cardiac stents and TKA

[lakersbaby]

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how clueless are some cardiologists and ortho surgeons. Cardiologist recommends a patient who had 4 cardiac stents 2 years ago to stop effient AND aspirin 11 days before a total knee arthroplasty. I informed the surgeon that ASA should not be stopped and I am esp concerned with the use of TXA for the case, he tells me that the cardiologist knows better about these things. would you call up this cardiologist and chastise him because i am very tempted to do so.

 

[lakersbaby]

i sent a nicely worded electronic letter to the cardiologist asking what his rationale was. Is that out of line? I am sure he will be offended but man, it seems that he should know this stuff.

 

[Noyac]

TXA should have no bearing on this.

 

[lakersbaby]

TXA should have no bearing on this.

i know thats what the studies show but a lot of those patients are on aspirin perioperatively. regardless of the study it makes me nervous to stop the asa and give txa on a guy with 4 stents

 

[Mman]

i sent a nicely worded electronic letter to the cardiologist asking what his rationale was. Is that out of line? I am sure he will be offended but man, it seems that he should know this stuff.

I once sent a nice electronic note to a cardiologist asking him that if in the future his recommendation was for the patient to continue his beta blocker perioperatively that he should ensure the patient is actually on a beta blocker. They never were. I said WTF am I supposed to do with this recommendation when he shows up for surgery? We did the case, but when something bad happens that's an awful sloppy trail that a lawyer is going to have fun highlighting for the jury.

This particular cardiologist apologized and thanked me for the heads up.

 

[Noyac]

i know thats what the studies show but a lot of those patients are on aspirin perioperatively. regardless of the study it makes me nervous to stop the asa and give txa on a guy with 4 stents

Why?

 

[Planktonmd]

The cardiologist is the consultant here and he is obviously willing to take full responsibility for stopping the anticoagulants, so let him take that responsibility.

 

[nap$ter]

The cardiologist is the consultant here and he is obviously willing to take full responsibility for stopping the anticoagulants, so let him take that responsibility.

i think you're being sarcastic here - can't tell with plank sometimes.

in this scenario, i call the surgeon or cardiologist, give the patient a full strength asa, and proceed. i also don't give TXA to cardiac stent patients. putative risk> putative benefit imho.

just yesterday i saw a preop pt for TKA - h/o afib ablated 3 yrs ago with no recurrence. cardiologist wrote him for a single (goodly) dose of metoprolol XR times 1 for the night before surgery for "h/o afib" (the pt is not chronically beta-blocked, HR in clinic was 84, NSR). i called the cardiologist and suggested we not do that, this time or ever again. he just hadn't considered the hypotension and stroke risk that would likely ensue (despite the incessant rec to "avoid hypotension" from his specialty)...

 

[deleted59964]

N Engl J Med. 2014 Apr 17;370(16):1494-503

 

[lakersbaby]

N Engl J Med. 2014 Apr 17;370(16):1494-503

Yeah but is this for just anyone taking aspirin or specifically patients with cardiac stents taking aspirin? Those are two very different scenarios.


http://www.ncbi.nlm.nih.gov/pubmed?term=25274620

" Perioperative aspirin (adjusted OR 0.27, 95 % CI 0.11-0.71, p=0.008) was significantly associated with a lower risk of MACE. The overall incidence of BARC ≥ 2 bleeding events at 30-days was significantly higher in patients who discontinued oral antiplatelet therapy (25.6 % vs 13.9 %, p< 0.001). However, after adjustment, antiplatelet discontinuation was not independently associated with BARC ≥ 2 bleeding. In conclusion antiplatelet discontinuation increases the 30-day risk of MACE, in patients with coronary stents undergoing cardiac and non-cardiac surgery, while not offering significant protection from BARC≥ 2 bleeding."

 

[deleted59964]

thanks for that - I hadn't seen that study.

poise 2 is a prospective double blinded placebo controlled RCT with 10,000 patients - so I wouldn't dismiss it too easily based on a retrospective observational study.

about 5 % of poise 2 patients had history of CABGs, and about 4% had stents.

i think it's often difficult to know what even large studies mean for any given patient in front of you ... number of stents, type of stent, location of stent, duration since stent, etc... so many factors.

