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Preoperative Cardiac Intervention
Case Synopsis
A 65-year-old man is admitted for a colon resection for a nonobstructing cancer. He had a myocardial infarction 4 months ago with placement of a drug-eluting stent. He has been asymptomatic since the stent placement. The patient is currently taking clopidogrel and aspirin, as well as atenolol for his hypertension. Surgery is scheduled for 7 days from now.
The anesthetic management of a patient who presents with a drug-eluting stent is a major challenge for the anesthesiologist, the surgeon, and the cardiologist. Soon after the introduction of percutaneous coronary interventions with coronary stents, there began to appear in the literature a series of case reports of stent thrombosis. The key question for a patient with a prior coronary stent placement is the optimal timing of surgery and management of the antiplatelet agents. Specifically, should the agents be continued or held, given the risks of stent thrombosis versus the risks of increased bleeding in the perioperative period? Acute thrombosis of a coronary stent has been known to lead to myocardial infarction and potentially death.
Problem Analysis
When patients present for surgery who have had a prior drug-eluting stent placed, a key decision preoperatively is when the surgery should be performed (i.e., how long to delay after stent placement) and the management of antiplatelet therapy. In 2016 the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines published a “focused update” on the duration of dual antiplatelet therapy in patients with coronary artery disease. There are no randomized trials of the optimal perioperative strategy including bridging therapy and therefore the recommendations were based on both randomized trials from the nonoperative setting and cohort studies of surgical patients. A second factor is the changes in antiplatelet management based on the generation of drug-eluting stent. The newer stents need shorter therapy because of the lower thrombotic tendency. The key question is the balance of bleeding risk from surgery performed on dual antiplatelet therapy versus thrombotic risk and the development of a myocardial infarction given the time from stent placement and reendothelialization and the use of different antiplatelet agents. The interventional cardiologists may take the anatomy of the stent placement into the calculus to decide on optimal treatment.
Definition
In a patient with a history of coronary stent placement undergoing noncardiac surgery, it is critical to determine (1) the indication for the coronary stent, (2) the type of coronary stent (first or second generation), (3) current antiplatelet therapy, and (4) the urgency of surgery.
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