Perioperative Cardiac Risk Assessment and Aspirin Management for Right Total Knee Arthroplasty
This patient has an intermediate perioperative cardiac risk (approximately 1-5%) for major adverse cardiovascular events, and aspirin should be CONTINUED perioperatively rather than held for 5-7 days. 1
Cardiac Risk Stratification
Risk Assessment:
- Total knee arthroplasty is classified as low-to-intermediate risk surgery with a 30-day cardiac event rate of <1% 1
- This patient has multiple cardiac risk factors including:
Functional Capacity Consideration:
- The patient's functional capacity is not explicitly stated, but the presence of CHF with mildly reduced EF suggests likely <4 METs 1
- With poor functional capacity (<4 METs) and multiple cardiac risk factors, this places the patient at intermediate perioperative cardiac risk 1
Overall Risk Estimate:
- Based on the Revised Cardiac Risk Index criteria (CAD, CHF), this patient has ≥2 risk factors, predicting a perioperative major adverse cardiovascular event risk of approximately 1-5% 2
- The combination of documented CAD (even if non-obstructive) and systolic dysfunction (EF 45-50%) elevates risk above the baseline for orthopedic surgery 1
Aspirin Management Decision
ASPIRIN SHOULD BE CONTINUED:
The 2024 ACC/AHA guidelines explicitly state that in patients with CAD undergoing noncardiac surgery, it is recommended to continue aspirin (75-100 mg) if possible to reduce the risk of cardiac events. 1
Key Evidence Supporting Continuation:
- For patients with established CAD (even non-obstructive), continuation of aspirin reduces perioperative thrombotic complications more than it increases bleeding risk in orthopedic surgery 1
- The 2014 ESC/ESA guidelines state that "continuation or discontinuation of aspirin should be based on an individual decision that depends on the perioperative bleeding risk weighed against the risk of thrombotic complications" 1
- Total knee arthroplasty has acceptable surgical bleeding risk that does not mandate aspirin discontinuation in patients with CAD 1
Evidence Against Routine Discontinuation:
- Routine perioperative discontinuation of aspirin in patients with CAD increases risk of myocardial infarction and stent thrombosis (if stents present) 1
- The 2024 guidelines specifically recommend against routine initiation of aspirin in patients without prior CAD, but this patient HAS documented CAD, making continuation appropriate 1
Common Pitfalls to Avoid
Critical Errors:
- Do NOT hold aspirin for 5-7 days in this patient with documented CAD—this significantly increases thrombotic risk without proportionate bleeding benefit in TKA 1
- Do NOT assume all orthopedic surgery requires aspirin discontinuation—the risk-benefit calculation favors continuation in patients with established CAD 1
- Do NOT discontinue aspirin without explicit discussion with the surgical team about bleeding risk versus thrombotic risk 1
Additional Perioperative Considerations:
- Continue beta-blockers if the patient is already taking them (not specified in this case, but critical if present) to avoid rebound tachycardia and hypertension 1
- Continue statins perioperatively, as they reduce postoperative cardiovascular complications (1.8% vs 2.3% mortality without statins) 2
- ACE inhibitors/ARBs should be held on the day of surgery to reduce intraoperative hypotension risk, then resumed postoperatively 3
- Ensure adequate perioperative monitoring given the patient's CHF with reduced EF and OSA 2, 4
Specific Recommendations
Aspirin Dosing:
- Continue aspirin 75-100 mg daily through the perioperative period 1
- Resume immediately postoperatively if held for any reason 1
Surgical Coordination:
- Confirm with orthopedic surgeon that bleeding risk is acceptable with continued aspirin (it should be for routine TKA) 1
- Consider enhanced hemostatic techniques intraoperatively (tranexamic acid, meticulous surgical technique) if bleeding concerns exist 1
Postoperative Management: