AHA Guidelines on post-cardiac stent operations: post-stent dual antiplatelet therapy (DAPT)

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One discussion last week included the AHA guidelines on post-stent DAPT.

Reference: Levine GN, et al. ACC/AHA Guideline Update on Duration of Dual Antiplatelet Therapy in CAD Patients. American College of Cardiology. Retrieved from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/25/14/56/2016-acc-aha-guideline-focused-update-on-duration-of-dapt.

Additional Reading: Capodanno D, et al. ACC/AHA versus ESC guidelines on dual antiplatelet therapy: JACC guideline comparison. Journal of the American College of Cardiology. 2018 Dec 11;72(23 Part A):2915-2931.  doi: 10.1016/j.jacc.2018.09.057.

Summary: Published on the website in March 2016, the following are “key points to remember about the updated guideline on duration of dual antiplatelet therapy (DAPT) in patients with coronary artery disease (CAD)”.

  1. The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y12 inhibitor) in patients with coronary artery disease (CAD).
  2. Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference.
  3. Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD.
  4. Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75–100 mg).
  5. In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).
  6. In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb).
  7. In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).
  8. In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue (prolong or extend) DAPT in patients treated with coronary stent implantation.
  9. In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa).
  10. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).
  11. In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y12inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I).
  12. Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).

(Levine et al, 2016)

 

 

AHA Guidelines on post-cardiac stent operations: Perioperative risk assessment

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A discussion last week included the AHA Guidelines for post-cardiac stent operations.

Reference: Fleisher LA, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2215-45. doi: 10.1161/CIR.0000000000000105.

Summary: Below are ACC/AHA recommendations on perioperative risk assessment, section 5.2 of the guidelines linked above.

5.2. Timing of Elective Noncardiac Surgery in Patients With Previous PCI

Class I

  1. Elective noncardiac surgery should be delayed 14 days after balloon angioplasty (Level of Evidence: C) and 30 days after BMS implantation. (Level of Evidence B)

  2. Elective noncardiac surgery should optimally be delayed 365 days after drug-eluting stent (DES) implantation.(Level of Evidence: B)

Class IIa

  1. In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful. (Level of Evidence: C)

Class IIb

  1. Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis. (Level of Evidence: B)

Class III: Harm

  1. Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom dual antiplatelet therapy will need to be discontinued perioperatively. (Level of Evidence: B)

  2. Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively. (Level of Evidence: C)

The role of evoked potentials in thoracoabdominal aortic repair

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One discussion this week involved the role of evoked potentials in thoracoabdominal aortic (TAA) repair.

Reference: Achouh PE, et al. Role of somatosensory evoked potentials in predicting outcome during thoracoabdominal aortic repair. The Annals of Thoracic Surgery. 2007 Sep; 84(3):782-787.

Summary:  Between January 2000 and April 2005, a study out of Houston, TX, used SSEP monitoring in 444 patients (270 thoracoabdominal aorta and 174 descending thoracic aorta).  Changes were classified as (1) no change, (2) transient changes that returned to baseline by the end of the procedure, or (3) persistent changes that did not return to baseline by the end of the procedure.

Primary findings included:

  • Somatosensory evoked potential changes occurred in 87 (19.6%) patients; 22 (25%) of these did not return to baseline.
  • Immediate neurologic deficit occurred in 8 of 444 patients (1.8%); five deficits (5 of 87; 5.8%) occurred in patients with SSEP changes, compared with three deficits (3 of 357; 0.8%) in patients without changes.
  • Somatosensory evoked potential was a poor screening tool for neurologic deficit, with a sensitivity of 62.5% and specificity 81.2%. Negative predictive value was 99.2%, indicating a very low event probability in the absence of SSEP changes. Delayed neurologic deficit occurred in 3.2% and was not related to SSEP changes.
  • Somatosensory evoked potential changes were also associated with increased 30-day mortality and low glomerular filtration rate.

Achouh et al (2007) conclude that “intraoperative SSEP monitoring was reliable in ruling out spinal injury in DTA and TAA repair, but had a low sensitivity. Somatosensory evoked potential did not predict delayed ND. Spinal SSEP change was an independent predictor for mortality in DTA and TAA repair and correlated with low preoperative glomerular filtration rate” (p.787).

Monitoring gastric residuals in ICU patients: Does it prevent ventilator-associated pneumonia?

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One discussion this week involved monitoring gastric residuals in ICU patients.

Reference: Reignier J, et al. Effect of not monitoring residual gastric volume on risk of ventilator-assisted pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized control trial. JAMA. 2013 Jan 16;309(3):249-56. doi: 10.1001/jama.2012.196377.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01137487.

Summary: Monitoring of residual gastric volume is recommended to prevent ventilator-associated pneumonia (VAP) in patients receiving early enteral nutrition. However, studies have challenged the reliability and effectiveness of this measure.

