This guideline addresses the perioperative management of anticoagulant and antiplatelet therapy in patients requiring elective surgery or procedures. Key recommendations include:
1) Stopping vitamin K antagonists (VKAs) 5 days before surgery instead of shorter durations.
2) Bridging anticoagulation for patients at high risk of thrombosis during VKA interruption, such as those with mechanical heart valves or atrial fibrillation.
3) Continuing aspirin in moderate-to-high risk patients undergoing non-cardiac surgery instead of stopping 7-10 days before surgery.
The recommendations aim to simplify management and minimize risks of thrombosis and bleeding in the perioperative period.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
This document proposes a new 5-stage classification system (A-E) for cardiogenic shock to improve communication and help guide treatment. Stage A is "at risk" for shock, stage B is "beginning" shock, stage C is "classic" shock with hypoperfusion, stage D means initial interventions did not restore stability despite 30 minutes of observation, and stage E is "extremis" with cardiovascular collapse. The goal is to have a simple, clinically applicable system that can be used across care settings and potentially help identify patients most likely to benefit from different treatments.
2017 Barcelona. Acute Cardiac Unloading and Recovery Working Group Meeting.
The Impella ventricular assist device support experience at Texas Children's Hospital.
Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Ou...Guilherme Barcellos
Draft que encontrei de apresentação em 201: Primeiro Encontro de Medicina Hospitalista da Argentina. Slides alguns já traduzidos, outros não - não encontrei versão final. De brasileiros no evento participaram eu, Lucas Zambon e Tiago Daltoé. Boas lembranças! Resgatei agora porque trata de evidência consolidada desde aquela época, e seguimos sobreutilizando o recurso. Ou algo novo que justifique?
This document summarizes the results of a randomized controlled trial comparing transcatheter aortic valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in patients at low surgical risk. The trial found that TAVR was superior to SAVR in reducing the composite outcome of death from any cause, stroke, or rehospitalization at 1 year. TAVR was also associated with lower rates of mortality at 30 days, life-threatening bleeding, and shorter hospital stays compared to SAVR. However, TAVR was associated with higher rates of new-onset left bundle branch block and mild paravalvular regurgitation compared to SAVR.
ACC guide line Cardiovascular risk assessment for non cardiac surgery2Nizam Uddin
This clinical practice guideline from the ACC/AHA provides recommendations for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by a writing committee and endorsed by several medical societies. The guideline covers clinical risk factors, calculating perioperative risk, approaches to preoperative cardiac testing and therapy, anesthetic considerations, and perioperative surveillance and management. The goal is to reduce perioperative cardiovascular complications for patients undergoing noncardiac surgery.
Cardiovascular risk assessment for non cardiac surgeryNizam Uddin
This document provides recommendations for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery based on a review of evidence. Key points include:
- It focuses on preoperative risk assessment, cardiovascular testing, perioperative pharmacological management including anesthesia, and perioperative monitoring.
- The goal is to provide patients and providers with information on cardiovascular risk in the context of overall surgery risk to facilitate shared decision making.
- Recommendations are made based on studies of noncardiac surgery patients, extrapolating from other areas only when no other data is available.
This article discusses changes in the timing of surgery for patients with mitral regurgitation and aortic regurgitation. While guidelines support imaging to assess severity and intervening when symptoms develop or left ventricular dysfunction occurs, some experts argue for earlier intervention before adverse effects occur. Advances in surgical techniques have improved outcomes for mitral valve repair. However, determining optimal timing is challenging without clinical trials. New biomarkers and imaging methods may help identify patients that could benefit from early surgery.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
This document proposes a new 5-stage classification system (A-E) for cardiogenic shock to improve communication and help guide treatment. Stage A is "at risk" for shock, stage B is "beginning" shock, stage C is "classic" shock with hypoperfusion, stage D means initial interventions did not restore stability despite 30 minutes of observation, and stage E is "extremis" with cardiovascular collapse. The goal is to have a simple, clinically applicable system that can be used across care settings and potentially help identify patients most likely to benefit from different treatments.
2017 Barcelona. Acute Cardiac Unloading and Recovery Working Group Meeting.
The Impella ventricular assist device support experience at Texas Children's Hospital.
Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Ou...Guilherme Barcellos
Draft que encontrei de apresentação em 201: Primeiro Encontro de Medicina Hospitalista da Argentina. Slides alguns já traduzidos, outros não - não encontrei versão final. De brasileiros no evento participaram eu, Lucas Zambon e Tiago Daltoé. Boas lembranças! Resgatei agora porque trata de evidência consolidada desde aquela época, e seguimos sobreutilizando o recurso. Ou algo novo que justifique?
