Annals Consult Guys - A Recent Stroke: Can You Decrease the Risk for Perioperative Stroke?
Authors: Geno J. Merli, Howard H. Weitz
Journal: Annals of Internal Medicine (2021)

Web ExclusivesApril 2021Annals Consult Guys - A Recent Stroke: Can You Decrease the Risk for Perioperative Stroke?FREEGeno J. Merli, MD, Howard H. Weitz, MDGeno J. Merli, MDThomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Search for more papers by this author, Howard H. Weitz, MDThomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/W20-0020 CME/MOC SectionsSupplemental MaterialAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Returning to their favorite topic of perioperative care, the Annals Consult Guys discuss the risk for perioperative stroke and strategies to decrease risk for this potentially devastating perioperative complication.For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys. Comments0 CommentsSign In to Submit A Comment The Consult GuysJefferson University5 January 2022 Author's response Dr. Farmer: Thanks for writing in to the Consult Guys. We appreciate the points that you present. The information that the Consult Guys received about the patient was that “the CVA was the first clinical manifestation of their atrial fibrillation” so we based our strategy and recommendations on the CVA being thromboembolic and a direct result of the atrial fibrillation. We agree with you that proceeding to surgery one day after the last dose of DOAC would be associated with an increased risk of bleeding but we felt that we had to balance the bleeding risk with the risk of major comorbidity if the surgery was delayed more than 24 hours. Added to that risk was the risk of thromboembolism while not fully anticoagulated in this patient with CHA2DS2-VASc score of 5. So based upon clinical judgement and risk – benefit considerations we believed that the best approach was to proceed to surgery with the last dose of DOAC being 24 hours before surgery. Cheryl Farmer MDRetired General Internist, St. Joseph Mercy Hospital, Ann Arbor, MI9 December 2021 Other factors to consider in this pre-op evaluation? Love your discussions! In this case, because his a fib was new, we assumed his CVA was embolic. But at 80, what is the status of his carotids, and if either is severely occluded, how does that impact on his peri-op risk for CVA? Also, should the fact that he will still have some level of DOAC on board factor into his need for pre-op transfusion? (Already anemic and this surgery has high bleeding risk). Inquiring minds want to know. Thanks! Disclosures: Doctor Author, Article and Disclosure InformationAffiliations: Thomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Disclosures: Geno J. Merli, MD, and Howard H. Weitz, MD, report that they have no financial relationships or interests to disclose.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics April 2021Volume 174, Issue 4Page: CG1 ePublished: 20 April 2021 Issue Published: April 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...