Elective surgery after recent MI

[Gasper]

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so you get an elective non-cardiac surgery case (intraabdominal), whose patient literally had a full inferior STEMI last week (troponin >2), became bradycardic & cardiogenic shock and ended up in ICU intubated on Dopa & Epi gtt. Echo showed mild global hypokinesis EF 45%, but cath showed diffused vasospasm without significant CAD. She recovered, echo normalized, and barely got discharged. Cardiologist said, well, since she doesn't have CAD and MI was purely due to vasospasm, OK to proceed with elective "low-risk" surgery.

Would you proceed?! Wait 6 weeks or...?! (Cardiologist cleared the pt and your colleague who reviewed the case also OK'd the pt! )

 

[Remxed]

If the case is elective, they should wait. ACC/AHA guidelines recommend waiting > 60 days after MI in the absence of any coronary intervention (i.e. stent). The reason is because the risk of MACE was found to decrease significantly after 60 days.

 

[Gasper]

If the case is elective, they should wait. ACC/AHA guidelines recommend waiting > 60 days after MI in the absence of any coronary intervention (i.e. stent). The reason is because the risk of MACE was found to decrease significantly after 60 days.

That's what I thought too, but I wasn't sure if there's some other guideline that's specific to vasospastic MI... something the cardiologist knows that I don't?! I hate to discredit the cardiologist and colleague but these preop "clearance" puts you between a rock and a hard place... it makes it so much more difficult to explain to a surgeon.

 

[Planktonmd]

The question is why did she have coronary vasospasm? Is it just prinzmetal angina that went too long which means it could happen again? Or was she on cocaine?

 

[kidthor]

That's what I thought too, but I wasn't sure if there's some other guideline that's specific to vasospastic MI... something the cardiologist knows that I don't?! I hate to discredit the cardiologist and colleague but these preop "clearance" puts you between a rock and a hard place... it makes it so much more difficult to explain to a surgeon.

Hence why they should never use the words “clearance” or “cleared”, ever.

 

[GravelRider]

What’s the case? Does the surgeon want to proceed? Most surgeons I work with are more conservative than me. They don’t want post-op complications. Depending on the urgency, I would wait the 60 days. The patient did infarct enough myocardial tissue to cause cardiogenic shock even if it was just vasospasm.

 

[coffeebythelake]

Is the pt on a ccb? I would still wait

 

[jwk]

so you get an elective non-cardiac surgery case (intraabdominal), whose patient literally had a full inferior STEMI last week (troponin >2), became bradycardic & cardiogenic shock and ended up in ICU intubated on Dopa & Epi gtt. Echo showed mild global hypokinesis EF 45%, but cath showed diffused vasospasm without significant CAD. She recovered, echo normalized, and barely got discharged. Cardiologist said, well, since she doesn't have CAD and MI was purely due to vasospasm, OK to proceed with elective "low-risk" surgery.

Would you proceed?! Wait 6 weeks or...?! (Cardiologist cleared the pt and your colleague who reviewed the case also OK'd the pt! )

Amazed that anyone would remotely consider doing a purely elective case on any patient one week post-STEMI.

 

[San Marzano]

This is giving me angina just thinking about it, I'd have to report to the ED for a full workup myself and let my esteemed “colleague” take the case instead.

 

[Planktonmd]

I have to say... bearing the risk of being accused of being not a team player, that cardiologists in general try their best to please the surgeons and the hospital administration by stretching the limits when it comes to the so called "cleared for surgery" stupid concept.
They feel entitled to do that because of the vacuum created by our specialty that historically preferred to sit in the background and just become nursing extenders as long as the money is good.
In an ideal world, a consultant anesthesiologist should be able to acquire the data, evaluate the patient, and finally determine if this patient is actually optimized for the planned surgery or not.
Unfortunately... many of us have been trained and are a accustomed to be the equivalent of a nurse... or a CRNA and that's why these other specialists like cardiologists, internists, or even nurse practitioners feel they can just dictate our anesthetic care.
Please don't deny it... you know that it is the freaking sad reality.