This document summarizes the results of a randomized controlled trial comparing transcatheter aortic valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in patients at low surgical risk. The trial found that TAVR was superior to SAVR in reducing the composite outcome of death from any cause, stroke, or rehospitalization at 1 year. TAVR was also associated with lower rates of mortality at 30 days, life-threatening bleeding, and shorter hospital stays compared to SAVR. However, TAVR was associated with higher rates of new-onset left bundle branch block and mild paravalvular regurgitation compared to SAVR.
ACC guide line Cardiovascular risk assessment for non cardiac surgery2Nizam Uddin
This clinical practice guideline from the ACC/AHA provides recommendations for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by a writing committee and endorsed by several medical societies. The guideline covers clinical risk factors, calculating perioperative risk, approaches to preoperative cardiac testing and therapy, anesthetic considerations, and perioperative surveillance and management. The goal is to reduce perioperative cardiovascular complications for patients undergoing noncardiac surgery.
Cardiovascular risk assessment for non cardiac surgeryNizam Uddin
This document provides recommendations for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery based on a review of evidence. Key points include:
- It focuses on preoperative risk assessment, cardiovascular testing, perioperative pharmacological management including anesthesia, and perioperative monitoring.
- The goal is to provide patients and providers with information on cardiovascular risk in the context of overall surgery risk to facilitate shared decision making.
- Recommendations are made based on studies of noncardiac surgery patients, extrapolating from other areas only when no other data is available.
This article discusses changes in the timing of surgery for patients with mitral regurgitation and aortic regurgitation. While guidelines support imaging to assess severity and intervening when symptoms develop or left ventricular dysfunction occurs, some experts argue for earlier intervention before adverse effects occur. Advances in surgical techniques have improved outcomes for mitral valve repair. However, determining optimal timing is challenging without clinical trials. New biomarkers and imaging methods may help identify patients that could benefit from early surgery.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
The executive summary introduces the 9th edition of the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis guidelines. This edition aims to provide concise recommendations and minimize length based on feedback. Key innovations include a systematic review of patient values and preferences, and strategies to estimate reductions in symptomatic events. However, limitations in publishing the full evidence rationale led to an abbreviated print version, with the full online version recommended for detailed information.
Management of Takotsubo Syndrome: A Comprehensive ReviewNicolas Ugarte
Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left
ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although
TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is
often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo
diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy,
anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone
receptor blockers, and statins. Treatment is usually provided for up to three months and has a
good safety profile. For TTS with complications such as cardiogenic shock, management
depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO,
inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated
in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and
patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our
comprehensive review discussed the management in detail, derived from the most recent
literature from observational studies, systematic review, and meta-analyses.
This document provides an updated summary of guidelines for blood conservation in cardiac surgery from The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists. Major revisions include new recommendations regarding dual anti-platelet therapy management before surgery, drugs that augment red blood cell volume or limit blood loss, blood derivatives, blood salvage management, minimally invasive procedures, extracorporeal membrane oxygenation, hemostatic agents, and insights into team-based interventions. The guidelines were updated based on a literature review using standardized search terms to ensure the recommendations reflect the most current evidence available.
This document discusses preoperative assessment and cardiac intervention prior to noncardiac surgery. It covers several topics:
1. Perioperative myocardial infarction is common in the first 48-72 hours after surgery due to hemodynamic stresses and alterations that can cause plaque rupture or oxygen supply-demand mismatch. Routine troponin testing detects many clinically silent infarcts.
2. For stable coronary artery disease, preoperative revascularization through PCI or CABG is generally not recommended as studies found no reduction in adverse cardiac events. Indications for preoperative angiography include extensive ischemia on testing or severe angina.
3. For surgery within 12 months of stent placement, the risks of stopping antiplatelet therapy must
The field of perfusion is becoming increasingly demanding both clinically and didactically. As the patient population continues to present with a variety of complex health issues, there is a greater need than ever for the Pefusionist to develop new techniques for patient care while on Cardiopulmonary Support. Ascending Aortic Arch dissections (AAAD), with its current mortality rates of 10%-15% with significant neurological complications associated, still remains a difficult case for Perfusionist’s to manage effectively. The most widely used technique during this type of repair surgery, is hypothermic circulatory arrest (HCA). Although this remains a premier technique, there continues to be a high reported incidence of neurological deficit post HCA. In order to address and limit this issue, the advent of selective cerebral perfusion is slowly gaining acceptance. This new technique has been shown to not only decrease the time of exposure of blood to a foreign surface, but limit the patient duration on full cardiopulmonary support. The most notable aspect of this technique; is it allows the surgeon to begin repairs immediately, since the process cools the brain only, while keeping the rest of body at moderate-mild hypothermic levels.
