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What drugs should be stopped before cardiac surgery and how long?

An article from the e-journal of the ESC Council for Cardiology Practice

Patients undergoing cardiac surgery are often on several medications. These may affect the anesthetic course and have potential interactions with drugs used during surgery. Substitution, adjustment or interruption of some of the most commonly used medications is outlined.

Cardiovascular Pharmacology and Pharmacotherapy


1. Beta blockers

A sudden stop can result in rebound hypertension, tachycardia and recurrent myocardial ischemia.
Action: To be continued up to and including morning of surgery and restarted immediately afterwards or eventually substituted with short acting beta blockers (eg. propranolol, metoprolol, esmolol). Cardiac pacing may be necessary during the immediate postoperative period.
Perioperative use can prevent postoperative myocardial ischemic events (1). 

2. ACE inhibitors and angiotensin receptor blockers

Continued use can result in peroperative hemodynamic instability (2).
Action: Protocol depends on indications
• for hypertension : continue up to the day of surgery.
• for heart failure : discontinue on day of surgery, especially if baseline blood pressure is low (3).

3. Calcium channel blockers

Anti-ischemic properties despite a theoretical risk of increased bleeding (4).
Action: To be continued up to and including day of surgery, except in the case of poor hemodynamics (hypotension or arrhythmia). Can be substituted with short acting calcium channel blockers (e.g. Diltiazem).

4. Nitrates

Action: To be continued up to and including day of surgery. Can be administered IV or transdermally, particularly if therapy cannot be interrupted e.g. frank ischemia (5).

5. Alpha 2 agonists

Abrupt withdrawal can cause extreme hypertension and myocardial ischemia.
Action: To be continued up to and including day of surgery. Substitution by transdermal clonidine or exceptionally IV methyl dopa.

6. Aspirin, Clopidogrel

Use may be associated with increased bleeding due to platelet dysfunction.
Action: To be stopped 5-7 days before surgery if possible. Transfusion of fresh platelets if bleeding is an issue postoperatively (6).
Restart in ward at discretion of treating physician.

7. Oral anticoagulants (Warfarin)

Action: Should be stopped 4 days prior to surgery, and substituted by IV heparin according to INR level.

8. Diuretics

Risk of hypovolemia and hypotension from continued use. Electrolyte disturbance is often easy to correct with cardioplulmonary bypass (7).
Action: To be continued up to day of surgery. Substitution by parenteral forms if necessary in postoperative period.

9. Digoxin and Antiarrhythmics

Action: To be continued up to day of surgery. Substitution by intravenous forms if necessary.

10. Statins

Action: To be continued up to and including day of surgery.
Shown to have a beneficial effect on outcome, especially after coronary artery bypass grafting thus merit to be continued in the perioperative period (8,9).

11. Oral hypoglycemics/ Insulin

Action: Patients with type II diabetes mellitus should stop oral hypoglycemics several days prior to surgery (especially metformin which is known to contribute to postoperative lactic acidosis). Patients on Insulin (SC or IV) should omit their morning dose. Peroperative blood glucose monitoring determines further insulin needs (10).

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

References


1. Wiesbauer F, Schlager O, Domanovits H, Wildner B, Maurer G, Muellner M, Blessberger H, Schillinger M. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth Analg. 2007;104:27-41.

2. Souza Neto EP, Loufouat J, Saroul C, Paultre C, Chiari P, Lehot JJ, Cerutti C. Blood pressure and heart rate variability changes during cardiac surgery with cardiopulmonary bypass. Fundam Clin Pharmacol. 2004;18:387-96.

3. Brabant SM, Bertrand M, Eyraud D, Darmon PL, Coriat P. The hemodynamic effects of anesthetic induction in vascular surgical patients chronically treated with angiotensin II receptor antagonists. Anesth Analg. 1999; 89:1388–1392.

4. Ferguson TB Jr. Preoperative calcium-channel blockade in cardiac surgery: the good, the bad, the issues. J Thorac Cardiovasc Surg. 2004;127:622-4.

5. Beloucif S, Beloucif L, Payen D. Nitrate derivatives and anesthesia-resuscitation: physiopathologic bases and therapeutic indications. Cah Anesthesiol. 1991;39:261-74.

6. Dempsey CM, Lim MS, Stacey SG. A prospective audit of blood loss and blood transfusion in patients undergoing coronary artery bypass grafting after clopidogrel and aspirin therapy. Crit Care Resusc. 2004;6:248-52.

7. Gulbis BE, Spencer AP. Efficacy and safety of a furosemide continuous infusion following cardiac surgery. Ann Pharmacother. 2006;40:1797-803.

8. Collard CD, Body SC, Shernan SK, Wang S, Mangano DT; Multicenter Study of Perioperative Ischemia (MCSPI) Research Group, Inc; Ischemia Research and Education Foundation (IREF) Investigators. Preoperative statin therapy is associated with reduced cardiac mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2006;132:392-400.

9. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39:967-75.

10. Evans JM, Ogston SA, Emslie-Smith A, Morris AD. Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin. Diabetologia. 2006;49:930-6.

VolumeNumber:

Vol5 N°19

Notes to editor


Prof. N. Al-Attar
Paris, France
Web editor of the Working Group on Cardiovascular Surgery

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.