From the Research
For a patient with a history of NSTEMI and substance use disorder undergoing CT-guided liver ablation, I recommend a comprehensive preoperative workup focusing on cardiac status and substance use management. The workup should include a recent electrocardiogram (ECG), echocardiogram, and cardiac stress testing to evaluate current cardiac function and risk of perioperative cardiac events, as suggested by the most recent guidelines 1. Laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Coagulation studies (PT/INR, PTT)
- Cardiac biomarkers A toxicology screen is essential to confirm abstinence from methamphetamine and cocaine, given the increased risk of cardiac complications associated with these substances 2. Cardiology consultation is necessary to optimize cardiac medications and determine if the patient requires continuation of antiplatelet therapy such as aspirin 81mg daily or clopidogrel 75mg daily, considering the latest recommendations on anticoagulation in NSTEMI patients 1. Anesthesiology consultation should address perioperative risk stratification and pain management planning, considering the patient's substance use history. The patient should abstain from methamphetamine and cocaine for at least 2 weeks before the procedure to reduce cardiac complications. Preoperative management should include beta-blockers such as metoprolol 25-50mg twice daily if not contraindicated, which should be continued through the perioperative period to reduce cardiac risk, as supported by the evidence on managing patients with NSTEMI 3. This comprehensive approach addresses both the cardiac risk factors and substance use concerns that could complicate the liver ablation procedure.