This study evaluated a novel transcatheter interatrial shunt device for treating heart failure with preserved ejection fraction (HFPEF). 64 patients underwent successful implantation of the device. At 6 months follow up, 71% of patients had a reduction in pulmonary capillary wedge pressure at rest or during exercise compared to baseline. The procedure was well tolerated with no safety issues. The results suggest the device may help reduce left atrial pressure and improve functional status for patients with HFPEF, though the study had limitations as an open-label single-arm trial with short follow up.
Coronary endarterectomy and patch angioplasty for diffuse coronary artery dis...Abdulsalam Taha
CABG may not be sufficient to treat the diffusely diseased coronary arteries. New techniques such as coronary endarterectomy with patch angioplasty may provide a solution.
Guidelines for the use of echocardiography as a monitor for therapeutic inter...Alexandra Victoria
This document provides guidelines for using echocardiography as a monitoring tool to guide therapy in critically ill patients. It outlines specific echocardiographic parameters that can be used for hemodynamic monitoring, including left ventricular dimensions, inferior vena cava size and collapsibility, mitral inflow, tissue Doppler imaging, and calculated parameters like stroke volume, cardiac output, and pulmonary artery pressure. The guidelines discuss advantages and recommendations for echocardiography as a monitoring tool and provide examples of its use in clinical scenarios such as acute congestive heart failure, critical care, pericardial tamponade, and various perioperative settings.
This document discusses guidelines for a clinical practice guideline on perioperative care. It summarizes discussions between guideline writing committees on how to address controversies surrounding certain clinical trials. Specifically, it was agreed that the controversial DECREASE trials led by Poldermans would be excluded from systematic reviews and recommendations. Nonretracted publications from these trials could be cited but not used as the basis for recommendations. The committees aimed to balance transparency with the availability of new evidence in developing their guidelines.
Gerstein et al-2015-anesthesia_&_analgesiasamirsharshar
POISE-2 was a large randomized controlled trial that investigated the risks and benefits of continuing low-dose aspirin perioperatively in patients undergoing noncardiac surgery. The trial found no difference in the primary outcome of death or myocardial infarction within 30 days between those who received aspirin or placebo. However, major bleeding was more common in the aspirin group. While providing important new evidence, the document notes several limitations of POISE-2 including that over 60% of subjects may not have met guidelines for aspirin therapy and many received other antithrombotic drugs postoperatively. On balance, the optimal perioperative aspirin management strategy remains unclear based on POISE-2 alone.
The document discusses the TAVR (transcatheter aortic valve replacement) procedure, which is a minimally invasive alternative to open-heart surgery used to replace the aortic valve in patients considered too high risk for open-heart surgery. The TAVR procedure involves inserting an artificial valve through the femoral or apical artery using a catheter. Potential complications include stroke, death, and bleeding issues. Physical therapy implications include screening patients who will be on lifelong aspirin therapy for risk of bleeding complications and addressing mobility issues common in the elderly patient population eligible for TAVR.
1) iFR measures the ratio of distal coronary pressure to aortic pressure at rest during the wave-free period, while FFR requires maximal hyperemia.
2) Studies have shown iFR performs similarly to FFR in assessing stenosis severity and matches PET perfusion.
3) A new study provides direct evidence that coronary autoregulation maintains blood flow at rest, explaining why iFR works without hyperemia.
4) An ongoing trial will evaluate using iFR to guide multi-vessel revascularization in STEMI patients.
The STITCH trial evaluated the effect of CABG plus optimal medical therapy (OMT) versus OMT alone on mortality in patients with left ventricular dysfunction and coronary artery disease. A sub-study examined the role of assessing myocardial viability to identify patients who benefit most from CABG. Of 601 patients who underwent viability testing, 487 had viable myocardium and 114 did not. There was no significant interaction between viability status and treatment assignment on mortality or other outcomes. Assessing viability did not identify patients with differential survival benefit from CABG versus OMT alone.
