Can any of the patient's blood thinners be held for an upcoming surgery?

Management of Blood Thinners for Surgery in a Patient with Coronary Artery Disease

For this 64-year-old female with diabetes, chronic kidney disease, hypertension, hyperlipidemia, and moderate-to-severe coronary artery disease on aspirin and clopidogrel (dual antiplatelet therapy), aspirin should be continued perioperatively while clopidogrel should be discontinued 7 days before surgery unless the procedure is in a closed space such as intracranial or spinal surgery.

Assessment of Patient's Cardiovascular Risk

This patient has:

• Multiple cardiovascular risk factors (diabetes, CKD, hypertension, hyperlipidemia)
• Documented coronary artery disease with moderate distal LED disease and severe stenosis
• Currently on dual antiplatelet therapy (aspirin and clopidogrel)

Management Algorithm for Antiplatelet Therapy

For Aspirin:

• Continue aspirin through the perioperative period for most procedures 1
• Exception: If the surgery involves a closed space (intracranial or spinal surgery), aspirin should be discontinued 5 days before the procedure 1

For Clopidogrel (or other thienopyridine):

• Discontinue clopidogrel 7 days before surgery 1
• If point-of-care testing for platelet function is available, this can guide timing of surgery 1
• Restart clopidogrel as soon as possible after surgery, ideally within 5 days 1

Special Considerations

Timing of Surgery After Stent Placement:

• If the patient has a coronary stent, the timing of surgery is crucial:
  • For bare metal stents: Delay elective surgery for at least 4-6 weeks after stent placement 1
  • For drug-eluting stents: Delay elective surgery for at least 6 months after stent placement 1

High Bleeding Risk Procedures:

• If the bleeding risk is exceptionally high and both antiplatelet agents must be stopped:
  • Stop both medications no sooner than 5 days before surgery
  • Restart both as soon as possible after surgery, certainly within 5 days 1
  • This approach should only be used when bleeding risk clearly outweighs stent thrombosis risk

Renal Considerations

Given the patient's chronic kidney disease:

• Carefully assess renal function before restarting any medications
• If the patient is on any direct oral anticoagulants (DOACs), these would require special consideration:
  • Dabigatran would need to be stopped 5 days before surgery due to renal dysfunction 1
  • Rivaroxaban or apixaban would need to be stopped 3 days before surgery 1

Common Pitfalls to Avoid

1. Complete discontinuation of all antiplatelet therapy: This significantly increases the risk of stent thrombosis and cardiovascular events
2. Failing to communicate with the cardiology team: Consultation with cardiology is essential, especially for patients with recent stent placement
3. Inappropriate bridging: Bridging anticoagulation is not required except in patients with recent (<3 months) history of pulmonary embolism or deep venous thrombosis 1
4. Restarting antiplatelet therapy too late: Thienopyridines should be restarted as soon as possible after surgery to minimize thrombotic risk

Conclusion for Preoperative Clearance

For this patient's preoperative cardiology clearance:

• Continue aspirin throughout the perioperative period
• Discontinue clopidogrel 7 days before surgery
• Restart clopidogrel as soon as possible after surgery (ideally within 24-48 hours if hemostasis is adequate)
• Communicate this plan clearly with the surgical team