Two leading heart groups in the US have issued new guidelines about what should be done for patients with heart disease before they undergo surgery on other parts of the body. The aim is to reduce a heart patient’s risk of complications during and after an operation. The recommendations were based on a critical review of studies, particularly those published since the two groups’ last guidelines in 2002.
A panel of experts from the American College of Cardiology and the American Heart Association wrote the guidelines, which affect the quality and cost of care. The guidelines cover a number of wide-ranging medical issues. One is whether to stop taking certain prescribed drugs before an operation. Another is whether to implant stents or perform coronary bypass surgery before conducting other types of elective surgery. The decisions depend on the urgency of the operation, its type and risk, a patient’s general ability to function and the hospital where the surgery is performed, the panel said.
Although the safety of surgery for heart patients has improved in recent years, problems affecting the heart and blood vessels are the most common and treatable complications of non-heart operations. For example, patients have a 40-70% increased risk of dying if they have a painful heart attack after surgery, the panelists wrote. If heart patients need emergency non-heart surgery, doctors should forgo heart testing and send a patient straight to an operating room, said the panel’s chairman Dr Lee A. Fleisher, who is also chairman of anesthesiology and critical care at the University of Pennsylvania School of Medicine.
But many people with heart disease can safely undergo non-emergency operations without first undergoing the extensive testing that is common practice. Doctors often do many screening tests and then repair the heart problem to prepare the patient for non-cardiac surgery. For example, doctors often perform an artery-opening procedure and implant a stent or do a coronary bypass operation. The panel said such interventions are rarely necessary to lower the risk of non-heart surgery unless a patient needed the intervention in any case.
The guidelines recommend that patients undergo evaluation and treatment before non-cardiac surgery only for active heart problems like severe angina, late-stage heart failure, serious heart rhythm abnormalities (arrhythmias) and severe heart valve disease. The guidelines also say new studies show that patients should not stop taking the cholesterol-lowering drugs called statins before surgery, an issue not addressed in earlier versions.
Another recommendation concerns the use of anti-clotting drugs that patients take after they have received a stent. In the past, such patients were advised to stop taking such drugs before surgery because of the risk of bleeding. Newer information shows that anti-clotting drug treatment is important after stent placement, and the guidelines urge patients to stop taking such drugs for as short a time as possible. The panel also urged researchers to conduct sufficiently large clinical trials to clarify areas where data is lacking. Among them are the safety and effectiveness of starting and stopping drugs like aspirin, statins and beta blockers before surgery. The guidelines will be published in the 23 October issue of the heart association’s journal ‘Circulation’.