 

[lakersbaby]

I once sent a nice electronic note to a cardiologist asking him that if in the future his recommendation was for the patient to continue his beta blocker perioperatively that he should ensure the patient is actually on a beta blocker. They never were. I said WTF am I supposed to do with this recommendation when he shows up for surgery? We did the case, but when something bad happens that's an awful sloppy trail that a lawyer is going to have fun highlighting for the jury.

This particular cardiologist apologized and thanked me for the heads up.

I sent a nicely worded letter to the cardiologist basically just asking him what his opinion was on the situation and that the surgeon defers to his judgement. No matter how nice I write it though he will probably take offense. No one likes being challenged on their judgement especially when its their "expertise".

 

[fakin' the funk]

how clueless are some cardiologists and ortho surgeons. Cardiologist recommends a patient who had 4 cardiac stents 2 years ago to stop effient AND aspirin 11 days before a total knee arthroplasty. I informed the surgeon that ASA should not be stopped and I am esp concerned with the use of TXA for the case, he tells me that the cardiologist knows better about these things. would you call up this cardiologist and chastise him because i am very tempted to do so.

Talk to your surgeon (nicely), let him/her know that you are worried about a potentially fatal thrombosis happening in this patient off DAPT.

Assuming the surgeon is halfway reasonable and also believes that a non-negligible risk of dying on the table (or on the ward) is a bad thing, you have pt chew a ASA325 in preop and everyone's happy.

 

[chessknt]

From a cards perspective, that asa is not critical to stent function on a daily basis 2 years out. It is epithelialized. Dapt has only been well supported 1 year from des placement. Are you,worried the stent will go down from an acute in stent thrombus because hes off asa for a week going in to surgery?

 

[GaseousClay]

From a cards perspective, that asa is not critical to stent function on a daily basis 2 years out. It is epithelialized. Dapt has only been well supported 1 year from des placement. Are you,worried the stent will go down from an acute in stent thrombus because hes off asa for a week going in to surgery?

Then how long can they stay off Asa without risk? 2 weeks? Months? Forever? The reality is we don't know exactly and I think in this case the benefit of keeping the aspirin outweighs the benefit of stopping it.

 

[fakin' the funk]

Are you,worried the stent will go down from an acute in stent thrombus because hes off asa for a week going in to surgery?

Not only are you taking him off his antiplatelet rx (which he otherwise would have continued probably lifetime), you're also creating a prothrombotic state with surgery.

So, yes, we're worried about that.

 

[chessknt]

From my understanding a cardiologist is not worried about in-stent thrombosis that far out. ASA is given for known CAD with elevated risk of plaque rupture (much much more likely in a non-stented area) rather than a risk of stent thrombosis. If he had low grade known coronary disease without a stent on ASA would you feel the same way?

There is not enough data in this specific group of people to support DAPT 2 years out in a normal outpatient setting so I imagine there probably isnt enough to support it in an intraoperative setting either. Not saying it is wrong, but continuing ASA because the stent instead of his risk from CAD alone is probably incorrect.

 

[Noyac]

I'm not Blade so I don't have search skills for studies. But I believe the recent literature does not support ASA in this scenario.

 

[Noyac]

Talk to your surgeon (nicely), let him/her know that you are worried about a potentially fatal thrombosis happening in this patient off DAPT.

Assuming the surgeon is halfway reasonable and also believes that a non-negligible risk of dying on the table (or on the ward) is a bad thing, you have pt chew a ASA325 in preop and everyone's happy.

I'm not sure I see it this way.
What's your line?
These stents are 2yrs old.

 

[GaseousClay]

If the cardiologist isn't worried about the stent why is pt on effient and asa for 2 yrs?

 

[nap$ter]

Not only are you taking him off his antiplatelet rx (which he otherwise would have continued probably lifetime), you're also creating a prothrombotic state with surgery.

So, yes, we're worried about that.

this.

cardiologists don't worry about a lot of things we do worry about and vice versa. different worlds, different concerns.

 

[nap$ter]

I'm not sure I see it this way.
What's your line?
These stents are 2yrs old.

the risk of stent thrombosis is death.

the downside of continuing asa is (unproven) slightly increased blood loss?

i have yet to meet a surgeon insisting on discontinuing asa in a pt c cardiac stents...

i don't allow discontinuation of aspirin in patients c cad risk factors without stents, either.

this is decent recent review:

Aspirin in the perioperative period: a review of the recent literature.
Kiberd MB, et al. Curr Opin Anaesthesiol. 2015.