A 63-year-old man is scheduled for coronary artery bypass surgery. He underwent cardiac catheterization for a 2-month history of effort-limiting angina and was found to have left main coronary artery stenosis. One year ago, the patient underwent drug-eluting stent placement in the right coronary artery. The patient's other medical problems include type 2 diabetes mellitus and obesity. His current medications are low-dose aspirin, clopidogrel, rosuvastatin, metoprolol, and basal-bolus insulin therapy.
Vital signs are within normal limits except for BMI of 35 kg/m². Cardiopulmonary examination is unremarkable.
ECG shows sinus rhythm with normal intervals, minimal voltage criteria for left ventricular hypertrophy, and no pathologic Q waves. The patient's most recent echocardiogram showed a left ventricular ejection fraction of 50% with no regional wall motion or valvular abnormalities.
Which of the following is the most appropriate management of this patient's antiplatelet medication before surgery?

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Quizplus · Accepted Answer

11ec193a_96c1_2377_853d_6f49acb74284_MD0002_00 Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (eg, clopidogrel, prasugrel, ticagrelor) is recommended after intracoronary stent placement to prevent stent thrombosis and subsequent myocardial infarction. Current guidelines recommend uninterrupted DAPT for at least 6-12 months to allow adequate endothelialization of the stent material. After that time, aspirin should be continued indefinitely; the decision to continue the P2Y12 inhibitor is based on bleeding risk and other individual patient factors. The use of P2Y12 inhibitors within 5-7 days of coronary artery bypass graft (CABG) is associated with an increased risk of significant bleeding, with increased requirements for blood transfusion and possible reoperation; current guidelines recommend that these agents be discontinued at least 5-7 days before CABG (Choice A). This patient has received DAPT for the minimum recommended interval and the clopidogrel can be stopped. However, aspirin should be continued through the perioperative period as it has been shown to significantly reduce the rate of early graft occlusion and overall cardiovascular morbidity and mortality (Choices C and D). (Choice B) Enoxaparin bridging is employed for patients on long-acting oral anticoagulants (eg, warfarin) who have conditions (eg, mechanical mitral valve, recent venous thromboembolism) associated with a high risk of thromboembolic complications. It is not needed for patients on DAPT for prior coronary stent placement. Educational objective: In preparation for coronary artery bypass graft, P2Y12 inhibitors (eg, clopidogrel, ticagrelor, prasugrel) should be discontinued at least 5-7 days before surgery to reduce the risk of bleeding complications. Aspirin reduces the rate of early graft occlusion and overall cardiovascular morbidity and mortality and should be continued. __________ References: 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (http://www.ncbi.nlm.nih.gov/pubmed/22064599)

A 63-Year-Old Man Is Scheduled for Coronary Artery Bypass Surgery