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Preoperative management of antiplatelet drugs for a coronary artery stent: how can we hit a moving target?

Vetter TR, Hunter JM, Boudreaux AM - BMC Anesthesiol (2014)

Bottom Line: We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.However, there is significant variance and inadequacy with these current applicable professional society guidelines.Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, 619 19th Street South, JT804, Birmingham, AL 35249-6810, USA.

ABSTRACT

Background: With the advent of percutaneous coronary intervention, specifically the bare metal stent and subsequently, the drug-eluting stent, the scope of interventional cardiology has greatly increased. Aspirin, in combination with a thienopyridine is the present-day cornerstone of oral antiplatelet therapy after coronary artery stent placement. Continuing this chronic antiplatelet therapy, to mitigate a perioperative major adverse cardiac event, can be challenging and remains controversial in patients with a coronary artery stent undergoing non-cardiac surgery. We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.

Discussion: A recent systematic review identified 11 clinical practice guidelines for the perioperative management of antiplatelet therapy in patients with a coronary stent who need non-cardiac surgery. However, there is significant variance and inadequacy with these current applicable professional society guidelines. Moreover, persistently variable success has been experienced in translating even well-grounded national clinical guidelines into local practice, including in the perioperative setting. Under the auspices of a broadly multidisciplinary institutional task force and applying the Consensus-Oriented Decision-Making model, we created two evidence-informed and local expert opinion-supported standardized clinical assessment and management plans for the preoperative management of antiplatelet therapy in patients with a coronary artery stent.

Summary: Patient care can be optimized via evidence-based, yet locally developed and reiterative standardized clinical assessment and management plans for patients with coronary artery stents undergoing surgical procedures. Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

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Related in: MedlinePlus

The Seven Steps Involved in the Consensus-Oriented Decision-Making (CODM) model [29].
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Related In: Results  -  Collection

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Figure 3: The Seven Steps Involved in the Consensus-Oriented Decision-Making (CODM) model [29].

Mentions: Over a 12-month period, our multidisciplinary anticoagulation task force applied the Consensus-Oriented Decision-Making (CODM) model to arrive at a consensus among the local clinical stakeholders. A detailed, step-wise process, the CODM model can be applied in any type of decision-making process (Figure 3). It outlines a process in which proposals can be collaboratively built with full participation of all stakeholders [29]. Consensus decision-making does not require unanimity but instead seeks the agreement of the majority of participants as well as the resolution or mitigation of minority held objection [30]. We took into consideration previously published applicable guidelines and other literature to create two evidence-informed protocols (see Additional file 1). These two protocols are presented here as suggested clinical management approaches.


Preoperative management of antiplatelet drugs for a coronary artery stent: how can we hit a moving target?

Vetter TR, Hunter JM, Boudreaux AM - BMC Anesthesiol (2014)

The Seven Steps Involved in the Consensus-Oriented Decision-Making (CODM) model [29].
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4151077&req=5

Figure 3: The Seven Steps Involved in the Consensus-Oriented Decision-Making (CODM) model [29].
Mentions: Over a 12-month period, our multidisciplinary anticoagulation task force applied the Consensus-Oriented Decision-Making (CODM) model to arrive at a consensus among the local clinical stakeholders. A detailed, step-wise process, the CODM model can be applied in any type of decision-making process (Figure 3). It outlines a process in which proposals can be collaboratively built with full participation of all stakeholders [29]. Consensus decision-making does not require unanimity but instead seeks the agreement of the majority of participants as well as the resolution or mitigation of minority held objection [30]. We took into consideration previously published applicable guidelines and other literature to create two evidence-informed protocols (see Additional file 1). These two protocols are presented here as suggested clinical management approaches.

Bottom Line: We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.However, there is significant variance and inadequacy with these current applicable professional society guidelines.Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, 619 19th Street South, JT804, Birmingham, AL 35249-6810, USA.

ABSTRACT

Background: With the advent of percutaneous coronary intervention, specifically the bare metal stent and subsequently, the drug-eluting stent, the scope of interventional cardiology has greatly increased. Aspirin, in combination with a thienopyridine is the present-day cornerstone of oral antiplatelet therapy after coronary artery stent placement. Continuing this chronic antiplatelet therapy, to mitigate a perioperative major adverse cardiac event, can be challenging and remains controversial in patients with a coronary artery stent undergoing non-cardiac surgery. We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.

Discussion: A recent systematic review identified 11 clinical practice guidelines for the perioperative management of antiplatelet therapy in patients with a coronary stent who need non-cardiac surgery. However, there is significant variance and inadequacy with these current applicable professional society guidelines. Moreover, persistently variable success has been experienced in translating even well-grounded national clinical guidelines into local practice, including in the perioperative setting. Under the auspices of a broadly multidisciplinary institutional task force and applying the Consensus-Oriented Decision-Making model, we created two evidence-informed and local expert opinion-supported standardized clinical assessment and management plans for the preoperative management of antiplatelet therapy in patients with a coronary artery stent.

Summary: Patient care can be optimized via evidence-based, yet locally developed and reiterative standardized clinical assessment and management plans for patients with coronary artery stents undergoing surgical procedures. Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

Show MeSH
Related in: MedlinePlus