DESIGN, SETTING, AND PATIENTS: Randomized, noninferiority, open-label, multicenter trial conducted from May 2010 through March 2011 in adults requiring invasive mechanical ventilation for more than 2 days and given enteral nutrition within 36 hours after intubation at 9 French intensive care units (ICUs); 452 patients were randomized and 449 included in the intention-to-treat analysis (3 withdrew initial consent).

INTERVENTION: Absence of residual gastric volume monitoring. Intolerance to enteral nutrition was based only on regurgitation and vomiting in the intervention group and based on residual gastric volume greater than 250 mL at any of the 6 hourly measurements and regurgitation or vomiting in the control group.

RESULTS: In the intention-to-treat population, VAP occurred in 38 of 227 patients (16.7%) in the intervention group and in 35 of 222 patients (15.8%) in the control group (difference, 0.9%; 90% CI, -4.8% to 6.7%). There were no significant between-group differences in other ICU-acquired infections, mechanical ventilation duration, ICU stay length, or mortality rates. The proportion of patients receiving 100% of their calorie goal was higher in the intervention group (odds ratio, 1.77; 90% CI, 1.25-2.51; P = .008). Similar results were obtained in the per-protocol population.

CONCLUSION AND RELEVANCE: Among adults requiring mechanical ventilation and receiving early enteral nutrition, the absence of gastric volume monitoring was not inferior to routine residual gastric volume monitoring in terms of development of VAP.

The authors further conclude that “eliminating residual gastric volume monitoring from standard care may have beneficial effects. First, in the present study, absence of residual gastric volume monitoring was associated with improved enteral nutrition delivery. High residual gastric volume values often lead to enteral nutrition discontinuation, which in turn causes underfeeding with increases in morbidity and mortality rates. We found no difference in mortality rates. However, our enteral nutrition protocol was more aggressive than previously reported protocols: enteral nutrition was started at the rate required to meet the calorie target and was stopped gradually in the event of intolerance. Moreover, enteral nutrition solution lost by vomiting, being discarded, or both was not measured, thus resulting in potential overestimation of delivered calories. These factors may have attenuated any mortality difference related to differences in delivered enteral nutrition volume” (p.255).

Prophylactic Flomax for prevention of postoperative urinary retention

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One discussion this week involved the use of prophylactic flomax in preventing postoperatuve urinary retention (POUR).

Reference: Ghuman A, et al. Prophylactic use of alpha-1 adrenergic blocking agents for prevention of postoperative urinary retention: A review & meta-analysis of randomized clinical trials. American Journal of Surgery. 2018 May;215(5):973-979. doi: 10.1016/j.amjsurg.2018.01.015. Epub 2018 Feb 3.

Summary: With an increase in outpatient and fast-track surgical procedures, urethral catheterization is used less commonly thus increasing the likelihood of POUR. Urethral catheterization, a mainstay of initial management for patients with POUR, can
be associated with prolonged length of hospital stay and complications, such as urinary tract infections that may increase cost of care.

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Sugarbaker vs Keyhole repair in parastomal hernias

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One discussion this week involved the Sugarbaker repair vs Keyhole repair.

Reference: DeAsis FJ et al. Current state of laparoscopic parastomal hernia repair: a meta-analysis. World Journal of Gastroenterology. 2015 Jul 28;21(28):8670-8677. doi: 10.3748/wjg.v21.i28.8670

Summary:  The primary differences between keyhole repair and Sugarbaker repair are the orientation of the bowel and the presence of a slit in the mesh. In the modified Sugarbaker approach, the bowel is exteriorized through the side of the mesh, whereas in the Keyhole approach the bowel is inserted through a 2 to 3 cm slit in the center of mesh. Both methods apply the mesh intraperitoneally (DeAsis et al, 2015, p.8673).

DeAsis et al (2015) performed a systematic review of PubMed and Medline. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications.

In an analysis of 15 articles involving 469 patients, the recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, and 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

The review concluded that the non-slit mesh modified Sugarbaker approach and the slit mesh Keyhole approach are currently the most reported options for laparoscopic repair. When choosing between the two, a modified Sugarbaker technique appears to be a superior method given the low recurrence rates compared to the keyhole technique if an ePTFE mesh is used (p.8676).

Use of DOTATATE in the surgical management of small bowel neuroendocrine tumors

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A discussion this week included the use of DOTATATE in the surgical management of small bowel neuroendocrine tumors.

Reference: Howe JR et al. The surgical management of small bowel neuroendocrine tumors: consensus guidelines of the North American Neuroendocrine Tumor Society (NANTES). Pancreas. 2017 Jul;46(6):715-731. doi:10.1097/MPA.0000000000000846

Summary: The three most commonly used 68Ga-labeled somatostatin receptor PET imaging agents are 68Ga-DOTATATE, 68Ga-DOTATOC and 68Ga-DOTANOC. Despite the slight variation of the somatostatin receptor affinity of these agents, all of them have shown excellent sensitivity in detection of NETs. At this time, there is no evidence of significant diagnostic superiority of one agent over the others.

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