New Developments In Preoperative Evaluation And Perioperative Management Of Coronary Artery Disease In Vascular Surgery Patients - VEITH Symposium

Main Category: Cardiovascular / Cardiology
Article Date: 24 Nov 2008 - 11:00 PDT

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Preoperative evaluation and perioperative management of coronary artery disease (CAD) in patients undergoing non-cardiac vascular surgery is an area of considerable interest and controversy.

The American College of Cardiology (ACC) and the American Heart Association (AHA) provide guidelines to identify and manage patients at risk for cardiac complications after non-cardiac vascular surgery.

Stephen Bauer, M.D., Instructor of Vascular Surgery and Fellow in Vascular Surgery at the New York University Medical Center, New York, discussed the present literature concerning the use of preoperative noninvasive stress testing, coronary revascularization, and adrenergic ß-blockade (Beta-blocker) and provided a scientific basis for the most recent guidelines.

The most controversial ACC/AHA guideline for non-invasive cardiac testing in patients undergoing non-cardiac vascular surgery is regarding the management of intermediate risk patients.

After thorough review, Dr. Bauer summarized stated that "clinical risk factors alone may identify patients of intermediate risk and in these patients simply optimizing medical therapy without the need of noninvasive cardiac stress testing is sufficient."

The most dramatic recent change in the way vascular surgery patients are treated is in the role for revascularization prior to the intended procedure. The Coronary Artery Revascularization Prophylaxis (CARP) study examined revascularization in patients undergoing non-cardiac vascular surgery and demonstrated that there was no significant change in mortality at six years between revascularization versus medical therapy, 22% versus 23% respectively.

The ACC/AHA revised the guidelines and no longer recommends revascularization prior to surgery in patients with stable CAD. The current ACC/AHA guidelines for β-blocker therapy are:

1. Recommendation is to continue the ß-blocker if the patient is already on the medication and initiate them if there is a positive stress test,

2. The evidence favors initiating them in high-risk patients (class IIa),

3. To begin them in low or intermediate risk patients although the evidence does not support this but it maybe be beneficial.

Dr. Bauer addressed the use of statin therapy in vascular surgery patients and stated, "Statins should be treated with statin therapy and maintained on them throughout the perioperative period and restarted in the postoperative period once oral medications can be given."

The recent 2007 ACC/AHA guidelines reflect the increasing evidence that a systemic approach to the perioperative cardiac care to vascular surgery patients is appropriate, and that a local interventional approach with identification of high grade stenotic arteries and revascularizing them with angioplasty and stenting or bypass surgery does not provide benefit.

VEITH SYMPOSIUM - New York, November 19th to 23rd

Now in its fourth decade, VEITH SYMPOSIUM provides vascular surgeons, interventional radiologists, interventional cardiologists and other vascular specialists with a unique and exciting format to learn the most current information about what is new and important in the treatment of vascular disease. The 5-day event features rapid-fire presentations from world renowned vascular specialists with emphasis on the latest advances, changing concepts in diagnosis and management, pressing controversies and new techniques.

VEITHsymposium is sponsored by Cleveland Clinic, Cleveland, OH.

www.veithsymposium.org

Source
Pauline T. Mayer
www.ptmhcm.com

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