David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Preoperative cardiac evaluation can be facilitated by use of one of the existing tools for estimating perioperative cardiac risk, such as the Revised Cardiac Risk Index.
The role of perioperative β-blockers in reducing surgical risk is uncertain, in light of mixed results of studies using variable dosing schedules. Perioperative β-blockers may decrease the risk of nonfatal MI, but may increase the risk for stroke and death.
Patients with coronary stents should continue aspirin through the perioperative period, unless bleeding risk precludes it. Patients with coronary stents should remain on dual antiplatelet therapy and have elective surgeries delayed for at least 4 weeks after placement of a bare-metal stent and for at least 3 to 6 months after placement of a drug-eluting stent.
Bridging anticoagulation is not recommended for patients with atrial fibrillation without a mechanical heart valve or with a CHADS2 score of 4 or less.
The inability to rapidly prognosticate in cases of OHCA makes it difficult to move from an aggressive resuscitation strategy to either termination of resuscitation efforts or aggressive organ procurement. The use of these clinical criteria could help with this conundrum by rapidly identifying patients who are unlikely to survive and might be appropriate candidates for organ donation.
An editorial notes the complexity of the decisions surrounding OHCA situations and suggests that there is much more to learn about how best to balance the imperatives of saving lives when possible, terminating efforts when futile, and ethically maximizing procurement of transplantable organs.
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Wesorick DH, Chopra V. Annals for Hospitalists - 20 December 2016. Ann Intern Med. 2016;165:HO1. doi: 10.7326/AFHO201612200
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Published: Ann Intern Med. 2016;165(12):HO1.
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