advertisement

periprocedural management of PCI patients

50 %
50 %
advertisement
Information about periprocedural management of PCI patients
Education

Published on September 19, 2009

Author: isoic

Source: authorstream.com

advertisement

:  PERI-PROCEDURAL MANAGEMENT OF PCI PATIENTS HR.Sanati M.D. 1/12/2009 1 HR.Sanati M.D. Allergic Reactions to Contrast Agents : Allergic Reactions to Contrast Agents 1/12/2009 2 HR.Sanati M.D. Slide 3: Anaphylactoid (activation of kinin system) or chemotoxic (hydrophobicity and hyperosmoticity of the contrast media itself) The overall incidence is lower with low- as compared to high-osmolality agents. However, the difference is primarily due to minor reactions such as nausea, vomiting and urticaria 1/12/2009 3 HR.Sanati M.D. Slide 4: Incidence varies between 4.6 and 8.5%, true anaphylaxis in 1%, and death in 0.001-0.009% No specific test to track down the susceptible pts Atopy is a predisposing factor 17-35% chance of recurrence in pts with a previous reaction Low-osmolality agents in high risk status (active asthma, significant allergies, impaired cardiac function, blood-brain barrier break down, and marked anxiety) True anaphylactoid reactions with agitation, shortness of breath, stridor, wheezing, changes of BP, dermal reactions (urticaria, pruritis and skin flushing), and mucosal edema, bronchoconstriction and laryngeal edema in severe cases 1/12/2009 4 HR.Sanati M.D. Slide 5: 1/12/2009 5 HR.Sanati M.D. Treatment algorithm : Treatment algorithm 1/12/2009 6 HR.Sanati M.D. Prophylactic measures : Prophylactic measures No clear evidence that any regimen prevents severe reactions Steroid pretreatment prevents mild reactions The only regimen found effective to date: methylprednisolon 32mg orally, 12 and 2h prior to IV contrast use. Concurrent use of specific H1 and H2 blockers recommended. X-ray angiography with gadolinium-based contrast media is an alternative technique. 1/12/2009 7 HR.Sanati M.D. Aspirin Sensitivity : Aspirin Sensitivity 1/12/2009 8 HR.Sanati M.D. Slide 9: A class I regimen, unless a true sensitivity reaction Thienopyridines as an alternative, but remember the long-time risks of these drugs and need of dual therapy Three presentations of allergic reactions: 1- Respiratory: 10% 2-Cutaneous (urticaria): 0.07-0.2% 3- Systematic sensitivity (anaphylaxis) 1/12/2009 9 HR.Sanati M.D. Aspirin-induced respiratory tract disease : Aspirin-induced respiratory tract disease -COX inhibition PGE 5-lipoxygenase activating Pr leukotrienes and histamines -Usually have a history of asthma (10-15%), nasal polyps, rhinitis, female gender -As excessive rhinorrhea, bronchospasm, and even laryngospasm 1/12/2009 10 HR.Sanati M.D. Aspirin-induced cutaneous reactions : Aspirin-induced cutaneous reactions As urticaria or angioedema History of atopy as asthma, hey fever and urticaria Aspirin-induced urticaria in 20-30% of pts with idiopathic urticaria Possible blended reactions (urticaria, angioedema, dyspnea, wheezing, cough, hoarseness and rhinorrhea) 1/12/2009 11 HR.Sanati M.D. Aspirin desensitization : Aspirin desensitization Eradication of pharmacological and immunological reactions by increasing oral doses of Aspirin Mechanism differs depending on the type of reaction Different protocol whether the pt has aspirin-induced respiratory or cutaneous reactions Some pts are cross-sensitive to NSAIDs that inhibit COX enzymes. In these kinds of pts, desensitization protocols have failed. 1/12/2009 12 HR.Sanati M.D. Slide 13: The desensitization mechanism differs depending on the type of reaction Desensitization Desensitization Reactions related to COX inhibition IgE mediated reactions 1/12/2009 13 HR.Sanati M.D. Slide 14: 1/12/2009 14 HR.Sanati M.D. H.I.T : H.I.T 1/12/2009 15 HR.Sanati M.D. Slide 16: HIT Types: type I: -Unknown mechanism, 10%, mild and transient decrease in PLT, not associated with an increased risk of thrombosis , disappears when the pt becomes heparin-free type II: -Immune-mediated, formation of heparin-related PLT activating antibodies against heparin-bounded PLT F.4 and induction of thrombin generation -Risk of thrombosis -1-5% (but antibody is more common) -Often with UFH -Rapid or delayed -Usually between 5th-10th day (unless prior exposure to heparin) -Moderate thrombocytopenia (50-80×10 9/1), sometimes within normal value but 50% less than pre-heparin value -PLT counts starts to rise 2-3 days after heparin is discontinued, and the antibodies disappear 2-3 mo afterwards. -The occurrence of thrombosis is associated with a 20-30% mortality. 1/12/2009 16 HR.Sanati M.D. Slide 17: A clinical score by Warkentin for estimating the probability of HIT The “four Ts” test Score≤3: Low probability (<5%) Score≥6: High probability (>80%) 1/12/2009 17 HR.Sanati M.D. Slide 18: When suspected, lab. tests must be requested: 1- Washed-PLT activating assays 2- Commercial PLT F.4/polyanion enzyme immunoassays -A negative test generally rules out HIT, but its important to interpret the test by estimating all clinical parameters. 