What preoperative management is recommended for a patient with a history of myocardial infarction (MI) taking aspirin and beta blocker, scheduled for rotator cuff repair surgery in 2 weeks?

Perioperative Management for Rotator Cuff Repair in a Patient with History of MI

For a patient with a history of MI 5 years ago who is currently stable and taking aspirin and beta blocker, beta blocker therapy should be continued throughout the perioperative period, and aspirin should be discontinued 7-10 days before rotator cuff repair surgery unless the patient has a coronary stent. 1, 2

Beta Blocker Management

Continue Beta Blocker

• Beta blockers should be continued without interruption through the perioperative period in patients who have been on them chronically (Class I recommendation, Level of Evidence B) 1
• Abrupt withdrawal of long-term beta blockers is harmful and can increase risk of cardiac events 1
• The patient should take their usual beta blocker dose on the morning of surgery

Rationale

• Continuing beta blockers reduces risk of perioperative cardiac events in patients with history of MI
• Multiple observational studies support the benefits of continuing beta blockers in patients undergoing surgery who are on these agents for longitudinal indications 1
• Discontinuation of beta blockers is associated with increased risk of myocardial ischemia, MI, and mortality

Aspirin Management

Discontinue Aspirin

• For rotator cuff repair (orthopedic surgery with moderate bleeding risk), aspirin should be discontinued 7-10 days before surgery 1, 2
• Exception: If the patient has a coronary stent placed within the last 12 months (drug-eluting) or 3 months (bare metal), aspirin should be continued throughout the perioperative period 2

Important Considerations

• Since the patient's MI was 5 years ago and they are currently stable with good functional capacity (able to do yard work without chest pain or SOB), the bleeding risk of continuing aspirin likely outweighs the cardiovascular benefit 3
• The POISE-2 trial showed that aspirin administration before surgery and throughout the early postsurgical period had no significant effect on reducing death or nonfatal MI but increased the risk of major bleeding 3
• If aspirin is discontinued, it should be restarted 24-48 hours after surgery once adequate hemostasis is achieved 2

Preoperative Cardiac Risk Assessment

Risk Stratification

• This patient has favorable prognostic indicators:
  • Remote MI (>5 years ago)
  • Good functional capacity (able to do yard work without symptoms)
  • No symptoms of chest pain or shortness of breath
  • Already on appropriate medical therapy (beta blocker and aspirin)

No Additional Testing Needed

• Given the patient's good functional capacity (>4 METs) and stable cardiac status, no additional cardiac testing is required before proceeding with surgery 1

Postoperative Management

• Resume beta blocker immediately after surgery without interruption
• Resume aspirin 24-48 hours after surgery once adequate hemostasis is achieved 2
• Monitor for cardiac symptoms in the postoperative period

Potential Pitfalls to Avoid

1. Abrupt beta blocker discontinuation: Never stop beta blockers suddenly as this can precipitate rebound ischemia and increased cardiac events 1

2. Continuing aspirin unnecessarily: For orthopedic procedures with moderate-high bleeding risk, continuing aspirin when not indicated (no recent stent, stable CAD) increases bleeding risk without significant cardiovascular benefit 3

3. Delaying surgery unnecessarily: This patient has good functional capacity and remote MI (>5 years), so additional cardiac testing would not change management and would only delay necessary surgery 1

4. Failure to restart aspirin postoperatively: Aspirin should be restarted within 24-48 hours after surgery once hemostasis is achieved to minimize thrombotic risk 2

5. Not involving a multidisciplinary team: If there are any concerns about the patient's cardiac status, consultation with cardiology may be beneficial before proceeding with surgery 2