1) The document discusses whether fractional flow reserve (FFR) guided interventions should be routine or individualized for patients with multivessel coronary artery disease (MVD).
2) It summarizes the findings of the FAME study which found that an FFR-guided approach reduced major adverse cardiac events compared to an angiography-guided approach alone.
3) The document concludes that while FFR provides useful functional information, an individualized approach is needed considering factors like the number of diseased vessels and whether the study directly compared outcomes to CABG.
Debate of opening non infarct related arteriesSwapnil Garde
This document discusses the debate around opening non-infarct related arteries (non-IRA) during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). It provides background on the higher mortality and reinfarction rates seen in patients with multi-vessel disease. It also summarizes several trials that have compared culprit-only PCI versus complete revascularization, with some trials like PRAMI and CvLPRIT finding lower event rates with complete revascularization, while others like CULPRIT-SHOCK found lower mortality and renal failure with culprit-only PCI in cardiogenic shock patients. The optimal strategy for managing non-IRA lesions during primary PCI for STEMI remains debated.
This document summarizes various medical treatments for chronic anal fissures (CAFs), with a focus on nonsurgical approaches involving smooth muscle relaxation. Lateral internal sphincterotomy (LIS) has traditionally been the gold standard surgical treatment for CAFs, but it can permanently weaken the internal sphincter and cause incontinence in some patients. Recently, nonsurgical treatments using pharmacological agents to relax the internal sphincter and promote healing have been developed, avoiding the risks of surgery. The document reviews several clinical trials examining the use of topical glyceryl trinitrate (GTN) at various concentrations for nonsurgical treatment of CAFs. GTN was found to heal CAFs in 33
This document discusses a study evaluating the incidence, predictors, and long-term outcomes of patients experiencing in-stent restenosis (ISR) after receiving long drug-eluting stents for coronary arteries. 421 patients received long drug-eluting stents and 371 patients underwent follow up. The overall incidence of ISR was 4%. Risk factors for ISR included diabetes and long lesions. Of those with ISR, 40% underwent repeat PCI, 46.7% underwent bypass surgery, and 13.3% were treated medically. During long-term follow up of 12-26 months, there were no deaths from ISR and the incidence of major adverse cardiac events was low. ISR did not
This document discusses recommendations for bridging anticoagulation therapy for patients on warfarin undergoing medical procedures. It provides guidance on stratifying patients into high, moderate, and low risk and makes recommendations for whether bridging therapy is needed for different types of procedures for each risk group. For example, it states that bridging is generally recommended for high risk patients undergoing procedures, but may not be needed for moderate risk patients. It also discusses specific procedures like dental work, pacemaker implantation, and cardioversion and provides bridging recommendations for different risk levels.
Risk reduction strategies for cardiac patientsAbeer Nakera
1. The document discusses risk reduction strategies for cardiac patients undergoing non-cardiac surgery, including preoperative risk stratification, coronary revascularization, pharmacological therapies, anesthetic considerations, and postoperative monitoring.
2. It provides recommendations on preoperative coronary revascularization for high-risk patients, as well as perioperative use of beta-blockers, statins, alpha-2 agonists, aspirin, calcium channel blockers, and nitroglycerin to reduce cardiac risks.
3. Intraoperatively, it recommends maintaining normothermia, considers the use of volatile anesthetics, and suggests using intraoperative echocardiography for acute hemodynamic issues. Tight control of blood glucose is also addressed.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
The executive summary introduces the 9th edition of the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis guidelines. This edition aims to provide concise recommendations and minimize length based on feedback. Key innovations include a systematic review of patient values and preferences, and strategies to estimate reductions in symptomatic events. However, limitations in publishing the full evidence rationale led to an abbreviated print version, with the full online version recommended for detailed information.
Management of Takotsubo Syndrome: A Comprehensive ReviewNicolas Ugarte
Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left
ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although
TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is
often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo
diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy,
anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone
receptor blockers, and statins. Treatment is usually provided for up to three months and has a
good safety profile. For TTS with complications such as cardiogenic shock, management
depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO,
inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated
in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and
patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our
comprehensive review discussed the management in detail, derived from the most recent
literature from observational studies, systematic review, and meta-analyses.
This document provides an updated summary of guidelines for blood conservation in cardiac surgery from The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists. Major revisions include new recommendations regarding dual anti-platelet therapy management before surgery, drugs that augment red blood cell volume or limit blood loss, blood derivatives, blood salvage management, minimally invasive procedures, extracorporeal membrane oxygenation, hemostatic agents, and insights into team-based interventions. The guidelines were updated based on a literature review using standardized search terms to ensure the recommendations reflect the most current evidence available.
