Anesthesia Toolbox Question:

A 79-year-old man presents for multiple infected wound debridement and possible arm amputation following a fall and prolonged immobility on a hard surface. His medical history is significant for transient ischemic attack, intracerebral hemorrhage, prior myocardial infarction 6 years ago, CABG 6 years ago, drug-eluting cardiac stents placed 2 months prior, and stable heart failure. He takes aspirin 81mg and clopidogrel 75mg daily for his stents. His EKG shows sinus rhythm without changes and prior inferior infarct from an EKG 1 year ago. Other laboratory and imaging are unremarkable. Which of the following statements best reflects how you proceed with laboratory workup or surgery? 

A. Hold both aspirin and clopidogrel and delay surgery for 7 days. X

B. Continue aspirin and clopidogrel and proceed to the operating room without further evaluation. ✔

C. Continue the aspirin and hold clopidogrel and delay surgery for 7 days. X

Read the discussion and key information below.

Discussion:

Patients with base metal or drug-eluting stents depend on antiplatelet therapy to reduce the risk of both early and late thrombosis. Thus, management of antiplatelet drugs in patients with coronary stents presenting for surgery is important to balance the risk of surgical bleeding against the risk of stent thrombosis. Based on the American College of Cardiology and the American Heart Association guidelines, dual antiplatelet therapy (DAPT) - usually aspirin and clopidogrel - should be continued for 6-12 months following placement of newer (non-first generation) drug eluting stents or for 1 month following bare metal stent placement. Patients at high ischemic risk and lower bleeding risk may be benefit from longer DAPT. Single antiplatelet therapy should be continued for life following placement of stents. 

In the setting of ongoing antiplatelet medication use and surgery, generally the risk of surgical bleeding is lower than that of coronary thrombosis if the antiplatelet medications are discontinued except in cases where bleeding may occur in closed spaces (e.g., intracranial surgery) or where excessive blood loss is expected. In high-risk cases but emergent cases, clopidogrel therapy should be discontinued and surgery should proceed. For urgent but not emergent high-risk cases, a consensus decision with surgery cardiology, and surgery about the relative risk of holding antiplatelet medications and the timing of surgery should occur. Often, clopidogrel is discontinued 7 to 10 days before proceeding with surgery to avoid an increased risk of bleeding. For elective cases that are not in close spaces or at high-risk for excessive blood loss, surgery should be delayed for 30 days after bare metal stent implantation or 3 months after drug eluting stent implantation. 

In this case, the need for debridement of necrotic and infected tissue and assessment of limb viability is emergent. Also, the relative ease of hemostasis in superficial wounds or a limb stump favor proceeding with surgery in the face of recent aspiring and clopidogrel therapy. Both drugs should be continued in the perioperative period to reduce the risk of stent thrombosis. 

Key Information:

The management of antiplatelet drugs in patients with coronary stents presenting for surgery is important to balance the risk of surgical bleeding against the risk of stent thrombosis. In the setting of ongoing antiplatelet medication use and surgery, generally the risk of surgical bleeding is lower than that of coronary thrombosis if the antiplatelet medications are discontinued except in cases where bleeding may occur in closed spaces (e.g., intracranial surgery) or where excessive blood loss is expected. 

References: 

Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary disease: A report of the A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-115  

Levine GN, Bates ER, Blankenship JC, et al. An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Circulation. 2011;124(23)  

Hillis, LD, Smith P, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Circulation. 2011;124(23) 

Fihn S, Gardin J, Abrams J, et al. 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Circulation 2012;126(25);3097-137.  

O’Gara PT, Kushner F, Ascheim D, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation 2013;127(4): e362- 425.  

Amsterdam E, Wenger N, Brindis R, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Circulation 2014;130(25) e344-426.  

Fleisher L, Fleischmann K, Auerbach A, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2014;130(24):2215-45.  

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