Bypass, strokes and Lou Caplan's call for action

Caplan LR. Translating what is known about neurological complications of coronary artery bypass graft complications into action. Arch Neurol 2009; 66: 1062-1064.

Dr Caplan editorializes about stroke and CABG and distills knowledge into 3 pages and a number of points that can be bulleted.

1. Complications from bypass are increasing as bypass patients are sicker. In 1994, the rate of stroke and delirium after bypass were 2.9 and 7.7 % respectively, at Johns Hopkins Hospital. In 2004, the respective rates were 4.5 and 13.8 %.

2. There is virtually no relationship between carotid disease, especially asymptomatic, and cardiac risk during bypass. In the large series, 95 % had strokes not in the territory of a diseased carotid artery. Of the four patients who did have strokes in the diseased carotid territory, the carotid was occluded in 3 of 4 so the mechanism was not hemodynamic but embolic.

3, Aortic atheromatosis is the most important cause of stroke after bypass, with cardiac factors second. The use of aortic filters, the use of off pump bypass or avoidance of cross clamping and identifying patients in advance results in improved outcomes. Identifying susceptible patients can be done with TEE, chest x ray, chest CT, or intraoperative epiaortic ultrasound before clamping. Most patients have not had this done.

4. ECHO to look at ventricular contractile function and thrombi is often not done but should be done.

5. Identification of a cardiologist and in some cases, neurologist in house to see patient preop would be helpful.

6. Risk of stroke is highest in those with previous TIA or stroke.

hypercoagulation profile based on scenario-Oregon

 NEUROLOGY VENOUS THROMBOSIS PANEL:
- Protein C Activity
- Protein S Activity
- Antithrombin Activity
- Activated Protein C Resistance
- Prothrombin G20210A PCR
- Lupus Anticoagulant
- Anticardiolipin IgG and IgM
- Homocysteine

NEUROLOGY ARTERIAL THROMBOSIS PANEL
- Lupus Anticoagulant
- Anticardiolipin IgG and IgM
- Homocysteine
- Lipoprotein (a)

NEUROLOGY ARTERIAL THROMBOSIS PANEL, WOMEN>40
- Lupus Anticoagulant
- Anticardiolipin IgG and IgM
- Homocysteine
- Lipoprotein (a)
- Activated Protein C Resistance
- Prothrombin G20210A PCR

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Hypercoagulable workup (incl effects warfarin on tests)

hat tip David Gordon, MD Professor/Chairman Neurology at OKL


Hypercoagulable Profile
􀂃 Protein C
􀂃 Protein S free and total
􀂃 Antithrombin III
􀂃 Fibrinogen
􀂃 Factor VII
􀂃 Factor VIII
􀂃 Activated protein C resistance (APCR)
􀂃 Factor V Leiden mutation
􀂃 Prothrombin G20210A mutation
􀂃 Anticardiolipin antibodies
􀂃 Anti-beta-2-glycoprotein I antibodies
􀂃 Antiphosphatidylserine antibodies
􀂃 Lupus anticoagulant
􀂃 Lipoprotein (a)
􀂃 C-reactive protein
􀂃 Methyltetrahydrofolate reductase C677T and A1298C
􀂃 Sickle prep (if African heritage)
Affect of Coumadin on Hypercoagulable Profile
􀂃 Protein C (may be decreased with warfarin)
􀂃 Protein S free and total (may be decreased with warfarin)
􀂃 Antithrombin III (not affected by warfarin)
􀂃 Fibrinogen (not affected by warfarin)
􀂃 Factor VII (may be affected by warfarin)
􀂃 Factor VIII (not affected by warfarin)
􀂃 Activated protein C resistance (must alter methods to compensate for warfarin)
􀂃 Factor V Leiden mutation (not affected by warfarin)
􀂃 Prothrombin 20210 mutation (not affected by warfarin)
􀂃 Anticardiolipin antibodies (not affected by warfarin)
􀂃 Anti-beta-2-glycoprotein I antibodies (not affected by warfarin)
􀂃 Antiphosphatidylserine antibodies (not affected by warfarin)
􀂃 Lupus anticoagulant (screening tests not affected by warfarin, but “mixing studies” to
confirm are affected by warfarin)
􀂃 Lipoprotein (a) (not affected by warfarin)
􀂃 C-reactive protein (not affected by warfarin)
􀂃 Methyltetrahydrofolate reductase C677T and A1298C (not affected by warfarin)
􀂃 Sickle prep (if African heritage) (not affected by warfarin