What is the perioperative medication management of coronary artery disease (CAD)?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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Answer

Answer

Patients with known coronary artery disease undergoing surgery should be monitored for evidence of myocardial ischemia and provided therapy to prevent and treat ischemia in the perioperative period.

Monitoring techniques during the perioperative period include surveillance of electrocardiographic ST-changes, echocardiographic assessment of the regional and global wall motion, and invasive measurement of pulmonary arterial and capillary wedge pressures. If ischemia is detected, medication should be titrated to specific endpoints of heart rate and blood pressure or until the ischemia resolves.

Beta-blockers provide the single best therapy for prevention of ischemia during the perioperative period. Postoperative myocardial infarction (MI) and angina have a peak incidence during the first 3 postoperative days but may occur for up to 5 days. Recent studies suggest that postoperative cardiac events may be decreased by use of perioperative beta-blocker regimens. In an excellent randomized, double-blind, placebo-controlled trial, Mangano et al showed that for patients who have or are at high risk for coronary artery disease and undergo noncardiac surgery, treatment with atenolol during hospitalization can reduce mortality and the incidence of cardiac complications for at least 2 years after the surgery. [2] Most hospitals now have clinical practice guidelines regarding perioperative beta-blockers.

Ischemia frequently presents atypically, with chest pain occurring only 50% of the time. In the event of possible signs of ischemia, following up the ECG with serial enzyme measurements, echocardiography, or nuclear perfusion studies may be required. If no evidence of perioperative ischemia or infarction is present, then using a simple 12-lead ECG immediately after surgery and for the first 2 postoperative days is sufficient to evaluate any change from baseline. The following chart indicates the perioperative drug management of patients with coronary artery disease.

Table 1. Outline of Perioperative Drug Management of Patients With Coronary Artery Disease (Open Table in a new window)

Drug

Day Before Surgery

Day of Surgery

During Surgery

After Procedure

Nitroglycerin

Usual dose

Usual dose

IV infusion if frank ischemia

Continue IV dose if needed or until medication can be taken PO

Beta-blockers

Usual dose

Usual dose plus beta-blocker protocol

Usual dose plus beta-blocker protocol

Usual dose plus beta-blocker protocol

Calcium channel blockers

Usual dose

Usual dose morning of surgery

Usual dose morning of surgery

Continue IV dose until medication can be taken PO

Aspirin

Discontinue 1 week before surgery

 

 

Restart postoperatively at discretion of surgeon

Ticlopidine

Discontinue 1 week before surgery

 

 

Restart postoperatively at discretion of surgeon


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