1/12/2009 18 HR.Sanati M.D. Slide 19: When HIT is clinically strongly suspected, in a patient requiring anticoagulation, the following should be observed: -Removal of the trigger (heparin cessation) is not sufficient to prevent thrombosis, so an alternative non-heparin anticoagulant is required to control thrombin formation. -Currently, danaparoid, lepirudin, and argatroban do not cross-react with HIT antibodies. -For chronic anticoagulation, treatment is required for at least 2-3 mo to prevent recurrence of thrombosis. 1/12/2009 19 HR.Sanati M.D. GpIIb/IIIa Is-Induced Thrombocytopenia : GpIIb/IIIa Is-Induced Thrombocytopenia 1/12/2009 20 HR.Sanati M.D. Slide 21: 1.1-5.6% (severe thrombocytopenia<20×10 9/L ranges from 0.1 to 0.5%) Exact mechanism is not yet defined. More often with abciximab Pts receiving eptifibatide and tirofiban should be monitored for 24h, and for pts receiving abciximab a PLT count at 2 and 4h after infusion When drug-induced thrombocytopenia is suspected, discontinuation of the agent, and PLT transfusion if severe Continuation of aspirin and plavix, unless high risk of major bleeding 1/12/2009 21 HR.Sanati M.D. Patients Requiring Cardiac and Non-Cardiac Surgical Procedures Following PCI : Patients Requiring Cardiac and Non-Cardiac Surgical Procedures Following PCI 1/12/2009 22 HR.Sanati M.D. Slide 23: The ACC/AHA guidelines state that it is ‘almost never appropriate’ to utilize revascularization procedures to reduce the risk of non-cardiac surgery, unless otherwise indicated. Peri-operative medical management emphasizing beta-blockade may effectively mitigate risk for most pts with CAD. Nevertheless, there remains a group of pts with multiple clinical risk factors and extensive ischemia who are at high risk for per-operative events despite beta-blockade, and who should be considered for revascularization. 1/12/2009 23 HR.Sanati M.D. BA prior to non-cardiac surgery : BA prior to non-cardiac surgery Reduced risk of perioperative death and MI with subsequent non-cardiac surgery by bypass surgery, esp. those with severe angina and multivessel disease requiring high risk procedures Several small studies reported low rates of peri-operative MI and mortality at least comparable to CABG. Timing of BA is important: No benefit with BA <90 days before non-cardiac surgery. Increased risk of ischemic events due to surgery-induced prothrombotic effects upon an acutely injured vessel with non-cardiac surgery conducted within days or weeks of BA 1/12/2009 24 HR.Sanati M.D. Coronary stenting prior to non-cardiac surgery : Coronary stenting prior to non-cardiac surgery Adherence to antiplatelet therapy is mandatory to avoid stent thrombosis with an associated mortality as high as 40-50% Increased risk of stent thrombosis and bleeding following non-cardiac surgery Striking risk of catastrophic outcomes in pts undergoing non-cardiac surgery <6 weeks (esp. 2 wks) after stent implantation 1/12/2009 25 HR.Sanati M.D. Slide 26: A distinct early hazard, with antiplatelet cessation, to proceeding with non-cardiac surgery up to 6 wks after BMS placement This is the risk period for stent thrombosis expected after BMS placement due to need for re-endothelialization and healing of the vascular surface. The surgical procedure promotes thrombosis and this risk maybe partially mitigate by continuation of antiplatelet therapy in the peri-operative period. Nevertheless, a hazard remains even on antiplatelet therapy, and these agents also increase the likelihood of hemorrhage. 1/12/2009 26 HR.Sanati M.D. Slide 27: Clearly non-cardiac surgical procedures should be avoided if at all possible for at least 6 weeks after PCI. Patients who must undergo urgent surgery (<4-6wks) may be considered for a provisional stenting approach to PCI, although it is probably feasible in only a minority of patients. Depending upon the surgical procedure it may be possible to continue dual antiplatelet therapy in the peri-operative period, accepting some increased risk of bleeding. However the systemic insult from the surgery may still increase the risk for an ischemic event. Heparin –coated stent? 1/12/2009 27 HR.Sanati M.D. Slide 28: If a patient requires surgery in the near-term (1-6mo) and can be delayed >6 weeks, then a BMS can be implanted and surgery can proceed with discontinuation of antiplatelet therapy. However, caution may be necessary for pts with high risk conditions for stent thrombosis (longer stents, bifurcations, DM,RF). DES placement should be strictly avoided if surgery is planned within 3-6 months. If a pt requires non-cardiac surgery before the end of the obligatory dual antiplatelet therapy period, if at all possible this therapy should continue in the peri-operative interval. Uncertainly regarding pts with DES who undergo surgery after the period of essential antiplatelet therapy (consider late stent thrombosis). 1/12/2009 28 HR.Sanati M.D. Slide 29: 1/12/2009 29 HR.Sanati M.D. Cardiac surgery following PCI : Cardiac surgery following PCI For acute failure or complications of PCI, recurrent restenosis after PCI, as a definite therapy for severe multivessel disease following culprit PCI, and as a part of hybrid cardiac procedure Cardiac surgery is complicated by the PCI-mandated adjunctive antiplatelet therapy, and in emergent situation, by acute ischemia and hemodynamic instability. 