In these slides I discuss what to do with the patient post stent who needs noncardiac surgery and I discuss what to do with anti-platelet therapy in the perioperative period. Watch my YouTube description of these slides at http://youtu.be/z8Okm3_GFbU.
there is detailed analysis of mitral valve segments by 2d transesophageal echo cardiography. There is a review on this and simplified approach how one can identify the pathological segment with great accuracy using two dimensional tee.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
there is detailed analysis of mitral valve segments by 2d transesophageal echo cardiography. There is a review on this and simplified approach how one can identify the pathological segment with great accuracy using two dimensional tee.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Isicam, high bleeding risk pci,2016,ismanIsman Firdaus
Presented by Dr. Isman Firdaus in ISICAM 2016
PCI in high bleeding risk patient was tricky management
Drug Coated Stent vs Bare Meta stent regarding LEADERS FREE trial.
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en intervencionismo coronario
Juan Miguel Ruiz Nodar (Hosp. General de Alicante)
Bare Metal Stents: Will Their Lower Thrombosis Advantage over DES Vanish Against the CoCr-Everolimus Eluting Stents? Armando Tellez, SOLACI Congress 2012, Mexico.
Presentation by Yaron Arbel, MD, from the Tel Aviv Medical Center, discussing the challenges facing medical device manufacturers when designing their stents
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
Anticoagulation and Regional AnesthesiaRajnish Gupta
Discussing the ASRA Guidelines for Anticoagulation and Antithrombotics during Regional Anesthesia including the considerations for neuraxial anesthesia and deep blocks. We also discuss the use of the ASRA Coags app. Question and Answer included.
Perioperative management of patients on corticosteroidsTerry Shaneyfelt
In these annotated PowerPoints I discuss the evaluation and perioperative management of patient taking or who have taken steroids. I discuss how to determine if the adrenal axis is suppressed and how to provide supplemental glucocorticoids if needed. Remember to download these slides to see the annotations for each slide.
Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal SurgeryTerry Shaneyfelt
In these annotated PowerPoint slides I describe the perioperative evaluation and management of patients with hypothyroidism needing nonthyroid surgery. Remember to download these slides to view the annotations for each slide.
Perioperative Diabetes Management in Patients on InsulinTerry Shaneyfelt
In these annotated PowerPoints I discuss the control of diabetes in the perioperative period in patients taking insulin. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
In these powerpoints I describe how to control glycemia in the perioperative period in patient with diabetes not taking insulin. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Preoperative evaluation of patients with diabetesTerry Shaneyfelt
In these annotated slides I discuss the things you need to consider in the preoperative evaluation of patients with diabetes. This sets the stage for perioperative management of diabetes. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
These annotated slides will help you interpret an OR or RR in clinical terms. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
Preoperative evaluation of adults with sleep apneaTerry Shaneyfelt
Patients with sleep apnea present unique challenges in the perioperative period. Over half of patients with sleep apnea are undiagnosed at the time of surgery. I review how to assess risk in patients with suspected or confirmed sleep apnea.
Gupta indices for postop pulmonary complicationsTerry Shaneyfelt
Gupta and colleagues developed 2 prediction rules that can be used to estimate a patient's risk for postoperative pneumonia or respiratory failure. I also review an older prediction rule and show how it compares to the Gupta rules.
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
Review of 2 metaanalyses of RCTs on the effects of statins in the perioperative period. Watch my YouTube video describing these slides: http://youtu.be/wHYlf26AH00
Who needs preoperative noninvasive cardiac testingTerry Shaneyfelt
Review of recommendations on noninvasive cardiac testing prior to noncardiac surgery. Watch my YouTube video describing these slides: http://youtu.be/lDRUrx45pMw
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
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3. Adverse Cardiac Events Following Noncardiac
Surgery in Patients With Stents
Hawn, et al. JAMA 2013;310:1462
4. • Class I
• Elective noncardiac surgery should be delayed
• 14 D after balloon angioplasty
• 30 D after BMS implantation
• 365 D after DES implantation
• Class IIb
• Elective noncardiac surgery after DES implantation may
be considered after 180 D if risk of further delay > risk
of stent thrombosis
2014 ACC/AHA Perioperative Guidelines
5. • Class III (Harm)
• Elective noncardiac surgery in which DAPT will need to
be discontinued should not be performed within
• 30 D after BMS
• 365 D after DES
• If elective noncardiac surgery is needed within 1-
12 months then place BMS with 4-6 wks of DAPT
with continuation of ASA perioperatively
2014 ACC/AHA Perioperative Guidelines
6. Approach to patients who need surgery after PCI
Wait 4-6 weeks Wait 12 months
Continue dual antiplatelet therapy if
surgery needed before completion of
recommended therapy
No matter what continue at least aspirin*
* Except for neurosurgery, post
eye, middle ear, and prostate
7.
