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 essential medications, such as beta-blockers (e.g., metoprolol) and statins (e.g., atorvastatin), to minimize cardiovascular risk. The patient's medications, including Eliquis (an anticoagulant), Farxiga, levothyroxine, metoprolol XL, and Entresto, should be evaluated individually based on their necessity, risk of withdrawal, and potential for surgical complications.

• Eliquis, as a direct oral anticoagulant, should be discontinued 1-3 days before surgery, depending on renal function and bleeding risk, as suggested by recent guidelines 1.
• Farxiga, an SGLT2 inhibitor, may be continued or held based on the patient's renal function and surgical risk, but there is limited specific guidance on its perioperative management.
• Metoprolol XL, a beta-blocker, should be continued perioperatively, as it is crucial for controlling heart rate and reducing the risk of cardiac complications in patients with heart failure and atrial fibrillation 1.
• Entresto, an ARB-neprilysin inhibitor, may be held on the day of surgery to avoid intraoperative hypotension, but its continuation or discontinuation should be decided based on the patient's individual risk factors and the surgical team's preference.
• Lasix (furosemide), a diuretic, is not mentioned as part of the patient's current medication regimen but may be considered for managing fluid overload in the perioperative period.

The Revised Cardiac Risk Index (RCRI) conditions for this patient include:

• High-risk type of surgery (e.g., major vascular, thoracic, abdominal, or orthopedic surgery)
• History of ischemic heart disease
• History of heart failure
• History of cerebrovascular disease
• Preoperative treatment with insulin
• Preoperative serum creatinine >2.0 mg/dL

Given the patient's complex medical history and the presence of multiple RCRI conditions, a thorough preoperative evaluation and close collaboration between the surgical team, anesthesiologist, and primary care physician are essential to minimize perioperative cardiovascular risk. Medication reconciliation should occur at each transition of care, with clear documentation of which medications to continue, adjust, or temporarily discontinue, and specific instructions for resumption postoperatively 1.

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.