 

[Arch Guillotti]

so you get an elective non-cardiac surgery case (intraabdominal), whose patient literally had a full inferior STEMI last week (troponin >2), became bradycardic & cardiogenic shock and ended up in ICU intubated on Dopa & Epi gtt. Echo showed mild global hypokinesis EF 45%, but cath showed diffused vasospasm without significant CAD. She recovered, echo normalized, and barely got discharged. Cardiologist said, well, since she doesn't have CAD and MI was purely due to vasospasm, OK to proceed with elective "low-risk" surgery.

Would you proceed?! Wait 6 weeks or...?! (Cardiologist cleared the pt and your colleague who reviewed the case also OK'd the pt! )

I would ask your colleague to do the case😱

 

[Gasper]

The question is why did she have coronary vasospasm? Is it just prinzmetal angina that went too long which means it could happen again? Or was she on cocaine?

The etiology of her vasospasm is still mysterious. I can't get a good answer reading all the cardiology & medicine notes. She presented with initial complaints of ITP flare with platelets of 17k with some gum bleeding, bruising and epistaxis. Also c/o abdominal pain. She has a chronic h/o severe gastritis on previous EGD. Later that night, her Hb dropped by 2 and she c/o chest pain and SOB, was found to be in cardiogenic shock / resp failure with inferior STEMI. No tox screen done this time but it was negative 3 previous times. Interestingly, just a month ago, she also presented to a different hospital with mild MI, severe abdominal pain / gastritis with anemia, and ITP flare. Never had cardiology f/u. Maybe it's pain / stress related vasospasm.

 

[Gasper]

What’s the case? Does the surgeon want to proceed? Most surgeons I work with are more conservative than me. They don’t want post-op complications. Depending on the urgency, I would wait the 60 days. The patient did infarct enough myocardial tissue to cause cardiogenic shock even if it was just vasospasm.

Surgery was splenectomy for ITP. Granted, she needs the surgery. However, she responded well to medical management and platelets are well in the hundreds now. She showed up for surgery days after her MI / cardiogenic shock feeling very weak and fatigued. After discussion with surgeon we cancelled the case. I think the outcome would have been quite poor if we had proceeded.

 

[Gasper]

Is the pt on a ccb? I would still wait

yes, CCB plus a nitrate

 

[Guillemot]

Below is a direct quote from the guidelines. Based on this, for a truly elective surgery, I would wait six months. From what you described, your patient's surgery may not be truly elective, but nevertheless the guidelines would seem to indicate that waiting longer is safer. A caveat to this however is that the guidelines do not seem to make a distinction based on the type or etiology of MI.

MACE after noncardiac surgery is often associated with prior CAD events. The stability and timing of a
recent MI impact the incidence of perioperative morbidity and mortality. An older study demonstrated very high
morbidity and mortality rates in patients with unstable angina (41). A study using discharge summaries
demonstrated that the postoperative MI rate decreased substantially as the length of time from MI to operation
increased (0 to 30 days =32.8%; 31 to 60 days =18.7%; 61 to 90 days =8.4%; and 91 to 180 days =5.9%), as did
the 30-day mortality rate (0 to 30 days =14.2%; 31 to 60 days =11.5%; 61 to 90 days =10.5%; and 91 to 180
days =9.9%) (42). This risk was modified by the presence and type of coronary revascularization (coronary
artery bypass grafting [CABG] versus percutaneous coronary interventions [PCIs]) that occurred at the time of
the MI (43). Taken together, the data suggest that ≥60 days should elapse after a MI before noncardiac surgery
in the absence of a coronary intervention. A recent MI, defined as having occurred within 6 months of
noncardiac surgery, was also found to be an independent risk factor for perioperative stroke, which was
associated with an 8-fold increase in the perioperative mortality rate (44).

