One picture takes you to comprehensively optimize the treatment of elderly patients with preoperative cerebrovascular diseases and old strokes (collection is recommended)

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4 Optimal treatment of elderly patients with preoperative cerebrovascular disease and old stroke 2.
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1 Risk factor control 2.
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1 Hypertension treatment Hypertension is the most important risk of stroke and TIA Factors
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For patients with ischemic stroke and TIA combined with hypertension, antihypertensive therapy is recommended [21]
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When lowering blood pressure, it is necessary to consider advanced age, basal blood pressure, usual medication and patient tolerability, the general goal should be ≤140/90 mm Hg, ideally ≤130/80 mm Hg[22, 23]
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In addition, patients with ischemic stroke or TIA of different etiologies have different target values ​​for blood pressure reduction, although there is still no basis: (1) For small subcortical strokes caused by small vessel disease, it is recommended to control systolic blood pressure <130mmHg [24 ]; (2) Acute ischemic stroke or TIA caused by hypoperfusion caused by intracranial and extracranial artery stenosis, early blood pressure reduction may aggravate cerebral hypoperfusion and cause stroke aggravation or recurrence [25].
At this time, the blood pressure reduction should be weighed The effect of speed and amplitude on cerebral perfusion
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[Recommendation] For patients with ischemic stroke and TIA combined with hypertension, antihypertensive therapy is recommended.
The general goal is ≤140/90 mm Hg, and the ideal is ≤130/80 mm Hg; according to different causes, the blood pressure reduction goal can be Make adjustments accordingly
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2 Blood glucose control 60% to 70% of patients with ischemic stroke have abnormal glucose metabolism or diabetes [26]
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For young diabetic patients, strict blood sugar control from the beginning of the disease can reduce the risk of diabetic microvascular complications
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For patients with diabetes or prediabetes, life>
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However, a recent systematic review pointed out that there are not enough RCT studies to prove the effect of strict blood glucose control in elderly patients or patients with macrovascular diseases; specific blood glucose control indicators and treatment goals need to take into account the patient’s age, disease progression, and age.
The ability of vascular disease, life>
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[Recommendation] It is recommended to control glycosylated hemoglobin (H7bA1c) before operation in elderly patients at <7%
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2 Anti-platelet aggregation therapy Anti-platelet aggregation therapy is an important measure for secondary prevention of ischemic stroke and transient ischemic attack
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However, the use of antiplatelet drugs in the perioperative period is still controversial.
Stopping antiplatelet drugs will increase the risk of recurring cerebral infarction [29], but continued use may increase the risk of surgical bleeding [30]
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The 2014 ESC/ESA guidelines and the 2016 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines believe that the use of aspirin during the perioperative period should be weighed against the risk of bleeding in different types of surgery and the risk of thrombosis in patients.
Comprehensive assessment of individual risks and benefits [16, 31]
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The American College of Chest Physicians recommends the use of thrombosis and bleeding risk stratification strategies (tables 4, 5) and the HAS-BLED score (table 6) to assess bleeding risk [7, 32-34]
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For patients using dual antiplatelet drugs, if it is an elective operation, it is recommended to postpone the operation until the end of the dual antiplatelet drug course
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If surgery must be performed and the risk of surgical bleeding is high, stop clopidogrel for 5 to 7 days and continue to use aspirin
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If the patient has previous coronary heart disease and a coronary stent is placed, the current guidelines recommend: (1) Postpone the elective surgery until the end of the course of dual antiplatelet drugs, and continue to use aspirin as much as possible in the follow-up treatment
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Patients with stable coronary heart disease who have previously placed bare metal stents are recommended to postpone elective surgery to at least 4 weeks, preferably 3 months, and continue to use as much as possible in the perioperative period on the basis of weighing the risk of surgical bleeding and stent thrombosis.
Aspirin
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For the first-generation drug-eluting stent, the dual antiplatelet application is up to 12 months; for the second and third-generation drug-eluting stents, the dual antiplatelet application is up to 6 months
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For patients with acute coronary syndrome, no matter what kind of stent, dual antiplatelet should be used for up to 12 months
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(2) For limited-time surgery, whether it is stable coronary heart disease or acute coronary syndrome, it is recommended that the double antibody treatment of the bare metal stent lasts for 4 weeks, and the drug-eluting stent (new generation) to 3 months
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 Table 4.
Types of surgery and bleeding risk [7, 32] Moderate to high risk low risk Neurosurgery dermatology minor surgery such as skin biopsy, spinal surgery, cataract or glaucoma surgery, urological surgery, dental surgery such as uncomplicated tooth extraction, vascular surgery, cholecystectomy Gastrointestinal surgery-large intra-abdominal surgery biopsy breast surgery intra-articular drainage or injection thoracic surgery invasive eye surgery orthopedic surgery pacemaker or ICD implantation liver tissue biopsy ICD: embedded cardioversion defibrillator Table 5 .
