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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Ischemic Heart Disease and Ongoing Surgery

The prevalence of ischemic heart disease in surgery patients is increasing. Up to 34 % of patients require surgery within one year of percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy (DAPT) should be introduced for at least 12 months to prevent late stent thrombosis, especially in drug-eluting stents (DES), where endothelisation of stented segment is slower. Risk of stent thrombosis is greater with recent myocardial infarction, bifurcation lesions, suboptimal stent deployment, first generation DES, while second generation DES and bare metal stents have lower risk of stent thrombosis. Although some randomized studies showed that it might be safe do discontinue DAPT 3-6 months after second generation DES implantation, stent thrombosis is still feared and grave complication in first year after PCI. The preoperative management of patients after PCI requires consideration of bleeding risk on DAPT and risk of stent thrombosis. There are no randomized data about optimal timing of surgery. Guidelines recommend postponing surgery for at least 6 months after percutaneous coronary intervention with drug-eluting stent implantation (DES-PCI) and 12 months if PCI was done following myocardial infarction. The 2016 American College of Cardiology/American Heart Association guidelines update strongly advises against elective noncardiac surgery <3 months after DES implantation, but surgery may be considered 3 to 6 months after DES-PCI, with discontinuation of DAPT if the delayed surgery risk is greater than the stent thrombosis risk. A big recent Danish study showed that surgery in first 12 months after DES-PCI was associated with an increased risk of myocardial infarction and cardiac death but not all-cause mortality compared to patients without ischemic heart disease. However, the increased risk was only present within first month after DES-PCI. According to PARIS registry it may be safe to interrupt DAPT for <14 days under physician guidance. Knowing both, surgery might be undertaken earlier than currently recommended. There is a consensus that excluding emergency, surgery can be done between 1 and 3 months after DES-PCI if there is uncontrolled bleeding or the outcome is strongly influenced by surgical delay. On the other hand, surgery should be delayed at least 3 to 6 months in acute coronary syndrome, diabetes mellitus, low left ventricular ejection fraction, history of stent thrombosis, PCI of left main, small stents and long stented segments.

Keywords: percutaneous coronary intervention, surgery, antiplatelet therapy.

Effects of a percutaneous coronary intervention or conservative treatment strategy on treatment outcomes in elderly female patients with acute coronary syndrome


Aim. To determine the difference in hospital outcomes between percutaneous coronary intervention (PCI) and conservative treatment of elderly female patients hospitalized for acute coronary syndrome (ACS).

Material and Methods. This controlled study included 123 female patients admitted to the Clinic for heart and cardiovascular diseases University Hospital of Split with a diagnosis of ACS and multiple cardiovascular risk factors. We recorded their habits, history, demographics, presenting symptoms, electrocardiograms, ultrasound results, laboratory tests, diagnostic tests and treatment. We compared these data between the two groups, i.e., those treated with conservative therapy and those treated with PCI.

Results. There were fewer arrhythmias (P<0.001) and episodes of heart failure (P<0.001) during hospitalization in the PCI group than in the conservative therapy group. There was no significant difference in complications between the groups (P=0.887).

Conclusion. Elderly female patients with ACS treated with PCI had less arrhythmias and heart failure during hospitalization than those treated with conservative therapy and there was no difference in complications. These results suggest that even high risk patients have better outcomes after treatment with PCI, and therefore PCI is suggested as first-line treatment in these patients, regardless of risk factors.

Key words: percutaneous coronary intervention, acute coronary syndrome, women

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Establishing Coronary Patency: A Key to Optimal Post Resuscitation Care


The formalizing post resuscitation care to include therapeutic hypothermia and cardiac angiography with percutaneous coronary intervention when needed could significantly improve survival following cardiac arrest. Any sudden death patient suspected to have a cardiac origin for their cardiac arrest should be considered for early catheterization and subsequent percutaneous coronary intervention (PCI) if a culprit lesion can be identified. Successful PCI improves survival to hospital discharge and cerebral performance category in patients with or without ST elevation. Current ‘report carding’ methodology needs to be changed regarding those resuscitated from cardiac arrest (patients with cardiac arrest not including them in any statistical reporting on PCI mortality report cards).

Key words: percutaneous coronary intervention, hypothermia, cardiac arrest, survival to hospital discharge, cerebral performance category, PCI report carding

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Baseline characteristics, time-to-hospital admission and in-hospital outcomes of patients hospitalized with ST-segment elevation acute coronary syndromes, 2002 to 2005


Objective. The purpose of this study was to retrospectively determine baseline patient characteristics, time-to-hospital admission, utilization of reperfusion therapy and outcomes of patients hospitalized with ST-segment elevation acute coronary syndromes (ACS) between 2002 and 2005, particularly after 24-h primary percutaneous coronary intervention (PCI) was introduced in 2004.
Methods. Included were all patients admitted to the intensive care unit (ICU) from 2002 to 2005 who met the criteria for ACS. Information on patients’ demographic characteristics, medical history, time-to-hospital admission, clinical characteristics on admission, laboratory examinations, ECG findings, treatments, hospital duration, and in-hospital outcomes was collected by completing a standardized case report form.
Results. There was a sustained increase in admissions between 2002 and 2005, altogether 899 patients were hospitalized. A significant decrease in time-to-hospital admission was achieved. More patients arrived within 4-6 hours (16.3% in 2002 vs. 31.5% in 2005) and less after 12 hours (35.0% in 2002 vs. 13.4% in 2005). A significant increase in primary PCI rate was achieved (16.9% in 2002 vs. 90% in 2005, P<0.001). Consequently, the rate of thrombolysis, postponed PCI and nonreperfusion medical therapy decreased. From 2002 to 2005, total in-hospital stay decreased significantly (15.4±13.0 days vs. 7.8±8.5 days, P<0.001), in-hospital mortality insignificantly (11.3% vs. 7.2%).
Conclusion. Despite the significant increase in primary PCI between 2002-2005, there was only an insignificant decrease in in-hospital mortality. Further shortening the time-to-hospital admission and increasing primary PCI among older hemodynamically unstable ACS patients, particularly those with cardiogenic shock, could achieve an additional decrease in mortality.

Key words: acute coronary syndrome, acute myocardial infarction, time-to-hospital admission, prognosis, management, percutaneous coronary intervention, mortality

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Cardiac protection by preoperative intervention in noncardiac surgery


Preoperative coronary intervention is one option to optimize the cardiac risk patient scheduled for noncardiac surgery. Such an intervention, however, is only justified for high risk procedures and if the indication for preoperative intervention is independent from surgery.
Currently, PTCA with stent implantation is the most commonly used practice. Dependent of the type of stent (bare-metal stent or drug-eluting stent) dual antiplatelet therapy is mandatory for 1 – 12 months.
The surgeon, the cardiologist and the anesthesiologist have to decide in an interdisciplinary approach the perioperative management to navigate the patient between stent thrombosis and surgical bleeding.

Key words: noncardiac surgery, cardiac risk, percutaneous coronary intervention, coronary stents

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