1/12/2009 30 HR.Sanati M.D. Slide 31: 1/12/2009 31 HR.Sanati M.D. Slide 32: The bleeding risk of abciximab can be mollified by PLT transfusion (short H.L and high receptor affinity) that can be given after discontinuation of extracorporeal circulation and heparin neutralization. Small molecule competitive GpIIb/IIIa Is (eptifibatide & tirofiban) have low receptor affinity and the amounts of unbound drug makes PLT transfusion ineffective. However, the effect subsides within 4-6h. Peri-operative aspirin appears to decrease peri-operative infarction and mortality, with no or slight increase in hemorrhage. 1/12/2009 32 HR.Sanati M.D. Slide 33: Increased bleeding and a resultant 5-10× higher risk for re-operation in early observational studies, when plavix is administered within 5-7 days of bypass surgery. However, recent reports are more mixed regarding the bleeding risk (predominantly moderate rather than major or life-threatening bleeding in CURE trial). PLT transfusion in pts exhibiting bleeding after heparin neutralization Antifibrinolytic therapy with the serine proteinase inhibitor, aprotonin to decrease postoperative bleeding and transfusion requirements in pts receiving aspirin and plavix (no prothrombotic hazard but associated with a 200% increased risk of RF, 55% increased risk of MI, and 181% increased risk of stroke or encephalopathy in a recent study) Data are not available regarding the use of aminocaproic acid and transexamic acid in these pts 1/12/2009 33 HR.Sanati M.D. The Hypotensive Pt After PCI : The Hypotensive Pt After PCI 1/12/2009 34 HR.Sanati M.D. Slide 35: Hypotension after PCI: - Dehydration Vasovagal reaction Cardiac arrhythmia Myocardial ischemia Anaphylaxis Access site bleeding Retroperitoneal hematoma Cardiac tamponade 1/12/2009 35 HR.Sanati M.D. Dehydration : Dehydration Due to prolonged fasting Esp. in pts on diuretic therapy S.L nitrates may precipitate severe hypotension, therefore, it should be replaced by I.C nitrates, esp. in pts with SBP<120 Rapid IV infusion of 0.9% sodium chloride solution will usually normalized BP. 1/12/2009 36 HR.Sanati M.D. Vasovagal reaction : Vasovagal reaction In up to 3% of cardiac catheterizations Volume administration and atropine are usual Tx Rapid reversion of hypotension may be mandatory in pts with critical coronary or valvular disease. Myocardial ischemia must be excluded as a cause of vasovagal reaction, and in most cases ECG can be used. The absence of ST-deviation particularly in the inferior leads should exclude this possibility 1/12/2009 37 HR.Sanati M.D. Arrhythmias : Arrhythmias Atrial and ventricular arrhythmias frequently occur In case of hemodynamic compromise, urgent treatment is required. 1/12/2009 38 HR.Sanati M.D. Retroperitoneal hematoma : Retroperitoneal hematoma A life-threatening complication Incidence is low (0.15-0.44%), but maybe is higher (undetected milder or fatal cases) Silent accumulation of blood in the retroperitoneum before sign and symptoms of hypovolemia, delayed diagnosis, high morbidity and potential mortality. When the puncture site is located above the inguinal ligament, the artery is accessed in the retroperitoneal space, and is called the external iliac artery. 1/12/2009 39 HR.Sanati M.D. The Kidney and PCI : The Kidney and PCI 1/12/2009 40 HR.Sanati M.D. Slide 41: Chronic renal insufficiency (CRI) defined as GFR<60ml/min, representing loss of half or more of the normal kidney function, or the presence of persistent proteinuria with an albumin/Cr ratio >30 mg/g in the urine samples. 1/12/2009 41 HR.Sanati M.D. Slide 42: CRI is a powerful predictor of worse short- and long-term outcomes after PCI (10 times higher in-hospital mortality in BARI trial). The prognosis is not necessarily related to the degree of renal impairment. In one study, in-hospital mortality was similarly high in pts with both mild and severe CRI. CRI predicted major bleeding in pts treated either with UFH plus planned GPIIb/IIIa Is or with bivalirudin. 1/12/2009 42 HR.Sanati M.D. Slide 43: Therapeutic doses of UFH are cleared by a combination of a rapid, saturable mechanism, and a slow, non-saturable, dose independent mechanism of renal clearance and close intraprocedural monitoring of anticoagulation is important in pts with CRI. Abciximab is rapidly cleared by the RE system, and increases the risk of bleeding in pts with CRI not exceeding that in pts without CRI Eptifibatide and tirofiban undergo renal clearance, requiring appropriate dosing adjustments. 1/12/2009 43 HR.Sanati M.D. C.I.N : C.I.N A curvilinear relationship between GFR and the risk of RF requiring dialysis in pts undergoing diagnostic angiography with or without PCI. 1/12/2009 44 HR.Sanati M.D. Slide 45: 1/12/2009 45 HR.Sanati M.D. Mehran ‘s scoring : Mehran ‘s scoring 1/12/2009 46 HR.Sanati M.D. Slide 47: 1/12/2009 47 HR.Sanati M.D. Slide 48: 1/12/2009 48 HR.Sanati M.D.