This document discusses preoperative assessment and cardiac intervention prior to noncardiac surgery. It covers several topics:
1. Perioperative myocardial infarction is common in the first 48-72 hours after surgery due to hemodynamic stresses and alterations that can cause plaque rupture or oxygen supply-demand mismatch. Routine troponin testing detects many clinically silent infarcts.
2. For stable coronary artery disease, preoperative revascularization through PCI or CABG is generally not recommended as studies found no reduction in adverse cardiac events. Indications for preoperative angiography include extensive ischemia on testing or severe angina.
3. For surgery within 12 months of stent placement, the risks of stopping antiplatelet therapy must
The field of perfusion is becoming increasingly demanding both clinically and didactically. As the patient population continues to present with a variety of complex health issues, there is a greater need than ever for the Pefusionist to develop new techniques for patient care while on Cardiopulmonary Support. Ascending Aortic Arch dissections (AAAD), with its current mortality rates of 10%-15% with significant neurological complications associated, still remains a difficult case for Perfusionist’s to manage effectively. The most widely used technique during this type of repair surgery, is hypothermic circulatory arrest (HCA). Although this remains a premier technique, there continues to be a high reported incidence of neurological deficit post HCA. In order to address and limit this issue, the advent of selective cerebral perfusion is slowly gaining acceptance. This new technique has been shown to not only decrease the time of exposure of blood to a foreign surface, but limit the patient duration on full cardiopulmonary support. The most notable aspect of this technique; is it allows the surgeon to begin repairs immediately, since the process cools the brain only, while keeping the rest of body at moderate-mild hypothermic levels.
This study evaluated a novel transcatheter interatrial shunt device for treating heart failure with preserved ejection fraction (HFPEF). 64 patients underwent successful implantation of the device. At 6 months follow up, 71% of patients had a reduction in pulmonary capillary wedge pressure at rest or during exercise compared to baseline. The procedure was well tolerated with no safety issues. The results suggest the device may help reduce left atrial pressure and improve functional status for patients with HFPEF, though the study had limitations as an open-label single-arm trial with short follow up.
Coronary endarterectomy and patch angioplasty for diffuse coronary artery dis...Abdulsalam Taha
CABG may not be sufficient to treat the diffusely diseased coronary arteries. New techniques such as coronary endarterectomy with patch angioplasty may provide a solution.
Guidelines for the use of echocardiography as a monitor for therapeutic inter...Alexandra Victoria
This document provides guidelines for using echocardiography as a monitoring tool to guide therapy in critically ill patients. It outlines specific echocardiographic parameters that can be used for hemodynamic monitoring, including left ventricular dimensions, inferior vena cava size and collapsibility, mitral inflow, tissue Doppler imaging, and calculated parameters like stroke volume, cardiac output, and pulmonary artery pressure. The guidelines discuss advantages and recommendations for echocardiography as a monitoring tool and provide examples of its use in clinical scenarios such as acute congestive heart failure, critical care, pericardial tamponade, and various perioperative settings.
This document discusses guidelines for a clinical practice guideline on perioperative care. It summarizes discussions between guideline writing committees on how to address controversies surrounding certain clinical trials. Specifically, it was agreed that the controversial DECREASE trials led by Poldermans would be excluded from systematic reviews and recommendations. Nonretracted publications from these trials could be cited but not used as the basis for recommendations. The committees aimed to balance transparency with the availability of new evidence in developing their guidelines.
Gerstein et al-2015-anesthesia_&_analgesiasamirsharshar
POISE-2 was a large randomized controlled trial that investigated the risks and benefits of continuing low-dose aspirin perioperatively in patients undergoing noncardiac surgery. The trial found no difference in the primary outcome of death or myocardial infarction within 30 days between those who received aspirin or placebo. However, major bleeding was more common in the aspirin group. While providing important new evidence, the document notes several limitations of POISE-2 including that over 60% of subjects may not have met guidelines for aspirin therapy and many received other antithrombotic drugs postoperatively. On balance, the optimal perioperative aspirin management strategy remains unclear based on POISE-2 alone.