 

[Gasper]

Below is a direct quote from the guidelines. Based on this, for a truly elective surgery, I would wait six months. From what you described, your patient's surgery may not be truly elective, but nevertheless the guidelines would seem to indicate that waiting longer is safer. A caveat to this however is that the guidelines do not seem to make a distinction based on the type or etiology of MI.

Yes, the guideline doesn’t distinguish the types or etiology of MI. And I agree the longer you wait the lower the risk, in addition to the stroke risk.

Ultimately this patient might not be able to wait 60 days, or 6 months, so it becomes a risk / benefit discussion. With her still being very fatigued less than 2 weeks after full MI / cardiogenic shock she may still be suffering from some post MI cardiomyopathy; I think it’d be too risky to proceed at this point especially with her ITP responding to medical treatment. So we’ll reassess in a month or so.

 

[AdmiralChz]

@Gasper why do you want to this case so bad? Literally no one says it’s a good idea, but you keep making excuses all around. Seriously stop and think about this.

 

[Gasper]

@Gasper why do you want to this case so bad? Literally no one says it’s a good idea, but you keep making excuses all around. Seriously stop and think about this.

No, I don’t want to do the case; I think it’s a bad idea. But with cardiologist & my senior colleague saying ‘yes it’s ok!’ it takes a lot of convincing to tell the surgeon it’s a bad idea.

 

[Arch Guillotti]

No, I don’t want to do the case; I think it’s a bad idea. But with cardiologist & my senior colleague saying ‘yes it’s ok!’ it takes a lot of convincing to tell the surgeon it’s a bad idea.

Have the other guy do it then!

 

[Gas you down]

This is pushing it pretty far. If you don’t feel comfortable doing the case for a myriad of reasons, say so. And your senior colleague sounds like a you know what. Not just for the decision to go forward, but by putting additional pressure on you to proceed. Easy to say why not when your name isn’t on the chart.

 

[deleted59964]

No, I don’t want to do the case; I think it’s a bad idea. But with cardiologist & my senior colleague saying ‘yes it’s ok!’ it takes a lot of convincing to tell the surgeon it’s a bad idea.

you don’t need to convince the surgeon, just the patient...

 

[BobLoblaw78]

Not sure I’d wait 6 months but definitely wait 6-8 weeks. Reassess at that point. You’ll get more respect for not being a doormat. People don’t like lame cancellations. This is not one. Feel reassured and cancel.

 

[T-burglar]

All I would require to do this case is for the cardiologist to have done a comprehensive evaluation and sign off that her vasospastic variant coronary problem is optimized. This isn't a ruptured plaque that needs to cool off before we induce an inflammatory prothrombotic post-surgical state.

The guidelines really assume typical atherosclerotic CAD and probably don’t apply in the same way to vasospastic angina.

 

[deleted59964]

All I would require to do this case is for the cardiologist to have done a comprehensive evaluation and sign off that her vasospastic variant coronary problem is optimized. This isn't a ruptured plaque that needs to cool off before we induce an inflammatory prothrombotic post-surgical state.

The guidelines really assume typical atherosclerotic CAD and probably don’t apply in the same way to vasospastic angina.

you have a lot of faith in your cardiologist colleagues.

 

[coffeebythelake]

All I would require to do this case is for the cardiologist to have done a comprehensive evaluation and sign off that her vasospastic variant coronary problem is optimized. This isn't a ruptured plaque that needs to cool off before we induce an inflammatory prothrombotic post-surgical state.

The guidelines really assume typical atherosclerotic CAD and probably don’t apply in the same way to vasospastic angina.

God forbid something actually happens to the patient. You would be drawn and quartered in the courts.

 

[deleted171991]

This sounds like stunned myocardium in the context of vasospasm. I would like to see a TTE back to baseline, before letting this patient have anesthesia. It's not the time that matters here (as others have said, there is no plaque), it's the functional recovery.

 

[Arch Guillotti]

This sounds like stunned myocardium in the context of vasospasm. I would like to see a TTE back to baseline, before letting this patient have anesthesia. It's not the time that matters here (as others have said, there is no plaque), it's the functional recovery.

