Perioperative

LOGO Management
on post - PCI Patients

Hari Hendriarto Satoto

Department & Intensive Therapy Kariadi Hospital /
Diponegoro University
Introduction

Coronary artery disease (CAD) syndromes resulting from

myocardial ischemia an imbalance between the supply
(perfusion) and demand of the heart for oxygenated blood.

Cardiac stent application on patients with CHD may decrease

mortality and morbidity

Patient CHD that scheduled for cardiac/non cardiac surgery need

more careful anesthesia management to lower the perioperative
complication

The skill with which the anaesthetic is selected and delivered is more
important than the drugs used
Top 10 leading causes of
mortality in Indonesia :

1. Stroke 289.917 people

2. IHD 208.360 people
3. Diabetes with complication 78.966 people
4. Pneumonia 65.634 people
5. Asthma 56.953 people
6. COPD 53.137 people
7. Diarrhea 51.597 people
8. Traffic accident 48.090 people
9. Lung cancer 31.692 people

Sample registration Survey (SRS) ~ Badan Penelitian dan Pengembangan

Kesehatan (Balitbangkes) Kementerian Kesehatan RI 2014
Management Prior to Surgery for
patients with CAD

Three options :

1. Optimal Medical Management (Pharmacological)

2. Revascularization by surgery (CABG)
3. Revascularization by PCI
Percutaneous Coronary Intervention
(PCI)

PCI a non surgical procedure that uses a catheter to place a stent to

open up blood vessels in the heart that have been narrowed by plaque
buildup, a condition known as atherosclerotic.

Indication:
1. Uncontrolled angina with drugs medication
2. 3 coronary vessel obstruction
3. Obstruction on Left Main coronary vessel
4. Acute STEMI
5. NSTEMI-ACS
6. Anginal equivalent (eg dyspneu, arrythmia, or diziness or syncope)
7. High risk stress test findings
Stent Type

Traditional bare-metal stent (BMS) coronary stents provide a mechanical

framework that holds the artery wall open, preventing stenosis of coronary
arteries

Newer drug-eluting stents (DES) are traditional stents coated with drugs,
which, when placed in the artery, release certain drugs over time. These types
of stents help prevent restenosis of the artery by suppressing tissue growth at
the stent site and local modulation of the body's inflammatory and immune
responses. They may be susceptible to an event known as "late stent
thrombosis

DAPT (DAPT; aspirin plus platelet P2Y12 receptor blocker) significantly lowers
the risk of stent thrombosis.
Stent Type

1. Bare metal stent

. First generation
. Cheaper
. Restenosis incidence 25% in 6
month

2. Drug Eluting Stent (DES)

. Using anti restenotic drugs
. Expensive
. Restenosis incidence 10% in 6
month
. Late in stent thrombotics
 More than 2 million patients undergoing PCI
annually, more than 90% will receive one or more
intracoronary stents

Approximately 5% of patients in this group will

undergo noncardiac surgery within the first year
after stenting

Newsome LT, et al. Coronary Artery Stents: II. Perioperative Considerations and
Management. Anesth Analg 2008;107:570 90
 Aspirin 75-100 mg daily plus Clopidogrel 75 mg
daily for at least 12 months are recommended after
PCI

Dual antiplatelet therapy (DAPT)

Mauri L, et al. "Twelve or 30 months of dual antiplatelet therapy after drug-eluting

stents". The New England Journal of Medicine. 2014. 371(23):2155-2166.
Commonly used antiplatelet
drugs

Oprea AD, Paspescu WM. Perioperative management of antiplatelet therapy. British

Journal of Anaesthesia 111 (S1): i3i17 (2013)
PERIOPERATIVE DILEMMA

increased
the intra-
risk of stent
and peri-
thrombosis
procedural
bleeding risk

consequences of
delaying the
desired surgical
procedure
J Am Coll Cardiol. 2016;68(10):1082-1115
CORONARY ARTERY STENTS
AND NONCARDIAC SURGERY

Newsome LT, et al. Coronary Artery Stents: II. Perioperative Considerations and
Management. Anesth Analg 2008;107:570 90
Time from discontinuation of
clopidogrel (triangles) and of
clopidogrel and aspirin (squares) to an
adverse clinical event [death,
myocardial infarction (MI)].

