A 65-year-old woman comes to the office for a preoperative evaluation. She is scheduled to undergo a total hip arthroplasty for osteoarthritis in 6 weeks. The patient walks slowly and uses a cane due to hip pain. She has no chest pain or shortness of breath. Her other medical problems include atypical ductal hyperplasia of the breast, gastroesophageal reflux disease, hypertension, and hyperlipidemia. Her mother was diagnosed with breast cancer at age 51, and her father had a myocardial infarction at age 62. She is a lifetime nonsmoker. Medications include amlodipine, naproxen, esomeprazole, rosuvastatin, and tamoxifen. Vital signs are within normal limits. Chest and abdominal examination is unremarkable. The patient asks whether any medication changes are necessary prior to the scheduled surgery. In addition to holding nonsteroidal anti-inflammatory medications 3 days prior to surgery, which of the following is the most appropriate course of action?

Question

A 65-year-old woman comes to the office for a preoperative evaluation.  She is scheduled to undergo a total hip arthroplasty for osteoarthritis in 6 weeks.  The patient walks slowly and uses a cane due to hip pain.  She has no chest pain or shortness of breath.  Her other medical problems include atypical ductal hyperplasia of the breast, gastroesophageal reflux disease, hypertension, and hyperlipidemia.  Her mother was diagnosed with breast cancer at age 51, and her father had a myocardial infarction at age 62.  She is a lifetime nonsmoker.  Medications include amlodipine, naproxen, esomeprazole, rosuvastatin, and tamoxifen.  Vital signs are within normal limits.  Chest and abdominal examination is unremarkable.  The patient asks whether any medication changes are necessary prior to the scheduled surgery.  In addition to holding nonsteroidal anti-inflammatory medications 3 days prior to surgery, which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Although tamoxifen has anti-estrogenic effects in the breast, it exerts estrogen-mimetic effects on the coagulation system and is associated with increased rates of venous thromboembolism (VTE). Risk of VTE is particularly high during the first 2 years of therapy and in those who require prolonged immobilization due to surgery (or travel). As a result, patients who take tamoxifen for primary prophylaxis (as in this patient with atypical ductal hyperplasia) should discontinue the medication 2-4 weeks prior to any surgery associated with a moderate or high risk of VTE (eg, hip replacement). Those on tamoxifen for cancer treatment should discuss perioperative cessation with their oncologist. Procedures associated with a low risk of VTE usually do not require tamoxifen cessation. (Choice A) Proton pump inhibitors (eg, esomeprazole) may have some perioperative benefit as the stress of surgery can increase the risk of gastric mucosal damage. (Choice B) Statin medications may reduce perioperative vascular events. They do not require discontinuation. (Choice D) This patient is on a stable antihypertension regimen with normal vital signs and is expected to undergo hip replacement; she has no indications for long-term beta blocker use (eg, systolic heart failure, prior myocardial infarction). Preoperative initiation of a beta blocker is generally not indicated for patients undergoing noncardiac surgery. (Choice E) Hip replacement surgery is associated with prolonged immobilization and a high risk of thromboembolic events. This patient, who is taking tamoxifen for breast cancer risk reduction, should discontinue the medication to reduce her risk of thromboembolism. Educational objective: Tamoxifen is associated with an elevated risk of venous thromboembolism (VTE). Patients who take tamoxifen for primary prevention of breast cancer should discontinue the medication prior to any surgery associated with a moderate or high risk of VTE (eg, hip arthroplasty). __________

A 65-Year-Old Woman Comes to the Office for a Preoperative