Per the OP, the echo is back to normal.

 

[deleted171991]

Per the OP, the echo is back to normal.

My mistake. Thanks. This is what I get for posting after a sleepless night. Residents, watch and learn! 🙂

Let me amend my previous post: this was a STEMI, even if vasospastic. There was myocardial injury. Hence ACC/AHA MI guidelines apply. 60 days, without parole.

Anyway, if she responded to medical management she doesn't need the splenectomy.

 

[Gasper]

My mistake. Thanks. This is what I get for posting after a sleepless night. Residents, watch and learn! 🙂

Let me amend my previous post: this was a STEMI, even if vasospastic. There was myocardial injury. Hence ACC/AHA MI guidelines apply. 60 days, without parole.

Anyway, if she responded to medical management she doesn't need the splenectomy.

exactly my thought. Vasospastic or whatever the etiology was, there was myocardial damage. The myocardium could be slightly stunned even if EF is now 50%; it should be "rested" for 60 days, especially if her ITP can be managed medically for now. The risk clearly outweighs the benefit to proceed with surgery now. I thought the cardiology "clearance" is a bit irresponsible... but ultimately it's us in the O.R. to make the final decision to proceed and take full responsibility.

 

[dpmd]

I am constantly amazed by the patients the cardiologist is willing to claim is not high risk for surgery. I basically treat it as a specific but not sensitive test. If they say high risk i listen. If they say something else i engage my brain some more and make a judgment. But it is easier for me as the surgeon because i have fewer people pushing me to do a case. If I do get pushback or if I am on the fence then I will ask anesthesia to swing by and see what they think (so i can be like "see, I told you it isn't a good idea" in the first case because if I think it is a bad idea they usually aren't going to disagree andnin the second case we can talk and hash out a plan.

 

[MoMoGesiologist]

God forbid something actually happens to the patient. You would be drawn and quartered in the courts.

What is the court going to say? You have a cardiologist saying the patient is optimized. If there is a post op cardiac event, wouldn’t the court go after the cardiologist?

As an anesthesiologist, I don’t get blamed if a surgeon takes out a gallbladder when the real problem was the appendix. The surgeon gets blamed for surgical mistakes. Shouldn’t the cardiologist get blamed for cardiac events? The anesthesiologist would get blamed for airway or anesthesia events.

Asking to increase my understanding of how much specialists are accountable compared to anesthesiologist, not because I think the case should move forward

 

[dpmd]

What is the court going to say? You have a cardiologist saying the patient is optimized. If there is a post op cardiac event, wouldn’t the court go after the cardiologist?

As an anesthesiologist, I don’t get blamed if a surgeon takes out a gallbladder when the real problem was the appendix. The surgeon gets blamed for surgical mistakes. Shouldn’t the cardiologist get blamed for cardiac events? The anesthesiologist would get blamed for airway or anesthesia events.

Asking to increase my understanding of how much specialists are accountable compared to anesthesiologist, not because I think the case should move forward

Put it this way. You are 100% going to be named in the suit. There is probably 0% chance you can get dropped pre trial by trying to put it all on the cardiologist. So you are either going to be dragged into court to try to defend yourself and the plaintiff lawyers are going to do their best to eviscerate you for not following published guidelines, or your malpractice insurer is going to settle. Not something you want any part of.

 

[Aether2000]

Cardiologists estimate risk of perioperative survival in their clearance, not intraoperative risk. Their "clearance" may be useful to the surgeons but are frequently useless to the anesthesiologist. This patient should wait. It is not the cardiologist that will be treating the intraop heart failure and infarction.

 

[Mman]

I am constantly amazed by the patients the cardiologist is willing to claim is not high risk for surgery. I basically treat it as a specific but not sensitive test. If they say high risk i listen. If they say something else i engage my brain some more and make a judgment. But it is easier for me as the surgeon because i have fewer people pushing me to do a case. If I do get pushback or if I am on the fence then I will ask anesthesia to swing by and see what they think (so i can be like "see, I told you it isn't a good idea" in the first case because if I think it is a bad idea they usually aren't going to disagree andnin the second case we can talk and hash out a plan.

