Should Recent Clinical Trials Change Perioperative Management in Patients with Cardiac Risk Factors?
A 75-year-old man with a known history of an ischemic cardiomyopathy presents for resection of a presumed malignant liver tumor. He had 2 cardiac stents placed in the last year and a half. His medications include spironolactone, lisinopril, pioglitazone,
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Should Recent Clinical Trials Change Perioperative Management in Patients with Cardiac Risk Factors? Corey S. Scher
Case A 75-year-old man with a known history of an ischemic cardiomyopathy presents for resection of a presumed malignant liver tumor. He had 2 cardiac stents placed in the last year and a half. His medications include spironolactone, lisinopril, pioglitazone, and atorvastatin. He also takes 81 mg aspirin per day. A recent cardiac catheterization showed that his stents were wide open and there was evidence of diffuse, cardiac arterial disease not amenable to stenting or surgery. His ejection fraction is 32 %, and there is diastolic dysfunction on his echocardiogram.
Question What is the best plan for anesthetic management in a patient with multiple cardiac risk factors? CON: I think I have all of the information I need to go ahead with a general anesthetic, a preoperative thoracic epidural and an awake arterial line before induction. I will use pulse pressure variation (PPV) to determine fluid status and use either hetastarch or albumin if he ends up on the steep portion of the Starling curve where it is essential to give fluids. A PPV >13 % means that stroke volume is changing with inspiration and expiration; these oscillations imply a decrease in preload. It follows that a patient with PPV of >13 % will be fluid responsive [1]. I would not hydrate to a PPV less than 13 % as there is a risk of fluid overload and congestive heart failure. I would go lightly on the crystalloids and be a bit heavy-handed on blood products or colloid to improve stroke volume. In addition, I will get a colleague to help me out with a trans-esophageal echocardiogram (TEE). C.S. Scher (&) Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY 10016, USA e-mail: [email protected]
PRO: I think that your plan is more than reasonable; I am curious how this plan evolved. I think there is more that you can offer the patient to improve his care based on essential clinical trials. To begin with, I think the patient would have beneļ¬ted if he had been on a statin. The CARE trial (Cholesterol And Recurrent Events) clearly showed that lowering low-density lipoproteins (LDL) with a statin lowered the risk of a cardiac event in patients with documented cardiac disease [2]. It is essential to note that this was not an anesthesia study but simply a study on the value of statins on both lipids and heart disease. There were fewer myocardial infarctions in the statin group compared to placebo. Statin use led to a lower incidence of infarction and stroke when interventions such as stents or surgery were chosen. More and more proof exists over time that taking perioperative statins is protective against complications [2]. While the relative success of the CARE trial was attributed to lowering LDL and its associated plaque formation, it is possible that the statin might have impacted the amount of inflammation in the coronary arteries. CON: Every patient should be managed on
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