Practice Perfect 910
The Pod Periop Medical Management Series # 4: Cardiac-Related Medications

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Practice Perfect April 30, 2024

Last week, in our ongoing series about perioperative medicine for the podiatrist, we discussed the preoperative cardiac exam, emphasizing the role of risk stratification with functional capacity and the Revised Cardiac Risk Index, downplaying the importance of the electrocardiogram. Today, as promised, we’ll deliver a quick, high-yield reference covering the use of cardiac-related medications in the perioperative period. In short, the question today is, “What medications should be continued, and which ones should be held around the time of surgery?” Let’s get right to it.

Note: Recommendations are excerpted from the 2014 ACC/AHA guidelines on perioperative management in the noncardiac surgery¹ unless cited separately.

Diabetic Foot Osteomyelitis – Medical or Surgical Management?

Don Curtis, DPM, FACFAS

Assistant Professor
Midwestern University
Glendale, AZ
Associate Professor
Arizona College of Podiatric Medicine
Glendale, AZ

Diabetic Foot Osteomyelitis – Medical or Surgical Management?

Dr Curtis gives a comprehensive study in Diabetic Foot Osteomyelitis from recognizing common clinical presentation to tools that assists with proper diagnosis and treatment.

Available Credits: CPME 0.5

Medication Class	Examples	Recommendation
Medications for Pulmonary Hypertension
Phosphodiesterase type 5 inhibitors	sildenafil, tadalafil, vardenafil, and avanafil	Continue periop.
Soluble guanylate cyclase stimulators	riociguat vericiguat	Continue
Endothelin receptor antagonists	macitentan, ambrisentan and bosentan	Continue
Medications for Hypertension
Beta blockers	atenolol, bisoprolol, carvedilol, nebivolol, metoprolol, propranolol	Continue if already on. Do not start if not previously taking.
Alpha blockers	doxazosin, prazosin, terazosin, tamsulosin	Continue
Alpha-2 agonists	clonidine	Continue
ACE inhibitors	benazapril, captopril, enalapril, lisinopril, ramipril	Hold 24 hours preop²
Angiotension Receptor Blockers (ARBs)	valsartan, olmesartan, losartan, irbesartan	Hold 24 hours preop.
Calcium channel blockers	amlodipine, diltiazem, nifedipine, verapamil, nicardipine	Continue
Thiazide diuretics	chlorthalidone, hydrochlorothiazide, metolazone	Continue
Loop diuretics	furosemide, bumetanide, torsemide	Hold on day of surgery unless concern for volume overload
Potassium-sparing diuretics	amiloride, spironolactone, triamterene	Continue
Medications for Cholesterol Disorders
HMG-CoA Reductase Inhibitors (Statins)	atorvastatin, lovastatin	Continue
Bile Acid Sequestrants	cholestyramine, colesevelam, colestipol	Hold on day of surgery.
Nicotinic Acid	niacin	Hold on day of surgery.
Fibrates	fenofibrate	Hold on day of surgery.
Antiplatelet Agents
Aspirin		Continue unless increased bleeding risk.
P2Y₁₂ Inhibitors	clopidogrel	Discontinue 3 days preop.³
Anticoagulants
Vitamin K Antagonists	warfarin	Discontinue > 3 days preop or cancel surgery. Bridging no longer recommended.⁴
Factor Xa Inhibitors	rivaroxaban, apixaban	Discontinue 24 - 96 hours preop. Restart 6 hours postop.⁵
Direct thrombin inhibitors	dabigatran	Discontinue 24 - 96 hours preop. Restart 6 hours postop.

One quick final note regarding ACE inhibitors. It was previously recommended by the ACC/AHA guidelines to continue these medications perioperatively, but subsequent research found an increased risk of hypotension. It’s now recommended that ACE inhibitors and ARBs be held on the day of surgery.

It’s now recommended that ACE inhibitors and ARBs be held on the day of surgery.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References

Fleisher LA, Fleischmann K, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC 2014 Dec 9;64(22):e77-137.
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Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Before Noncardiac Surgery: An Analysis of the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Prospective Cohort. Anesthesiology. 2017 Jan;126(1):16-27.
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Chaya BF, Rodriguez Colon R, Boczar D, et al. Perioperative Medication Management in Elective Plastic Surgery Procedures. Journal Craniofac Surg. 2023 May 1;34(3):1131-1136.
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Smilowitz NR, Berger JS. Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. JAMA. 2020 Jul 21;324(3):279-290.
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Chen A, Stecker E, Warden BA. Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges. J Am Heart Assoc. 2020 Jul 7;9(13):e017559.
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