I think some of it from the cardiologists is they don't always understand what the surgery will entail. They have risk calculators that call certain types of surgery high risk or low risk, but there can be some pretty broad groups of surgery that aren't all the same. The surgeon and anesthesiologist have a better understanding of how long and involved a case might be as well as things like blood loss that obviously increase risk.

 

[Robotic Wis-Hipple]

What is the court going to say? You have a cardiologist saying the patient is optimized. If there is a post op cardiac event, wouldn’t the court go after the cardiologist?

As an anesthesiologist, I don’t get blamed if a surgeon takes out a gallbladder when the real problem was the appendix. The surgeon gets blamed for surgical mistakes. Shouldn’t the cardiologist get blamed for cardiac events? The anesthesiologist would get blamed for airway or anesthesia events.

Asking to increase my understanding of how much specialists are accountable compared to anesthesiologist, not because I think the case should move forward

You do have a cardiologist saying the patient is cleared here. But you would still be named in the suit and imo you’d still be at risk. There’s a standard of care to be upheld. There are ACC/AHA guidelines that sure, you could argue, and this specific cardiologist likely would argue that the guidelines apply to atherosclerotic plaque rupture etiology and not vasospasm but I would be willing to bet there’s enough cardiologists that would say wait that I’m not betting against. You have anesthesia standard of care which again, I’d bet most would say an MI is an MI and this case is not urgent/emergent.

Just because a consultant steps out on a ledge and opines that it’s ok this does not excuse you from following your own standard of care. The guy had an MI and cardiogenic shock and his spleen isn’t going to be the cause of his death inside of 6mo etc. Follow the guidelines, delay the case.

 

[deleted950463]

Surgery was splenectomy for ITP. Granted, she needs the surgery. However, she responded well to medical management and platelets are well in the hundreds now. She showed up for surgery days after her MI / cardiogenic shock feeling very weak and fatigued. After discussion with surgeon we cancelled the case. I think the outcome would have been quite poor if we had proceeded.

How about splenic embolization by IR to tie her over? Those can be done with just sedation

 

[ArMed]

How are her platelets suddenly back to normal? Did she go into failure after her transfusion? This might not be as elective as initially advertised. Let me play devils advocate and say that A) the cause of her STEMI has since resolved B) Cath is normal. What is going to change in 60 days? Other than her ITP flaring up again and a repeat of this cycle.

 

[Timeoutofmind]

Below is a direct quote from the guidelines. Based on this, for a truly elective surgery, I would wait six months. From what you described, your patient's surgery may not be truly elective, but nevertheless the guidelines would seem to indicate that waiting longer is safer. A caveat to this however is that the guidelines do not seem to make a distinction based on the type or etiology of MI.

just revisiting this issue and came across this thread…

“ In the absence of coronary intervention“ it says

so if someone has gotten a stent, it’s OK to proceed before 60 days?

 

[Aether2000]

This demonstrates the complete uselessness of "cardiac clearance". The cardiologist, who may have never evaluated the patient or their records, may be opining based on their PA who saw the patient for them. In any case, the answer to this particular dilemma is absolutely not.

 

[dannyboy1]

This demonstrates the complete uselessness of "cardiac clearance". The cardiologist, who may have never evaluated the patient or their records, may be opining based on their PA who saw the patient for them. In any case, the answer to this particular dilemma is absolutely not.

The only point of “cardiac clearance” is to defend yourself in event of a bad outcome. I don’t really need his advice to “avoid hypotension and hypoxia”. Weather it will actually work in a court of law is probably case dependent but it’s certainly better than nothing.....

 

[dchz]

Would anyone try to speak with the patient in this case? Nvm Someone already mentioned this.

