How should medications be managed perioperatively for a high-risk patient with multiple comorbidities undergoing surgery?

From the Guidelines

Perioperative medication management for the 87-year-old female patient with multiple comorbidities, including atrial fibrillation, hypertension, heart failure with preserved ejection fraction, and severe tricuspid regurgitation, should prioritize the continuation of beta-blockers like metoprolol, statins, and antihypertensives, with careful consideration of anticoagulants and other medications. The patient's medications, including Eliquis, Farxiga, and Lasix, should be evaluated individually based on their necessity during surgery, potential for adverse interactions with anesthesia, and risk of complications if discontinued.

• Eliquis, a direct oral anticoagulant, should be discontinued 2-3 days before surgery, depending on renal function, to minimize the risk of bleeding complications 1.
• Farxiga, an SGLT2 inhibitor, may be held on the morning of surgery due to the risk of acute kidney injury and the potential for hypovolemia, but this decision should be made in consultation with the patient's primary care physician and the surgical team.
• Lasix, a diuretic, should be used with caution in the perioperative period, as it may contribute to hypovolemia and electrolyte imbalances, but its use may be necessary to manage the patient's heart failure and fluid status. The patient's RCRI (Revised Cardiac Risk Index) conditions, including heart failure, cerebrovascular disease is not mentioned, high-risk type of surgery (e.g., vascular surgery is not mentioned but the patient is undergoing a major orthopedic surgery), preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL (not mentioned), should be carefully assessed to determine the patient's overall cardiac risk and guide perioperative management decisions 1. It is essential to balance the risks of medication discontinuation against potential surgical complications, with the goal of maintaining physiological stability throughout the perioperative period. The patient's beta-blocker therapy, including metoprolol, should be continued perioperatively, as it is likely to reduce the risk of cardiac complications, including myocardial infarction and cardiac death 1. The patient's statin therapy should also be continued, as it has been shown to reduce the risk of cardiac complications in patients undergoing noncardiac surgery 1. The patient's antihypertensive medications, including Entresto, should be carefully managed in the perioperative period to minimize the risk of hypotension and other complications 1. Overall, the patient's perioperative medication management should be individualized based on her unique clinical profile and the specific surgical procedure she is undergoing, with careful consideration of the potential risks and benefits of each medication.

From the FDA Drug Label

In ARISTOTLE, the results for major bleeding were generally consistent across most major subgroups including age, weight, CHADS2 score The safety of apixaban tablets has been evaluated in 1 Phase II and 3 Phase III studies including 5924 patients exposed to apixaban tablets 2. 5 mg twice daily undergoing major orthopedic surgery of the lower limbs Table 3: Bleeding During the Treatment Period in Patients Undergoing Elective Hip or Knee Replacement Surgery The efficacy profile of apixaban was generally consistent across subgroups of interest for this indication (e.g., age, gender, race, body weight, renal impairment).

The patient has atrial fibrillation, hypertension, heart failure with preserved EF due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism. The patient is taking Eliquis (apixaban), atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto.

Eliquis (apixaban) should be held before surgery due to the risk of bleeding. Farxiga may need to be held before surgery due to the risk of acute kidney injury. Lasix may need to be held before surgery due to the risk of dehydration and electrolyte imbalance.

The RCRI (Revised Cardiac Risk Index) conditions in this patient are:

• High-risk surgery (hip replacement)
• History of heart failure
• History of cerebrovascular disease (not explicitly mentioned, but the patient has atrial fibrillation, which increases the risk of stroke)
• Preoperative treatment with a sema (e.g. theophylline) or a beta-blocker (the patient is taking metoprolol XL)
• Preoperative serum creatinine >2.0 mg/dL (not mentioned, but the patient has nonischemic cardiomyopathy, which may affect kidney function) 2 2

From the Research

Medication Management for High-Risk Patient

The patient in question is an 87-year-old female with a history of atrial fibrillation, hypertension, heart failure with preserved ejection fraction due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism. She is currently taking Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto.

Perioperative Medication Recommendations

• Eliquis: It is generally recommended to hold anticoagulants such as Eliquis perioperatively to reduce the risk of bleeding 3, 4. However, the decision to hold Eliquis should be made in consultation with the patient's cardiologist and anesthesiologist.
• Farxiga: There is no clear consensus on holding SGLT2 inhibitors like Farxiga perioperatively. However, some studies suggest that they may be continued in patients with heart failure 5, 6.
• Lasix: As a loop diuretic, Lasix is often used to manage fluid overload in patients with heart failure. Its use perioperatively should be guided by the patient's volume status and renal function.

RCRI Conditions

The Revised Cardiac Risk Index (RCRI) is a tool used to predict cardiac risk in patients undergoing noncardiac surgery. The patient in question has several RCRI conditions, including:

• History of heart failure
• History of cerebrovascular disease (not explicitly mentioned, but possible given the patient's history of atrial fibrillation)
• High-risk type of surgery (orthopedic surgery, such as hip replacement, is considered high-risk)
• Preoperative treatment with a sema (e.g., metoprolol XL)

These conditions increase the patient's cardiac risk and necessitate careful perioperative management. The patient's cardiologist and anesthesiologist should be consulted to develop a comprehensive perioperative plan.

Additional Considerations

• The patient's hypothyroidism should be well-controlled perioperatively to minimize the risk of cardiac complications.
• The patient's severe tricuspid regurgitation may require special consideration during anesthesia and surgery.
• The patient's history of mitral clip and nonischemic cardiomyopathy may also impact her perioperative management.

It is essential to consult with the patient's cardiologist and anesthesiologist to develop a personalized perioperative plan that takes into account her complex medical history and current medications.