What are the recommendations for dental treatment in a patient with a history of coronary artery disease, hypertension, and hyperlipidemia, who is currently taking aspirin, Plavix, losartan, and atorvastatin?

Dental Treatment Recommendations for This Patient

Continue both aspirin and Plavix without interruption for dental treatment, as the risk of stent thrombosis from discontinuing antiplatelet therapy far exceeds any manageable bleeding risk from dental procedures. 1

Antiplatelet Management

Both aspirin and clopidogrel (Plavix) must be continued for this patient's dental treatment without any interruption. 2

• This patient had recent PCI with stent placement to the obtuse marginal branch, making him extremely high-risk for stent thrombosis if antiplatelet therapy is discontinued 2
• The ACC/AHA guidelines explicitly state that dual antiplatelet therapy (DAPT) should be continued for at least 12 months after coronary stent implantation, and this patient is still within that critical window 2
• Multiple joint statements from the American Heart Association, American College of Cardiology, American Dental Association, and American College of Surgeons confirm there is little or no indication to interrupt antiplatelet drugs for dental procedures 1
• Prospective randomized trials demonstrate no statistically significant difference in postoperative bleeding between patients on aspirin and placebo for dental extractions 1

Perioperative Cardiac Risk Assessment

This patient's perioperative cardiac complication risk is MODERATE to HIGH due to recent coronary intervention. 2

• The recent PCI (appears to be within the past several months based on the clinical note) places him in a higher-risk category 2
• His documented coronary anatomy shows severe disease: 100% occlusion of the right posterolateral branch with collaterals, moderate mid-LAD disease, and recent stenting of the obtuse marginal 2
• The syncopal episode and fall that led to his hospitalization suggests potential hemodynamic instability 2

Antibiotic Prophylaxis

Antibiotic prophylaxis for subacute bacterial endocarditis (SBE) is NOT recommended for this patient. 3

• He has no prosthetic cardiac valves, only trace mitral regurgitation and mild tricuspid regurgitation with aortic valve sclerosis 3
• Current guidelines do not recommend antibiotic prophylaxis for native valve disease or coronary artery disease 3

Local Anesthesia Considerations

Local anesthesia with epinephrine-containing solutions can be safely used in this patient. 4

• Effective local anesthesia is critical to avoid stress and pain during the procedure, which pose greater cardiovascular risk than the epinephrine itself 4
• Limit epinephrine to standard dental concentrations (1:100,000 or 1:200,000) and avoid epinephrine-impregnated gingival retraction cord 4
• The patient's blood pressure is well-controlled at 110/68 mmHg, making epinephrine use safer 4

Hemostatic Management

Local hemostatic measures should be readily available and applied to manage any minor bleeding. 1

• Use absorbable gelatin sponge, sutures, and consider tranexamic acid rinse if needed 1
• These measures are highly effective at controlling bleeding in patients on antiplatelet therapy 1
• No well-documented cases exist of clinically significant bleeding from dental extractions in patients on aspirin therapy when local hemostatic measures are employed 1

Timing Considerations

Elective dental procedures should ideally be delayed if the PCI was performed within the past 6 weeks, but urgent/necessary dental treatment can proceed with appropriate precautions. 3

• For drug-eluting stents, the highest risk period for stent thrombosis is the first 6 months, during which DAPT is absolutely critical 2
• Given this patient's documented need for dental treatment and his current stable cardiovascular status, proceeding is reasonable with continued DAPT 2, 1

Medication Management on Day of Procedure

The patient should take all usual cardiac medications on the morning of the dental procedure, including aspirin, Plavix, losartan, and atorvastatin. 4

• Continuing beta-blockers and ACE inhibitors/ARBs perioperatively reduces cardiovascular risk 2
• Statins should be continued as they may reduce periprocedural inflammation 5

Critical Pitfalls to Avoid

Never discontinue clopidogrel in a patient with recent coronary stent placement - this is the single most dangerous error, as stent thrombosis carries 20-45% mortality. 2

• Even brief interruption of DAPT dramatically increases thrombotic risk 2
• The bleeding risk from dental procedures is minimal and manageable, while stent thrombosis is catastrophic 1
• If the dentist insists on stopping antiplatelet therapy, the procedure should be postponed and alternative dental management sought 1

Patient Counseling

Inform the patient that continuing both antiplatelet medications is safer than stopping them, and provide clear instructions about post-operative bleeding management. 1

• Explain that minor oozing for 12-24 hours is normal 1
• Instruct to apply firm pressure with gauze for 30 minutes if bleeding occurs 1
• Define abnormal bleeding as continuous active bleeding beyond 24 hours or bleeding that does not respond to pressure 1
• Provide emergency contact information if concerning bleeding develops 1