The etiology of her vasospasm is still mysterious. I can't get a good answer reading all the cardiology & medicine notes. She presented with initial complaints of ITP flare with platelets of 17k with some gum bleeding, bruising and epistaxis. Also c/o abdominal pain. She has a chronic h/o severe gastritis on previous EGD. Later that night, her Hb dropped by 2 and she c/o chest pain and SOB, was found to be in cardiogenic shock / resp failure with inferior STEMI. No tox screen done this time but it was negative 3 previous times. Interestingly, just a month ago, she also presented to a different hospital with mild MI, severe abdominal pain / gastritis with anemia, and ITP flare. Never had cardiology f/u. Maybe it's pain / stress related vasospasm.

Given that history I don't think this case is totally elective. They assumed it was vasospasms because the artery is angiographically normal, but DDx (remember we are doctors too!) also include anemia (causing demand supply mismatch), coronary thrombosis with rapid clot lysis (i'm not an immunologist but i think this is totally possible with ITP), microemboli, myocarditis, and coagulopathy; some of which might be helped with a splenectomy. It is a possibility we wait and the patient has 3 more episodes and actually does worse.

I do agree if she wanted a breast aug we are waiting 6 months. But I think this case is worth talking about with the patient and surgeon and discuss it without a pre-determined prejudice to cancel the case. After all, sometimes our best decision is not a good one. But the patient should be involved and understand everything. I'd delay this case until the patient and the surgeon gets what we're doing in the context of the convoluted picture.

 

[vector2]

so you get an elective non-cardiac surgery case (intraabdominal), whose patient literally had a full inferior STEMI last week (troponin >2), became bradycardic & cardiogenic shock and ended up in ICU intubated on Dopa & Epi gtt. Echo showed mild global hypokinesis EF 45%, but cath showed diffused vasospasm without significant CAD. She recovered, echo normalized, and barely got discharged. Cardiologist said, well, since she doesn't have CAD and MI was purely due to vasospasm, OK to proceed with elective "low-risk" surgery.

Would you proceed?! Wait 6 weeks or...?! (Cardiologist cleared the pt and your colleague who reviewed the case also OK'd the pt! )

The fact that you work in a hospital where the CCU put a cardiogenic shock pt on a dopamine drip in the Year of our Lord Two Thousand and Twenty tells me all I need to know about the cardiology dept there.

 

[dchz]

The fact that you work in a hospital where the CCU put a cardiogenic shock pt on a dopamine drip in the Year of our Lord Two Thousand and Twenty tells me all I need to know about the cardiology dept there.

I know one study in sepsis patients that showed that norepi is superior to dopamine with some pretty convincing evidence.

In low cardiac output state patients, I'm not aware of any study that says any pharmacologic agent is superior to the other, as long as they increase the cardiac output, in a setting of no angiographic evidence of CAD. (obv i prefer MCS like IABP, but may be OP's institution doesn't have it). Isn't dopamine better since it spares alpha 1 here in the setting of "vasospasms"??

I think i need to be educated here as well...

 

[vector2]

I know one study in sepsis patients that showed that norepi is superior to dopamine with some pretty convincing evidence.

In low cardiac output state patients, I'm not aware of any study that says any pharmacologic agent is superior to the other, as long as they increase the cardiac output, in a setting of no angiographic evidence of CAD. (obv i prefer MCS like IABP, but may be OP's institution doesn't have it). Isn't dopamine better since it spares alpha 1 here in the setting of "vasospasms"??

I think i need to be educated here as well...

You’re thinking of the SOAP II trial which compared norepinephrine vs dopa in the treatment of all kinds of shock. Mortality was equivalent in septic and hypovolemic shock groups. There was a trend toward higher mortality with dopa in the cardiogenic shock subgroup analysis and that was statistically significant. Arrhythmia was indisputably more frequent with dopa in all shock types.

https://www.nejm.org/doi/full/10.1056/NEJMoa0907118

From a physiologic standpoint, there also is absolutely no reason to use dopamine for cardiogenic shock because as you titrate up you start hitting all kinds of alpha and beta with various, unpredictable effects. If pt is low CO and with a lowish MAP even in the face of compensatory high SVR, starting some dobutamine will frequently raise the CO and MAP (otoh, in about to die, profoundly low MAP cardiogenic shock I’m starting norepinephrine + [epi or dobut] while I call IC for a IABP or impella). As far as spasm, a bonus effect is that dobutamine increases coronary blood flow in the absence of CAD.

