Peri-operative Medication Management - β-Blockade and Other Cardiac Drugs:
Evaluate for peri-operative β-blockade
• Continue β-blocker: if already taking for other indication (e.g. CAD, arrhythmia, HTN) for goal HR 55-65 (Class I, LOE C)
• Initiate β-blocker: ≥3 RCRI risk factors or if pt has indication for βB otherwise (Class IIa, LOE B). Never start on day of surgery!
• Uncertain role of β-blocker: if no known CAD but either +stress test or high risk factors
• 1° prevention – can generally be held prior to surgery
• 2° prevention – continue ASA 81mg unless high risk of bleeding (intramedullary spine, intracranial, hip, knee, possibly prostate)
• DAPT post PCI: POBA <14d, BMS <30d, DES <6-12mo→ delay elective surgery. If urgent, continue ASA, hold P2Y12i x5d.
ACEi/ARB: Pts have more transient peri- and post-op episodes of HoTN; no diff in death, post-op MI, stroke; ↑ or ↓ AKI unclear
• Discontinue ACEi/ARB night before surgery (unless used for HF and BP ok), failure to restart ARB within 48h ↑ 30-d mortality
Other: All other anti-hypertensives should be continued perioperatively to goal BP <180/100 to avoid bleeding.
Anticoagulation: Recommendations for bridging in patients using VKAs stratified by risk
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