Thromboembolic risk sub-risk [7, 32] high risk a medium risk low risk mechanical heart valve any mechanical mitral valve cage valve or tilt valve aortic valve implantation recent (within 6 months) stroke or Transient ischemic attack 1.
Two-leaflet aortic valve implantation combined with one or more of the following risk factors: atrial fibrillation, previous stroke or TIA hypertension, diabetes, congestive heart failure, age> 75 years old, two-leaflet aortic valve implantation Not accompanied by atrial fibrillation or other risk factors that cause stroke.
Atrial fibrillation has rheumatic valvular disease.
Recently (within 3 months) stroke or TIACHADS2 score of 5-6 points CHADS2 score of 3 to 4 points CHADS2 score 0-2 (Presumably no history of stroke or TIA) Venous thromboembolism Venous thromboembolism within 3 months Severe thrombotic tendency (protein C, S or antithrombin deficiency or antiphospholipid antibody; multiple abnormalities) 3-12 months Venous thromboembolism recurrence Venous thromboembolism not serious thrombotic tendency (such as heterozygous V Leiden mutation or prothrombin gene mutation) cancer (within 6 months or palliative treatment) 12 months prior to venous thrombosis or no other risk factors injection : CHADS2 score includes risk factors: (1) congestive heart failure, (2) hypertension, (3) diabetes, (4) age> 75 years, (5) history of stroke or TIA, thromboembolism, each score is 1 point, 2 points for stroke or TIA attack or thromboembolism history
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High-risk patients, including patients with stroke or TIA 3 months before elective surgery, patients whose CHADS2 score is less than 5, and patients who have formed thromboembolism during the interruption of vitamin K antagonists, and those who are undergoing certain types of surgery have increased Patients at risk of stroke or other thromboembolism (eg, heart valve replacement, carotid endarterectomy, large vessel surgery)
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 Table 6.
HAS-BLED[33] Clinical manifestation score H Hypertension 1A Abnormal liver and kidney function (one point for each item) 1/2S stroke 1B bleeding history or tendency to bleeding easily 1L unstable INR1E old age (>65 years old) 1D drugs Or alcohol (one point for each item) 1/2 Note: Hypertension: systolic blood pressure> 160mmHg; Bleeding: Except for hemorrhagic stroke, any bleeding that needs treatment and/or hemoglobin reduction 2g/L and/or inducement of bleeding such bleeding diathesis, anemia
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Hemorrhagic stroke: Sudden central nervous system dysfunction, diagnosed by a neurologist, lasting more than 24 hours
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Abnormal renal function: chronic kidney dialysis or kidney transplantation, blood creatinine ≥200μmol/L
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Liver damage: Chronic liver diseases such as liver cirrhosis or abnormal biochemical indicators: bilirubin exceeds the upper limit of normal 2 times and aspartate aminotransferase/alanine aminotransferase exceeds the upper limit of normal 3 times
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Unstable INR: INR value is variable/high or does not reach the treatment range (such as <60%); drugs: antiplatelet drugs (aspirin or clopidogrel), non-steroidal anti-inflammatory drugs
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Alcohol: >8 U/wk
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Points ≥ 3 points indicate "high risk".
Whether patients at high risk of bleeding receive warfarin or aspirin treatment, they should be cautious, and regularly review and deal with correctable bleeding risk factors after starting antithrombotic therapy
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 At present, there are few clinical studies on clopidogrel and dipyridamole, but it is generally believed that clopidogrel should be stopped 7 days before non-cardiac surgery, and dipyridamole should be stopped 7 to 10 days before surgery
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For patients with high risk of perioperative thrombosis, low molecular weight heparin can be used for bridging after discontinuation of antiplatelet therapy
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[Recommendation] For patients who have taken antiplatelet drugs for a long time before surgery, it is necessary to decide whether to stop before surgery, the type of discontinuation, the time of discontinuation, and the alternative plan based on the surgical site, the size of the trauma, and the risk of perioperative bleeding/thrombosis.
The risk of bleeding/thrombosis during the perioperative period is minimized
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3 Whether oral anticoagulant treatment of stroke patients needs to continue anticoagulant treatment before surgery, it is necessary to balance the risk of thrombosis caused by stopping the drug and the risk of bleeding caused by continued drug use.
