A 65-year-old female with a PMH notable for paroxysmal atrial fibrillation and recent coronary stent placement presents to your office for preoperative evaluation for repair of a ventral hernia. She has had the hernia for many years; however, it has recently begun to cause some occasional discomfort after she stands for prolonged periods of time. The hernia has always been easily reducible, and she has had no previous episodes of bowel obstruction related to it. With regard to her cardiovascular history, in addition to the paroxysmal a-fib, she reports poorly controlled hypertension, diabetes, and a transient ischemic attack a few years ago. Since that time, she has been taking warfarin. One month ago she underwent cardiac stress testing that demonstrated ST changes in the inferior leads resulting in cardiac catheterization and deployment of a drug-eluting stent. An echocardiogram demonstrated an ejection fraction of 35%. Plavix was added to her medical regimen and she has been doing quite well since that time. She denies any ongoing chest pain or dyspnea on exertion.
1. Should this patient’s hernia repair be delayed?
2. If the patient undergoes an elective hernia repair 12 months later, should Plavix and warfarin be held?
Perioperative Anticoagulation and Antiplatelet Drugs
Perioperative management of anticoagulation and antiplatelet drugs can often be overwhelming for the junior resident since improper decision making can have serious consequences. Moreover, this area of perioperative medicine has been involved in the highest number of litigation events. These facts are only stated to emphasize that a multidisciplinary approach should be encouraged in dealing with perioperative anticoagulation. Typically, the decision should at a minimum include the patient, the surgeon, and the patient’s primary care physician or cardiologist. That being said, there is no reason for this subject to cause intimidation as there is an algorithmic and methodical way to go about dealing with it.
The first question that should always be considered is whether or not the procedure is elective or emergent, and if elective, whether the procedure should be delayed. Regardless of whether or not anticoagulants will be held, the timing of an operation can have a significant impact on the risk of postoperative thrombotic complications. For example, patients who have experienced venous thromboembolism are at the highest risk for recurrence within the first three months. Likewise, patients who have experienced an arterial embolic event from a cardiac source have a risk of recurrence of 0.5% per day in the first month. Finally, in the case of antiplatelet agents that were started for coronary stent placement, it is recommended that these medications be continued through the perioperative period if the stent was placed less than six weeks prior for bare metal stents, or less than 12 months prior for drug-eluting stents. Stopping antiplatelet agents within these windows may otherwise lead to a devastating stent thrombosis. Given these considerations, ...