The document discusses the TAVR (transcatheter aortic valve replacement) procedure, which is a minimally invasive alternative to open-heart surgery used to replace the aortic valve in patients considered too high risk for open-heart surgery. The TAVR procedure involves inserting an artificial valve through the femoral or apical artery using a catheter. Potential complications include stroke, death, and bleeding issues. Physical therapy implications include screening patients who will be on lifelong aspirin therapy for risk of bleeding complications and addressing mobility issues common in the elderly patient population eligible for TAVR.
1) iFR measures the ratio of distal coronary pressure to aortic pressure at rest during the wave-free period, while FFR requires maximal hyperemia.
2) Studies have shown iFR performs similarly to FFR in assessing stenosis severity and matches PET perfusion.
3) A new study provides direct evidence that coronary autoregulation maintains blood flow at rest, explaining why iFR works without hyperemia.
4) An ongoing trial will evaluate using iFR to guide multi-vessel revascularization in STEMI patients.
The STITCH trial evaluated the effect of CABG plus optimal medical therapy (OMT) versus OMT alone on mortality in patients with left ventricular dysfunction and coronary artery disease. A sub-study examined the role of assessing myocardial viability to identify patients who benefit most from CABG. Of 601 patients who underwent viability testing, 487 had viable myocardium and 114 did not. There was no significant interaction between viability status and treatment assignment on mortality or other outcomes. Assessing viability did not identify patients with differential survival benefit from CABG versus OMT alone.
1) The document discusses whether fractional flow reserve (FFR) guided interventions should be routine or individualized for patients with multivessel coronary artery disease (MVD).
2) It summarizes the findings of the FAME study which found that an FFR-guided approach reduced major adverse cardiac events compared to an angiography-guided approach alone.
3) The document concludes that while FFR provides useful functional information, an individualized approach is needed considering factors like the number of diseased vessels and whether the study directly compared outcomes to CABG.
Debate of opening non infarct related arteriesSwapnil Garde
This document discusses the debate around opening non-infarct related arteries (non-IRA) during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). It provides background on the higher mortality and reinfarction rates seen in patients with multi-vessel disease. It also summarizes several trials that have compared culprit-only PCI versus complete revascularization, with some trials like PRAMI and CvLPRIT finding lower event rates with complete revascularization, while others like CULPRIT-SHOCK found lower mortality and renal failure with culprit-only PCI in cardiogenic shock patients. The optimal strategy for managing non-IRA lesions during primary PCI for STEMI remains debated.
This document summarizes various medical treatments for chronic anal fissures (CAFs), with a focus on nonsurgical approaches involving smooth muscle relaxation. Lateral internal sphincterotomy (LIS) has traditionally been the gold standard surgical treatment for CAFs, but it can permanently weaken the internal sphincter and cause incontinence in some patients. Recently, nonsurgical treatments using pharmacological agents to relax the internal sphincter and promote healing have been developed, avoiding the risks of surgery. The document reviews several clinical trials examining the use of topical glyceryl trinitrate (GTN) at various concentrations for nonsurgical treatment of CAFs. GTN was found to heal CAFs in 33
This document discusses a study evaluating the incidence, predictors, and long-term outcomes of patients experiencing in-stent restenosis (ISR) after receiving long drug-eluting stents for coronary arteries. 421 patients received long drug-eluting stents and 371 patients underwent follow up. The overall incidence of ISR was 4%. Risk factors for ISR included diabetes and long lesions. Of those with ISR, 40% underwent repeat PCI, 46.7% underwent bypass surgery, and 13.3% were treated medically. During long-term follow up of 12-26 months, there were no deaths from ISR and the incidence of major adverse cardiac events was low. ISR did not
This document discusses recommendations for bridging anticoagulation therapy for patients on warfarin undergoing medical procedures. It provides guidance on stratifying patients into high, moderate, and low risk and makes recommendations for whether bridging therapy is needed for different types of procedures for each risk group. For example, it states that bridging is generally recommended for high risk patients undergoing procedures, but may not be needed for moderate risk patients. It also discusses specific procedures like dental work, pacemaker implantation, and cardioversion and provides bridging recommendations for different risk levels.
Risk reduction strategies for cardiac patientsAbeer Nakera
1. The document discusses risk reduction strategies for cardiac patients undergoing non-cardiac surgery, including preoperative risk stratification, coronary revascularization, pharmacological therapies, anesthetic considerations, and postoperative monitoring.
2. It provides recommendations on preoperative coronary revascularization for high-risk patients, as well as perioperative use of beta-blockers, statins, alpha-2 agonists, aspirin, calcium channel blockers, and nitroglycerin to reduce cardiac risks.