There is no best management strategy
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For patients treated with warfarin, surgery with a lower risk of bleeding can continue to be used [35, 36]; if the risk of bleeding and trauma is large, it is recommended to stop using it for 5-7 days before surgery [37-39] and switch to low-molecular-weight heparin Bridging therapy can reduce the relative risk of thromboembolism by 66 to 80% [40, 41]
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For patients with new oral anticoagulants such as dabigatran and rivaroxaban, due to their short half-life [42, 43], it can be in the range of 24-96 hours before surgery according to the preoperative renal function and the risk of surgical bleeding The drug is stopped internally, see Table 7 for the specific stop time.
For patients with normal renal function, preoperative bridging therapy is not necessary [7]
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 Table 7.
Preoperative stopping time of new oral anticoagulants, creatinine clearance rate (ml/min) stopping time (h) bleeding risk, rivaroxabandabigatran ≥80 low ≥24≥24 high ≥48≥4850~ 79 Low ≥ 24 ≥ 36 High ≥ 48 ≥ 7230~49 Low ≥ 24 ≥ 48 High ≥ 48 ≥ 96 15 to 29 Low ≥ 36 No evidence High ≥ 48 No evidence ＜ 15 Such drugs cannot be used [Recommendation] Oral Chinese medicine before surgery For patients treated with legal anticoagulation, if the trauma is severe and the risk of bleeding is high, it is recommended to stop warfarin for 5 to 7 days before surgery and use low molecular heparin for replacement therapy
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Patients who take short-acting anticoagulants orally before surgery do not need bridging treatment, and the drug can be stopped within 24 to 96 hours before surgery based on renal function and risk of surgical bleeding
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For patients with a lower risk of bleeding, warfarin does not need to be discontinued before surgery
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4 Use of β-blockers In the POISE study, perioperative use of metoprolol sustained-release agents can reduce cardiovascular mortality and the incidence of acute myocardial infarction, but it increases the postoperative brain of non-cardiac surgery patients.
The incidence of stroke (hazard ratio 2.
17, 95% CI 1.
26~3.
74; P=0.
0053) and overall mortality [44]
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However, in observational opinions, long-term use of β-blockers (³30 days) before surgery does not increase the risk of perioperative stroke [45]
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The 2014 guidelines of the American ACC/AHA Association recommend that the use of β-blockers during the perioperative period requires a balance between the risk of major adverse cardiovascular events (MACE) and the risk of perioperative stroke [46]
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It is currently believed that patients who have been taking β-blocker drugs for a long time before surgery can continue to take them
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[Recommendation] For patients who take β-blocking drugs for a long time before surgery, they can be taken orally until the morning of the operation day; whether β-blocking drugs should be given during the perioperative period should be carried out between the prevention of cardiovascular events and the risk of acute stroke Weigh
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5 Statins The use of statins can reduce the incidence of atrial fibrillation and other risk factors that may be related to stroke
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Interruption of statin therapy may impair vascular function
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Current evidence suggests that if stroke patients have been taking statins for a long time, they should continue to take them before surgery [47]
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In actual work, the target value of LDL-C is still an important reference for clinicians to evaluate the efficacy and compliance of statin therapy.
It is recommended that LDL-C be controlled at <2.
5mmol/L (100mg/d1), with LDL-C <1.
8 mmol/L (70mg/d1) is the best [14, 21]
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[Recommendation] Patients who have taken statins for a long time before surgery can continue to take them during the perioperative period
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5 Surgery timing selection based on the risk of perioperative stroke and postoperative outcome.
Studies have shown that recent strokes, especially strokes within 3 months, have a higher incidence of cardiovascular events after non-cardiac surgery [OR 14.
23, 95% CI (11.
61~17.
45)], 30-day mortality rate increased [OR 3.
07, (95%CI, 2.
30~4.
09)][48]
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Therefore, for patients with recent stroke or transient ischemic attack (TIA), it is safer to postpone elective surgery until 3 months later [49]
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In the case of emergency and limited-time surgery, the perioperative blood pressure should be maintained at the baseline level to within 20% above the baseline.
It is recommended to implement goal-oriented fluid management combined with preventive vasoconstrictor drugs under continuous arterial pressure monitoring to ensure cerebral blood perfusion[ 50]
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If conditions are available, it is recommended to monitor the depth of anesthesia sedation and non-invasive cerebral oxygen saturation, and implement individualized brain function protection strategies
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[Recommendation] For patients with recent stroke or TIA, elective surgery is recommended to be postponed until 1 to 3 months later; emergency or limited surgery patients should fully weigh the risks and benefits, and continuous arterial pressure monitoring and goal-oriented fluid management should be implemented during the perioperative period Combined with preventive vasoconstrictor drug therapy, the patient's blood pressure is maintained at baseline to 20% above baseline
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When conditions are available, individualized brain function protection strategies can be implemented in combination with the depth of anesthesia sedation and non-invasive brain oxygen saturation monitoring
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