Am J Cardiol 2007;99:103943
Is there any new recommendation ?

Yes, here is 2016 recommendation

Recommendation
JACC/AHA Guidelines

16
20
Elective non cardiac surgery should be delayed 30
days after BMS implantation and optimally 6
months after DES implantation
Recommendation
JACC/AHA Guidelines

16
20
In patients treated with DAPT after coronary stent
implantation who must undergo surgical procedures that
mandate the discontinuation of P2Y12 inhibitor therapy

aspirin be continued if possible and the P2Y12

platelet receptor inhibitor be restarted as soon as
possible after surgery.
Recommendation
JACC/AHA Guidelines

16
20
When non cardiac surgery is required in patients currently
taking a P2Y12 inhibitor

a consensus decision among treating clinicians as to

the relative risks of surgery and discontinuation or
continuation of antiplatelet therapy can be useful
Recommendation
JACC/AHA Guidelines

16
20
Elective noncardiac surgery after DES implantation in
patients for whom P2Y12 inhibitor therapy will need to be
discontinued

may be considered after 3 months if the risk of

further delay of surgery is greater than the expected
risks of stent thrombosis.
 Surgical blood loss is increased 2.520% by aspirin alone
and 3050% by aspirin and clopidogrel but with no
increased risk of bleeding-related mortality, except during
intracranial surgery

Risk of severe, life-threatening bleeding (defined as

fatal bleeding, intracranial bleeding, or bleeding requiring
surgical intervention or transfusion of 4 units of blood
products) was reported to be 4% with single antiplatelet
therapy and 21% with DAPT
Anesthesiology 11 2014, Vol.121, 1093-1098
The bridge therapy was performed after discontinuation of the oral
P2Y12 inhibitor by using i.v. tirofiban infusion. Net Adverse Clinical
Events (NACE) was the primary outcome

perioperative bridge therapy using tirofiban was associated with

reduced 30-day NACE rate, particularly when surgery was performed
within 60 days after stent implantation
 DAPT

VS

REGIONAL ANESTHESIA

www.themegallery.com
 81 mg aspirin dose could potentially cause an
epidural hematoma

Reports of anticoagulation induced spinal

epidural hematoma is common, however, anti-
platelet causing spinal epidural hematoma is rare
Case Study: Safety of spinal anaesthesia in patients with recent coronary stents.
South Afr J Anaesth Analg 2013;19(2):124-126
 Isolated use of aspirin does not increase the risk of spinal
haematoma and does not represent a contraindication to
neuraxial blocks

The precautions regarding higher doses do not seem to

be justified. Although aspirin alone is considered to be
safe in neuraxial anaesthesia, the concurrent
administration of other antithrombotic drugs significantly
increases the risk of spinal haematoma and the
recommended safety times for each of these other drugs
must be strictly followed.
Br. J. Anaesth. (2015) 115 (5):688-698
Thank You
Preoperative recommendation

14
20
Fleisher, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing Noncardiac Surgery
Regional Anesthesia

1. Nonsteroidal anti-inflammatory drugs seem to represent no added

significant risk for the development of spinal hematoma in patients
having epidural or spinal anesthesia

2. In patients receiving NSAIDS, we recommend against the

performance of neuraxial techniques if the concurrent use of other
medications affecting clotting mechanisms, such as oral
anticoagulants, UFH, and LMWH, is anticipated in the early
postoperative period because of the increased risk of bleeding
complications

3. The actual risk of spinal hematoma with ticlopidine and clopidogrel

and the GP IIb/IIIa antagonists is unknown.
Regional Anesthesia & Pain Medicine:
January/February 2010 - Volume 35 - Issue 1 - pp 64-101
Coronary Stent Trombosis

Acutely manifests as a STEMI or a sudden

malignant dysrhythmia.
Must be treated with immediate reperfusion
Primary PCI.

Surgical procedures should be performed in

institutions where 24-h interventional cardiology is
available to provide immediate and emergent
intervention