3. Intraoperatively, it recommends maintaining normothermia, considers the use of volatile anesthetics, and suggests using intraoperative echocardiography for acute hemodynamic issues. Tight control of blood glucose is also addressed.
Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
Prevention of venous thromboembolism in nonsurgical patients ̣̣_ phòng ngừa h...SoM
This document provides guidelines from the American College of Chest Physicians on the prevention of venous thromboembolism in nonsurgical patients. It was developed by a team with expertise in thrombosis and bleeding disorders. The guidelines make recommendations on thromboprophylaxis for hospitalized medical patients at increased or low risk of thrombosis, critically ill patients, cancer patients, chronically immobilized outpatients, long-distance travelers, and persons with asymptomatic thrombophilia. Support for the guideline development was provided by several pharmaceutical companies and organizations have endorsed the guidelines.
Perioperative cardiac assessment for non-cardiac surgeryAnor Abidin
Non-cardiac surgery represents an opportunity to assess patients' short-term and long-term cardiac risk and treat any significant cardiac diseases or risks. The referring physician should inform patients of the evaluation results and implications for their prognosis. Further, physicians should avoid stating a patient is "cleared for surgery" and instead focus on perioperative cardiac optimization and management of risks.
Patient undergoing non-cardiac surgery represents an opportunity to assess cardiac risk both in the short and long term. A full evaluation should be performed to understand prognosis and any need for treatment of underlying cardiac conditions or risks. The referring physician should be informed of the evaluation results and their implications. Patients should not be described as simply "cleared for surgery".
This document provides information about warfarin therapy for patients with mechanical heart valves, including:
1) Warfarin is the anticoagulant most commonly prescribed for patients with mechanical heart valves to reduce the risk of blood clots and thromboembolism by inhibiting vitamin K-dependent clotting factors.
2) The main risk of warfarin is hemorrhage, with 2-5% of patients experiencing major bleeding annually. Intracranial bleeding risk is 0.2-0.4% annually and fatal bleeding risk is 0.5-1.0% annually.
3) Warfarin is given orally once daily and the international normalized ratio (INR)
Perioperative cardiovascular assessment of patients undergoing noncardiac sur...kazi alam nowaz
Perioperative cardiovascular assessment is necessary for patients undergoing noncardiac surgery to evaluate medical status, cardiac risks, and recommend strategies to improve short and long term outcomes. Surgeries are stratified as low, intermediate, or high risk depending on the procedure. For patients at elevated risk, further testing like stress testing may be considered to guide management. Guidelines recommend continuing medications like beta blockers and statins perioperatively, as well as delaying surgery for patients with stents based on type. The timing and risks of surgery must be weighed based on a patient's cardiovascular condition and procedure.
Appropriteness Criteria for Coronary RevascularizationLalit Kapoor
The document discusses guidelines for determining the appropriateness of revascularization procedures like angioplasty and coronary artery bypass grafting. It summarizes several major clinical trials that have compared medical therapy to revascularization and PCI to CABG. The guidelines developed by an expert panel rate 180 clinical scenarios on appropriateness based on factors like symptoms, risk level, coronary anatomy, and response to medical therapy. Revascularization is deemed appropriate for high-risk patients but uncertain or inappropriate for low-risk, asymptomatic patients or late interventions after heart attacks.
Appropriteness Criteria for Coronary RevascularizationLalit Kapoor
The document discusses guidelines for determining the appropriateness of revascularization procedures like angioplasty and coronary artery bypass grafting. It summarizes several major clinical trials that have compared medical therapy to revascularization and PCI to CABG. The guidelines developed by an expert panel rate 180 clinical scenarios on appropriateness based on symptoms, risk level, coronary anatomy and medical therapy. Revascularization is deemed appropriate for high-risk patients but uncertain for intermediate-risk asymptomatic patients. CABG is preferred over PCI for left main stenosis and multi-vessel disease.
This document summarizes guidelines from the 2017 ESC/EACTS for the management of valvular heart disease. It provides recommendations on the choice of mechanical vs. bioprosthetic valves for aortic and mitral positions based on patient age, risk factors, and lifestyle. It also outlines antithrombotic therapy indications and targets for mechanical valves, including the use of vitamin K antagonists (VKAs), aspirin, and antiplatelet therapy for patients also receiving coronary stents. Recommendations are provided on antithrombotic management for bioprosthetic valves as well.
