siguientes.
• El pronóstica de la trombosis del stent parece ser peor que la de una
oclusión coronaria de novo, y el cese prematuro de la DAG en pacientes
con un implante de stent reciente es el predictor más poderoso para
trombosis del stent
• El manejo de la DAG y la programación de cirugía debe discutirse con el
cirujano para balancear el riesgo de sangrado mortal por antiagregantes
(más conocido por cirujanos) y el riesgo mortal de la trombosis del stent sin
DAG
• Para reducir el riesgo de sangrado y transfusión se recomienda demorar cirugía
hasta completar DAG y en la medida de lo posible operar sin interrumpir aspirina.
• Elective surgery should be postponed for a minimum of 4 weeks and ideally for up
to 3 months after BMS implantation. CONTRADICTORIO
• It is recommended that DAPT be administered for at least 1 month after BMS
implantation in stable CAD, for 6 months after new-generation DES implantation,
and for up to 1 year in patients after ACS, irrespective of revascularization strategy.
Importantly, a minimum of 1 (BMS) to 3 (new-generation DES) months of DAPT
might be acceptable, independently of the acuteness of coronary disease, in cases
when surgery cannot be delayed for a longer period

42. Doble antiagregación
• In patients needing surgery within a few days, current ESC
Guidelines recommend withholding clopidogrel and ticagrelor for
five days and prasugrel for seven days prior to surgery unless there
is a high risk of thrombosis. No tienen valor los test de función
plaquetaria
• For patients with a very high risk of stent thrombosis, bridging
therapy with intravenous, reversible glycoprotein inhibitors, such as
eptifibatide or tirofiban, should be considered
• The use of low-molecular-weight heparin (LMWH) for bridging in
these patients should be avoided.
• Dual anti-platelet therapy should be resumed as soon as possible
after surgery and, if possible, within 48 hours
• Reversal of anti-platelet therapy: For patients receiving anti-platelet
therapy, who have excessive or life-threatening peri-operative
bleeding, transfusion of platelets is recommended.

45. Anticoagulación y AVK-HBPM
• If the international normalized ratio(INR) is ≤1.5, surgery can be performed safely;
however, in anticoagulated patients with a high risk of thrombo-embolism—for
example, patients with:
– AF with a CHA2DS2-VASc [Cardiac failure, Hypertension, Age ≥75 (Doubled), Diabetes, Stroke
(Doubled) – Vascular disease, Age 65–74 and Sex category (Female)] score of ≥4
– mechanical prosthetic heart valves, newly inserted biological prosthetic heart valves
– mitral valvular repair (within the past 3 months)
– recent venous thrombo-embolism (within 3 months)
– thrombophilia,
• Discontinuation of VKAs is hazardous and these patients will need bridging therapy
with unfractionated heparin (UFH) or therapeutic-dose LMWH. In general, there is
better evidence for the efficacy and safety of LMWH
• In patients with a high thrombo-embolic risk, therapeutic doses of LMWH twice
daily are recommended, and prophylactic once-daily doses in low-risk patients.
The last dose of LMWH should be administered no later than 12 hours before the
procedure
• LMWH or UFH is resumed at the pre-procedural dose 1–2 days after surgery,
depending on the patient’s haemostatic status, but at least 12 hours after the
procedure. VKAs should be resumed on day 1 or 2 after surgery— depending on
adequate haemostasis
• In patients undergoing surgery with a low risk of serious bleeding, such as
cataract- or minor skin surgery, no change in oral anticoagulation therapy is
needed; however, it is wise to keep INR levels in the lower therapeutic range

46. Anticoagulación y NACO´s
• Have a well-defined ‘on’ and ‘off’ action, ‘bridging’ to surgery is in most cases
unnecessary, due to their short biological half-lives. The overall recommendation is to
stop NOACs for 2–3 times their respective biological half-lives prior to surgery in surgical
interventions with ‘normal’ bleeding risk, and 4–5 times the biological half-lives before
surgery in surgical interventions with high bleeding risk.
• Because of the fast ‘on’-effect of NOACs (in comparison with VKAs), resumption of
treatment after surgery should be delayed for 1–2 (in some cases 3–5) days, until post-surgical
bleeding tendency is diminished.

47. Anticoagulación y NACO´s
• For procedures with immediate and complete
haemostasis, the NOAC can be resumed 6–8 h
after the intervention. The same applies after
atraumatic spinal/epidural anaesthesia or clean
lumbar puncture (i.e. non-bloody tap).
• For many surgical interventions, however,
resuming full dose anticoagulation within the
first 48–72 h after the procedure may carry a
bleeding risk that could outweigh the risk of
cardio-embolism

48. Anticoagulación y sangrado
• Patients who are receiving VKAs and who require reversal of
the anticoagulant effect for an urgent surgical procedure, low-dose
(2.5–5.0 mg) intravenous or oral vitamin K is
recommended. The effect of vitamin K on INR will first be
apparent after 6–12 hours. If more immediate reversal of the
anticoagulant effect of VKAs is needed, treatment with fresh-frozen
plasma or prothrombin complex concentrate (PCC), is
recommended, in addition to low-dose intravenous or oral
vitamin K.
• In patients who are receiving LMWHs, the anticoagulant effect
may be reversed within eight hours of the last dose because
of the short half-life. If immediate reversal is required,
intravenous protamine sulphate can be used, but anti-Xa
activity is never completely neutralized (maximum 50%).
• When severe bleeding complications occur under the
influence of NOACs, symptomatic treatment should be
initiated (Figure 2) because of the lack of specific antidotes
(these are currently under development). Preliminary data
have shown a potential benefit for the use of PCC or activated
PCC when bleeding occurs under the direct factor Xa inhibitor
rivaroxaban, and is also applicable to apixaban and
dabigatran, whereas haemodialysis is an effective method for
eliminating dabigatran from the circulation but does not help
when a direct factor Xa inhibitor has been used

55. Vacíos en la evidencia / Gaps in evidence
• ¿Cuál es el tipo óptimo, dosis y duración de los beta-bloqueantes
en la cirugía de alto riesgo y sus beneficios en pacientes con riesgo
quirúrgico intermedio?
• ¿Beneficios de las estatinas en cirugía de alto riesgo?
• Estudio de intervención o resultados para biomarcadores,
hemodinámica perioperatoria y profundidad de la anestesia.
• Cómo los factores de riesgo no cardíacos (fragilidad,
extremadamente bajo o muy alto IMC, anemia, situación
inmunológica) interaccionan con los factores de riesgo CV e
impactan sobre los resultados de la cirugía no cardíaca.
• Las escalas de riesgo que puedan predecir mortalidad por causas no
cardíacas.
• Efectos de la situación del paciente, factores de riesgo no cardíacos,
tamaño o habilidades del equipo quirúrgico, y la invasividad de los
procedimientos sobre los resultados pronósticos.

56. European Heart Journal (2014) 35, 2781–2788

58. @rafavidalperez