Add a comment

Related presentations

Related pages

Periprocedural glycemic control in patients with diabetes ...

Periprocedural glycemic control in patients with diabetes mellitus undergoing coronary ... (PCI). However, periprocedural management of ... Patients with ...
Read more

Periprocedural myocardial infarction following ...

Periprocedural myocardial infarction following percutaneous coronary intervention. ... of patients undergoing PCI ... Management of Patients ...
Read more

Periprocedural complications of PCI in acute MI patients ...

Periprocedural complications of PCI in acute MI patients - acute stent thrombosis Lene Holmvang, ... ”How to prevent acute stent thrombosis in pPCI
Read more

Novel Anticoagulants: Management in the Periprocedural ...

Novel Anticoagulants: Management in the Periprocedural ... questions regarding periprocedural management and ... pertain to the management of patients ...
Read more

Periprocedural Stroke and Cardiac Catheterization

Periprocedural Stroke and Cardiac Catheterization ... cardiac catheterization or PCI. Patients ... patients with periprocedural stroke in
Read more

Periprocedural Glycemic Control in Patients With Diabetes ...

... who underwent percutaneous coronary intervention (PCI). ... (PCI). However, periprocedural management of ... medications before PCI in patients ...
Read more

Improvement of Periprocedural Guidewire Management for ...

Improvement of Periprocedural Guidewire Management for ... Periprocedural management of guidewire placement and removal ... patients for PCI without ...
Read more

Periprocedural Management and Approach to Bleeding in ...

Periprocedural Management and Approach to Bleeding in Patients Taking Dabigatran. ... Periprocedural Management. ... In patients with normal ...
Read more

Myocardial Infarction Due to Percutaneous Coronary ...

... Myocardial Infarction Due to Percutaneous ... MRI in 25% of patients after PCI, ... majority of patients with periprocedural ...
Read more