Within the sources used by the EKL, there is limited information which is specific to management of postoperative pain in patients with cardiovascular disease.

However, as these patients are characterized by:

• Receiving anticoagulation therapy.
• Renal insufficiency
• Arterial hypertension

These issues should be addressed when planning postoperative pain management of this patient population.

Condition specific perioperative analgesic issues

• Whenever possible, patients should be given multimodal pain management therapy.

  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.

  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.

Non-selective NSAIDs (nsNSAIDs) and COX-2 inhibitors

The information related to cardiovascular risks associated with use of nsNSAIDs and coxibs is derived from long term treatment data and may not reflect the risk of short-term use in the acute pain setting. According to an FDA publication from 2005 ¹‘short term use of nsSAIDs to relieve acute pain, particularly low doses, does not appear to confer an increased risk of serious CV events (with the exception of valdecoxib in hospitalized patients immediately after coronary artery bypass surgery)’ ANZCA chapter 4.2.3., page 77.

Coxibs and nsNSAIDs are associated with similar rates of cardiovascular effects, in particular myocardial infarction. Naproxen may be associated with a lower risk than other nsNSAIDs and celecoxib may be associated with lower risk than other coxibx and nsNSAIDs overall. ANZCA p xxiii.

The FDA issued a caution about the concomitant use of ibuprofen and immediate release preparations (non enteric coated) aspirin. ‘At least 8 hours should elapse after ibuprofen dosing, before giving aspirin, to avoid significant interference’. There is insufficient data to make any recommendations on the use of enteric coated aspirin (FDA, 2006). ANZCA chapter 4.2.3, cardiovascular effects page 77.

Patient controlled analgesia and regional analgesia techniques

Intravenous Patient Controlled Analgesia provided better analgesia at 48 hours after surgery compared to nurse administered analgesia following cardiac surgery. ANZCA chapter 7, p 171. Epidural analgesia has been shown to improve pain and decrease arrhythmias following cardiac surgery. But early reports of reduced postoperative myocardial infarction and impact on mortality have not been replicated. ANZCA chapter 1.5.3., p 19. See also reference 2 in the recommended reading.

When planning regional analgesia, national guidelines for the administration of regional anaesthesia for patients receiving antithrombotic and thrombolytic therapy should be followed ANZCA chapter 7.4.2., ‘Key messages’ p195.

Summary

There is little information related specifically to cardiac patients within the sources of the EKL. However, postoperative pain management of these patients should take into account that these patients receive anticoagulation therapy and have renal comorbidities. According to an FDA report from 2005, short term use of non-selective NSAIDs to relieve acute pain, particularly low doses, does not appear to confer an increased risk of serious cardiovascular events.

Supplementary reading

1. FDA (2005) Analysis and recommendations for Agency action regarding non-steroidal anti-inflammatory drugs and cardiovascular http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm106201.pdf

2. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012 May;37(3):310-7.