A 60-year-old man comes to the office for presurgical evaluation before right total knee replacement. He describes pain and limited mobility due to severe knee osteoarthritis. The patient has gained 4.5 kg (10 lb) over the last 6 months due to decreased physical activity. He has a history of coronary artery disease, hypertension, and hyperlipidemia. Current medications are low-dose aspirin, prasugrel, metoprolol, valsartan, and rosuvastatin.
A year ago, the patient underwent sirolimus-eluting stent implantation into the left anterior descending artery due to angina. Two months ago, echocardiogram showed normal left ventricular systolic function and no wall motion abnormalities.
Which of the following is the best preoperative recommendation for this patient?

Question

A 60-year-old man comes to the office for presurgical evaluation before right total knee replacement.  He describes pain and limited mobility due to severe knee osteoarthritis.  The patient has gained 4.5 kg (10 lb) over the last 6 months due to decreased physical activity.  He has a history of coronary artery disease, hypertension, and hyperlipidemia.  Current medications are low-dose aspirin, prasugrel, metoprolol, valsartan, and rosuvastatin.
A year ago, the patient underwent sirolimus-eluting stent implantation into the left anterior descending artery due to angina.  Two months ago, echocardiogram showed normal left ventricular systolic function and no wall motion abnormalities.
Which of the following is the best preoperative recommendation for this patient?

Quizplus · Accepted Answer

11ec193a_974d_abbe_853d_8dab3c0a2753_MD0002_00 Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor blocker (eg, clopidogrel, prasugrel) is recommended after intracoronary stent placement to prevent stent thrombosis. Current guidelines recommend continuing DAPT for a minimum of 6-12 months after either bare-metal stent or drug-eluting stent placement. In select patients (eg, those with a high risk of bleeding), a minimum duration of 4 weeks can be considered following bare-metal stent placement. Elective surgeries should be postponed until after the minimum duration of DAPT is completed (ie, 6 months in most patients). Once the minimum duration of therapy is completed, it is most appropriate to stop P2Y12 receptor blockers 3-7 days prior to surgery. Unless the surgery carries a high risk of severe bleeding complications, aspirin is continued perioperatively due to evidence that it reduces the risk of thrombotic complications in these patients. Morbidity from bleeding after knee replacement surgery is relatively low, and aspirin should be continued in this patient. (Choice B) Continuing DAPT can be appropriate for patients undergoing minor surgery (eg, dental procedure, skin biopsy). In patients who require surgery prior to the completion of the minimum duration of DAPT therapy, aspirin should be continued perioperatively and a P2Y12 receptor blocker should be held for the shortest time possible. (Choice C) Continuing a P2Y12 receptor blocker and discontinuing aspirin is not a perioperative strategy that is typically recommended. (Choice D) For patients who have undergone stent placement, discontinuing both antiplatelet agents is recommended only for surgeries with a high risk of severe bleeding complications (eg, neurosurgery). (Choice E) This patient underwent drug-eluting stent placement a year ago and has completed the recommended minimum duration of DAPT; there is no need to delay elective surgery. Educational objective: Dual antiplatelet therapy (DAPT) is recommended for a minimum of 6-12 months following placement of either a bare-metal or drug-eluting stent. Elective surgeries should be delayed until the minimum duration of DAPT is completed. At that point, P2Y12 receptor blockers (eg, clopidogrel, prasugrel) should be stopped prior to surgery and aspirin should be continued perioperatively unless there is a high risk of severe bleeding complications (eg, neurosurgery). __________ References: The perioperative management of antithrombotic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). (http://www.ncbi.nlm.nih.gov/pubmed/18574269)

A 60-Year-Old Man Comes to the Office for Presurgical Evaluation