8. • Aspirin (and aspirin/dipyridamole)
• POISE-2 trial (N Engl J Med 2014; 370:1494-1503)
suggests that aspirin is of no benefit in patients at
moderate to high risk for cardiovascular events who are
undergoing noncardiac surgery
• Stop 7-10 days prior to surgery
• Bleeding time is a poor predictor of perioperative
hemorrhage
Managing antiplatelet agents in the
perioperative period
9. • Platelet P2Y12 receptor blockers
• Clopidogrel and ticagrelor: stop at least 5 days before
surgery
• Prasugrel: stop at least 7 days before surgery
• Cilostazol
• Selective phosphodiesterase-3 enzyme inhibitor with
weak, reversible antiplatelet activity
• Stop 5 days before surgery
Managing antiplatelet agents in the
perioperative period
Editor's Notes
Noncardiac surgery after recent stent implantation is fairly common. These patients are at increased risk of adverse cardiac events and bleeding. These slides will review the management of these patients. This is a field undergoing intensive study and recommendations could change at any minute. It is best to consult with the cardiologist caring for the patient needing surgery.
The issue that arises in patients with recent PCI is what to do about the timing of surgery and what to do about antiplatelet therapy. The issue revolves around weighing the risk of stent thrombosis with stopping antiplatelet therapy to the risk of bleeding with continuing it. In most cases, the risk of stent thrombosis outweighs bleeding risk.
Hawn and colleagues performed a large retrospective cohort study on 28,000 veterans who underwent noncardiac surgery within 24 months of PCI. Overall, the rate of MACE (all-cause mortality, MI, and cardiac revascularization) was 4.7% at 30 days (top panel). Figure A shows the rates of MACE by stent type (drug eluting stent vs bare metal stent). The rates are high early but level off after 6 months. Furthermore, bare metal stents have a slightly higher rate that might be due to higher risk patients who will need surgery shortly after PCI being preferentially given bare metal stents. Finally, Table 3 shows the top 3 (of 12) predictors of MACE: nonelective surgical admission, having an MI within the 6 mos prior to surgery, and high RCRI score. Stent type was the least important of the predictors in their model.
These are the updated recommendations by the ACC on the timing of surgery post PCI.
These are the updated recommendations by the ACC on the timing of surgery post PCI.
So what should you do if you have a bare metal stent (BMS) or a drug eluting stent (DES):
BMS- wait at least 6 weeks after stent placement before performing elective noncardiac surgery.
DES- wait at least 6 months (though current guidelines recommend 12 months) after stent placement before performing elective noncardiac surgery.
Dual antiplatelet therapy (DAT) should be continued thru the perioperative period is surgery must be conducted prior to the recommended DAT treatment duration.
If the risk of stent thrombosis is lower than the risk of bleeding on DAT and it is decided to stop clopidogrel (or similar drug) aspirin should be continued throughout the perioperative period. Clopidogrel (or similar drug) should be restarted asap after surgery. The risk of stent thrombosis is highest in the first days after surgery.
Certain surgical procedures (like spinal or intracranial surgery, posterior eye surgery and prostate surgery) carry such catastrophic outcomes related to bleeding that all antiplatelet therapy must be stopped perioperatively. Definitely consult with a cardiologist in these patients as they might need urgent PCI for stent thrombosis.
This is a graphic display of the 2014 guidelines on the timing of surgery peristent implantation and antiplatelet therapy decision making in the peristent placement period.
Aspirin doesn’t seem to be beneficial in patients at risk for perioperative events (POISE 2 trial). Approximately 23% of the study population had known CAD but I couldn’t find any report of outcomes in this group to know if continuing aspirin was beneficial or not. The ACC guideline states the continuation of aspirin in these patients might be reasonable.