Antithrombotic in difficul clinical condition umeshMohit Aggarwal
This document discusses antithrombotic therapy in difficult clinical conditions. It covers high ischemic burden, high bleeding risk, non-cardiac surgery post procedures, high INR levels, pregnancy with prosthetic valves, renal dysfunction, and atrial fibrillation. It provides guidance on treatment strategies for balancing thrombotic and bleeding risks in these complex patients, including medication choices, dosing, and timing of therapy.
The executive summary provides a concise overview of the key changes and innovations in the 9th edition of the Antithrombotic Therapy and Prevention of Thrombosis guidelines. To minimize length, the printed version includes this summary, an introduction, methods article, and recommendations from each article embedded in the table of contents. The full online version contains narrative summaries and evidence tables supporting over 600 recommendations across 9 articles. The executive summary successfully highlights the efforts taken to balance brevity with comprehensive coverage of antithrombotic therapy.
Management of patients on long term anticoagulant therapy.Diwakar vasudev
This document discusses the management of anticoagulation in patients undergoing surgical procedures. It notes that anticoagulants prevent blood clotting but increase bleeding risks during surgery. Newer direct-acting anticoagulants like dabigatran, rivaroxaban, apixaban and edoxaban have shorter half-lives, making it easier to discontinue and resume them rapidly around procedures compared to warfarin. The risks of bleeding during surgery and thromboembolism without anticoagulation must be balanced on a case-by-case basis. Guidelines are provided for interrupting and resuming various anticoagulants based on procedure bleeding risk. Bridging with heparin may
Anaesthesia for patient with anticoagulantAnaestHSNZ
This document discusses guidelines for managing patients on anticoagulant therapy who require surgery. It is important to balance the risk of thromboembolic events from stopping anticoagulants against the risk of bleeding from continued anticoagulation. Factors like the urgency and type of surgery, the indication for anticoagulation and the patient's risk profile are considered. Bridging with low molecular weight heparin may be used when anticoagulants need to be stopped temporarily to reduce thromboembolic risk. Regional anesthesia can be used cautiously in anticoagulated patients when benefits outweigh bleeding risks.
This document discusses carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for treatment of carotid artery stenosis. It provides details on patient selection criteria and describes the CAS procedure, including diagnostic arteriography, embolic protection device placement, stent placement, and post-procedure care. Several major clinical trials are summarized that demonstrated CAS to be non-inferior to CEA for reducing risk of stroke in both symptomatic and asymptomatic patients.
This document discusses carotid artery stenting as an alternative to carotid endarterectomy for treating carotid artery stenosis. It provides details on:
1) Clinical trials that have established carotid stenting as an equivalent option to carotid endarterectomy for reducing risk of stroke, with some trials finding stenting superior for certain patient groups.
2) Guidelines from organizations like the ACC/AHA that recommend carotid stenting as a Class I or IIa option for symptomatic and select asymptomatic patients.
3) The procedure of carotid artery stenting, including patient preparation, diagnostic arteriogram, techniques for embolic protection and stent placement.
Preoperative Management Of Coronary Stentshospital
This document discusses recommendations for continuing dual antiplatelet therapy (aspirin and clopidogrel) in the perioperative period for patients who have received coronary stents and will undergo surgery. It recommends continuing this medication for 6 weeks for patients with bare metal stents and 12 months for those with drug-eluting stents. Discontinuing clopidogrel alone while maintaining aspirin may be relatively safe for drug-eluting stent patients in the short term. The risk of stent thrombosis is greatest during and immediately after surgery.
This document provides guidelines for the use of antithrombotic therapy and prevention of thrombosis during pregnancy and lactation. It recommends low-molecular-weight heparin over unfractionated heparin for preventing and treating venous thromboembolism in pregnant women. It also recommends continuing anticoagulation treatment for at least 6 weeks postpartum for women diagnosed with acute VTE during pregnancy. The guidelines state that there is a need for more appropriately designed studies in this population as most recommendations are based on observational studies and extrapolation from other groups.
Similar to Manejo perioperatorio de la terapia antitrombótica, chest, 2012 (20)
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Gender and Mental Health - Counselling and Family Therapy Applications and In...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Beyond Degrees - Empowering the Workforce in the Context of Skills-First.pptxEduSkills OECD
Iván Bornacelly, Policy Analyst at the OECD Centre for Skills, OECD, presents at the webinar 'Tackling job market gaps with a skills-first approach' on 12 June 2024
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
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Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.