A 60-year-old man comes to the office for presurgical evaluation before right-sided total knee replacement. He has pain and limited mobility due to severe knee osteoarthritis, and has gained 4.5 kg (10 lb) over the last 6 months due to decreased physical activity. Other medical problems include coronary artery disease, hypertension, and hyperlipidemia. Four months ago, the patient underwent sirolimus-eluting stent implantation into the left anterior descending artery due to angina. Current medications are low-dose aspirin, prasugrel, metoprolol, valsartan, and rosuvastatin.
ECG shows sinus rhythm with no pathologic Q waves or ST-segment abnormalities. Echocardiogram shows normal left ventricular systolic function and no wall motion abnormalities.
Which of the following is the best recommendation for this patient before surgery?

Question

A 60-year-old man comes to the office for presurgical evaluation before right-sided total knee replacement.  He has pain and limited mobility due to severe knee osteoarthritis, and has gained 4.5 kg (10 lb) over the last 6 months due to decreased physical activity.  Other medical problems include coronary artery disease, hypertension, and hyperlipidemia.  Four months ago, the patient underwent sirolimus-eluting stent implantation into the left anterior descending artery due to angina.  Current medications are low-dose aspirin, prasugrel, metoprolol, valsartan, and rosuvastatin.
ECG shows sinus rhythm with no pathologic Q waves or ST-segment abnormalities.  Echocardiogram shows normal left ventricular systolic function and no wall motion abnormalities.
Which of the following is the best recommendation for this patient before surgery?

Quizplus · Accepted Answer

11ec193a_974e_20ef_853d_83bc38ec1b25_MD0002_00 Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (eg, clopidogrel, prasugrel, ticagrelor) is recommended after intracoronary stent implantation to prevent stent thrombosis and subsequent myocardial infarction. Current guidelines recommend uninterrupted DAPT for at least 6-12 months after stent implantation to allow adequate endothelialization of the stent material. After that time, aspirin should be continued indefinitely. Whenever possible, elective noncardiac surgery should be postponed until at least 6 months after stent placement (or 1 month after bare-metal stent placement). If surgery cannot be delayed, DAPT (or at least aspirin alone) should be continued throughout the perioperative period to minimize the risk of catastrophic stent thrombosis. However, both drugs may need to be discontinued in patients undergoing surgery in which perioperative bleeding may cause significant morbidity, such as neurosurgery (Choice D). (Choices A and C) This patient had DES placement 4 months ago and needs DAPT with aspirin and prasugrel for a minimum of 2 more months. Whenever possible, elective surgery should be postponed until the minimum recommended duration of DAPT is completed. (Choice B) Continuing both aspirin and prasugrel increases the risk of perioperative bleeding; delaying surgery is preferred. Educational objective: Current guidelines recommend uninterrupted dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (eg, clopidogrel, prasugrel, ticagrelor) for at least 6-12 months after intracoronary stent placement. Whenever possible, elective noncardiac surgery should be postponed until the minimum recommended duration of dual antiplatelet therapy is completed. __________ References: 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. (http://www.ncbi.nlm.nih.gov/pubmed/27026020)

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