What are the optimal medical therapy medications for patients undergoing vascular surgery?

Optimal Medical Therapy for Vascular Surgery Patients

Patients undergoing vascular surgery should receive statin therapy, antiplatelet therapy, and appropriate blood pressure management as the cornerstone of optimal medical therapy to reduce perioperative and long-term cardiovascular risk. 1

Core Medication Regimen

Statin Therapy

• All vascular surgery patients should receive statin therapy regardless of baseline cholesterol levels 1
• For patients already on statins, therapy should be continued perioperatively 1
• High-intensity statins are preferred to achieve >50% LDL-C reduction and target LDL-C <1.4 mmol/L (55 mg/dL) 1
• Initiate statins at least 2 weeks before elective vascular surgery when possible

Antiplatelet Therapy

• Single antiplatelet therapy (preferably aspirin 75-100 mg daily) is recommended for all vascular surgery patients without contraindications 1
• For patients with recent carotid intervention:
  • After carotid endarterectomy (CEA): Low-dose aspirin or clopidogrel long-term 1
  • After carotid artery stenting (CAS): Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for at least 1 month, then single antiplatelet therapy long-term 1
• For patients with coronary stents undergoing vascular surgery:
  • If possible, delay surgery until completion of recommended DAPT duration 1, 2
  • For urgent surgery, continue DAPT if bleeding risk is acceptable 1

Blood Pressure Management

• Optimize blood pressure control before surgery 1
• ACE inhibitors or ARBs should be considered in stable patients with left ventricular systolic dysfunction 1
• Consider temporary discontinuation of ACE inhibitors/ARBs on the day of surgery in hypertensive patients 1
• Resume antihypertensive medications as soon as possible postoperatively 1

Perioperative Thromboprophylaxis

• For vascular surgery patients at moderate-to-high risk of VTE who are not at high bleeding risk, use LMWH or LDUH 1
• For patients at high bleeding risk, use mechanical prophylaxis (preferably intermittent pneumatic compression) until bleeding risk decreases 1
• For high-risk vascular surgery patients, consider adding mechanical prophylaxis to pharmacologic prophylaxis 1

Special Considerations

Carotid Surgery Patients

• Continue antiplatelet therapy perioperatively 1
• After carotid stenting, DAPT for at least 1 month, then long-term single antiplatelet therapy 1
• Intensive lipid-lowering therapy targeting >50% LDL-C reduction 1

Patients with Coronary Stents

• Balance thrombotic risk against bleeding risk 1
• For drug-eluting stents (DES), delay elective surgery for 12 months if possible 2
• For urgent surgery with recent stent placement, continue DAPT despite increased bleeding risk 2
• Consider multidisciplinary consultation for semi-urgent surgery 2

Medication Adherence and Long-term Management

• Long-term adherence to optimal medical therapy is essential but often suboptimal 3, 4
• Triple therapy (antiplatelet, statin, and antihypertensive) reduces long-term mortality 3
• Annual follow-up is recommended to check for cardiovascular risk factors and treatment compliance 1

Common Pitfalls to Avoid

1. Discontinuing statins perioperatively - This increases cardiovascular risk; statins should be continued 1
2. Inappropriate antiplatelet management - Premature discontinuation increases thrombotic risk; unnecessary continuation may increase bleeding 1, 2
3. Inadequate VTE prophylaxis - Vascular surgery patients are at high risk for VTE 1
4. Poor long-term medication adherence - Only 44-50% of patients receive optimal triple therapy 4
5. Failure to optimize modifiable risk factors - Smoking cessation, diabetes management, and blood pressure control are essential 5

By implementing this comprehensive medical therapy regimen, perioperative and long-term morbidity and mortality can be significantly reduced in vascular surgery patients.