HCPLive Network

Updates in Surgery: Percutaneous Coronary Intervention, Perioperative Biomarkers, and Troponin

 
During his presentation “Perioperative Medicine II” at the 2013 Southern Hospital Medicine Conference in New Orleans, Steven Cohn, MD, internist at the University of Miami Miller School of Medicine, discussed perioperative biomarkers, percutaneous coronary intervention (PCI) and timing of subsequent noncardiac surgery.
 
In his discussion of biomarkers, Cohn talked about BNP (a prohormone) and NT-proBNP (an inactive cleavage product), both secreted by ventricular cardiomyocytes in response to stretching of the atrial/ventricular wall, which occurs in left ventricle dysfunction, myocardial ischemia, arrhythmias, and valvular abnormalities. Preoperative elevations of BNP/NT-proBNP are associated with adverse CV events in noncardiac and vascular surgery. Cohn said there is much that is not yet known about using either as biomarkers in surgery. For example, when to test, which to test, which patients to test, what levels are predictive, and what effect testing has on management and outcome are all questions yet to be answered. There are still no evidence-based outcome studies.
 
Troponins are proteins that are involved in muscle contraction; they are released when muscle cells are injured, as in MI, which is the most common major perioperative vascular complication (most occur within 48 hours of surgery, and most deaths occur within several days of MI). Troponin elevation may predict short- or long-term mortality and cardiac events, but whether levels should be routinely monitored is unclear. Which patients are at risk for what procedures is also not fully known. Using troponins as postoperative biomarkers may help improve outcomes, but there is no real evidence of this yet.
 
Cohn then discussed PCI and the timing of subsequent elective noncardiac surgery. After PCI, the risks of stent thrombosis (ST) and major adverse cardiac events (MACE) are increased by the stress of surgery and the discontinuation of antiplatelet therapy. Current guidelines recommend delaying elective noncardiac surgery (NCS) for at least 30-45 days after bare metal stents (BMS) are implanted, and 12 months after drug-eluting stents (DES). Cohn stated that these guidelines should be individualized to patients. Management options include continuing dual antiplatelet therapy, stopping clopidogrel, prasugrel, or ticagrelor 5-7 days preop and continuing aspirin, or stopping both. If bridging therapy is used, tirofiban should be stopped 3-6 hours before surgery, and eptifibatide, about 6 hours before.
 

Further Reading
A new study of Illinois’ Medicaid programs suggests healthcare improvements and cost savings are not incompatible.
Clostridium difficile (C. diff) infection is now the leading cause of infectious nosocomial diarrhea in the industrialized world. But by following Infectious Disease Society of America (IDSA) treatment guidelines, clinicians can significantly reduce recurrence and mortality, a Texas Tech University Health Sciences Center School of Pharmacy team reports.
A vaccine meant to protect against 9 types of human papillomavirus could prevent 90% of all cervical cancers, according to a study published in the October issue of Cancer Epidemiology, Biomarkers & Prevention.
Nearly 2 million children younger than 5 died worldwide in 2013 of complications from premature birth and pneumonia, according to a study published online Oct. 1 in The Lancet.
For patients in the intensive care unit with septic shock, outcomes are similar for those who receive blood transfusion at a higher or lower hemoglobin threshold, according to a study published online Oct. 1 in the New England Journal of Medicine. The research was published to coincide with the annual meeting of the European Society of Intensive Care Medicine, held from Sept. 27 to Oct. 1 in Barcelona, Spain.
Scientists from Sanofi Pasteur’s Swiftwater, PA facility have published results of a study indicating that a high-dose, trivalent, inactivated influenza vaccine (IIV3-HD or high dose Fluzone®) improves antibody responses to influenza among adults 65 years of age or older.
Prescription medications for mental health diagnoses (e.g. antidepressants, antipsychotics, and mood stabilizers) consume approximately 25% of commercial health insurers’ pharmacy budgets and almost 35% of public payers’ pharmacy spending. In 2011, an estimated 26.8 million US adults—more than 11%—took prescription medications for mental illness.
More Reading
A new study of Illinois’ Medicaid programs suggests healthcare improvements and cost savings are not incompatible.