 

[dannyboy1]

Would anyone try to speak with the patient in this case? Nvm Someone already mentioned this.



Given that history I don't think this case is totally elective. They assumed it was vasospasms because the artery is angiographically normal, but DDx (remember we are doctors too!) also include anemia (causing demand supply mismatch), coronary thrombosis with rapid clot lysis (i'm not an immunologist but i think this is totally possible with ITP), microemboli, myocarditis, and coagulopathy; some of which might be helped with a splenectomy. It is a possibility we wait and the patient has 3 more episodes and actually does worse.

Also cocaine...

 

[lunaire]

just revisiting this issue and came across this thread…

“ In the absence of coronary intervention“ it says

so if someone has gotten a stent, it’s OK to proceed before 60 days?

Post intervention, the issue is the dual antiplatelet therapy more than anything else. DAPT is to continue for 30 days after bare metal stent, and at least 3 months after drug eluting stent (depending on the drug). Operating on plavix/brillinta will result in extra bleeding, no question. It is up to the surgeon to decide if the risk of delaying surgery is greater than the risk of bleeding intra/postop.

 

[Timeoutofmind]

See #12

It answered my question.

Elective non cardiac surgery should be 6 months after DES.

The following are key points to remember about the updated guideline on duration of dual antiplatelet therapy (DAPT) in patients with coronary artery disease (CAD):

1. The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y12 inhibitor) in patients with coronary artery disease (CAD).
2. Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference.
3. Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD.
4. Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75–100 mg).
5. In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).
6. In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb).
7. In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).
8. In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue (prolong or extend) DAPT in patients treated with coronary stent implantation.
9. In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa).
10. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).
11. In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y12 inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I).
12. Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).

ACC/AHA Guideline Update on Duration of Dual Antiplatelet Therapy in CAD Patients - American College of Cardiology

www.acc.org

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease | JACC: Journal of the American College of Cardiology

 

[dchz]

Also cocaine...

Cocaine is def on the DDx but it would be one that would make me wait rather than proceed with surgery. I was trying to show that I don't think this is a clear cut wait 6 months case.

 

[Guillemot]

See #12

It answered my question.

Elective non cardiac surgery should be 6 months after DES.

The following are key points to remember about the updated guideline on duration of dual antiplatelet therapy (DAPT) in patients with coronary artery disease (CAD):

1. The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y12 inhibitor) in patients with coronary artery disease (CAD).
2. Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference.
3. Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD.
4. Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75–100 mg).
5. In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).
6. In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb).
7. In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).
8. In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue (prolong or extend) DAPT in patients treated with coronary stent implantation.
9. In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa).
10. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).
11. In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y12 inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I).
12. Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).

ACC/AHA Guideline Update on Duration of Dual Antiplatelet Therapy in CAD Patients - American College of Cardiology

www.acc.org

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease | JACC: Journal of the American College of Cardiology

Although the guidelines state delay surgery(and subsequently may discontinue DAPT) for 6 mo for DES & 30 days for BMS, I think there may be more subtleties in regard risk and whether to proceed.

Note that the duration of elective surgical delay corresponds to recommended DAPT duration for SIHD.

DAPT duration is now recommended to be 12 months in setting of ACS for BMS, DES, CABG, and lysis.

Why is surgical delay/ minimum DAPT duration for elective non-cardiac surgical candidates not longer for those who had ACS? It would appear that they are at greater thrombotic risk.

The guidelines dont seem to address this sufficiently.

Does anyone with more expertise want to comment?