Is it prudent to defer arthroscopy in a patient with a recent acute myocardial infarction (AMI)?

Deferring Arthroscopy After Acute Myocardial Infarction

Yes, elective arthroscopy should be deferred for at least 3-7 days after acute myocardial infarction in hemodynamically stable patients to allow myocardial recovery and reduce perioperative mortality risk. 1

Timing Considerations Based on Clinical Stability

Hemodynamically Stable Patients

• Defer elective surgery for 3-7 days minimum after AMI to allow myocardial recovery and reduce surgical mortality, which is significantly elevated during the first week post-infarction 1
• The optimal waiting period balances the risk of recurrent ischemic events against the elevated surgical risk in the immediate post-MI period 1
• Patients who have been stabilized without ongoing ischemia, hemodynamic compromise, or life-threatening arrhythmias should have surgery delayed to allow myocardial recovery 1

Urgent/Emergency Situations

• Proceed immediately with arthroscopy if the procedure is truly urgent and delaying poses greater risk than the surgery itself (e.g., septic joint, compartment syndrome) 2
• The benefits of urgent intervention must outweigh the substantially elevated perioperative cardiac risk in the acute post-MI period 2

Pre-Operative Cardiac Assessment

Before proceeding with arthroscopy in a recent AMI patient, perform the following:

• Obtain echocardiography to assess left ventricular ejection fraction (LVEF), right ventricular function, and exclude mechanical complications such as free wall rupture, ventricular septal defect, or pseudoaneurysm 2
• Ensure hemodynamic stability with systolic blood pressure >90 mmHg and absence of cardiogenic shock (cardiac index >2.5 L/min/m², pulmonary capillary wedge pressure <18 mmHg) 2
• Verify absence of ongoing ischemia through clinical assessment and ECG monitoring 1
• Assess for life-threatening arrhythmias that would preclude safe anesthesia 1

Risk Stratification

High-Risk Features Requiring Longer Delay

Patients with the following features require extended waiting periods (ideally >7 days):

• Significant fall in left ventricular function (LVEF <40%) 1
• Anterior wall MI or large infarct territory 1
• Killip class >I (signs of heart failure) 1
• Cardiogenic shock or hemodynamic instability 2
• Ongoing or recurrent ischemia 1
• Complex ventricular arrhythmias 3

Lower-Risk Features Allowing Earlier Surgery

Patients with preserved LVEF, complete revascularization, and stable hemodynamics may safely undergo surgery within several days of infarction 1

Antiplatelet Management During Perioperative Period

Aspirin

• Continue aspirin (75-150 mg daily) throughout the perioperative period as arthroscopy is a low-bleeding-risk procedure and stopping aspirin increases thrombotic risk 2, 4

Dual Antiplatelet Therapy (DAPT)

• Continue DAPT (aspirin plus P2Y12 inhibitor) if the patient is on it, as arthroscopy is considered low-bleeding-risk 2
• If the patient received PCI with stent placement, interrupting DAPT significantly increases risk of stent thrombosis and recurrent MI 4
• The timing recommendations for DAPT interruption (3 days for ticagrelor, 5 days for clopidogrel, 7 days for prasugrel) apply to high-bleeding-risk surgeries, not arthroscopy 1

Intraoperative and Postoperative Monitoring

• Maintain continuous cardiac monitoring during and after the procedure 1
• Avoid hypotension (maintain SBP >90 mmHg) as this can precipitate cardiac decompensation in patients with compromised ventricular function 2
• Monitor for signs of myocardial ischemia including chest pain, ECG changes, and hemodynamic instability 1

Common Pitfalls to Avoid

• Do not proceed with elective arthroscopy within 24-48 hours of AMI unless the procedure is truly emergent, as surgical mortality is highest during this period 2
• Do not stop aspirin perioperatively in post-MI patients undergoing low-bleeding-risk procedures like arthroscopy—the thrombotic risk far exceeds bleeding risk 2, 4
• Do not interrupt DAPT in patients with recent stent placement, as this dramatically increases risk of stent thrombosis 4
• Do not proceed without echocardiography if the patient has signs of mechanical complications (new murmur, hemodynamic instability, refractory heart failure) 2
• Do not delay truly urgent arthroscopy (e.g., septic arthritis) even in the early post-MI period, as infection-related mortality may exceed cardiac risk 2

Evidence Quality and Nuances

The primary evidence comes from ACC/AHA guidelines addressing timing of CABG after MI, which demonstrate elevated mortality when surgery is performed within 3-7 days of infarction 1. While these guidelines specifically address cardiac surgery, the principles apply to non-cardiac surgery with general anesthesia. The Praxis Medical Insights document on paracentesis provides analogous guidance for procedural timing post-MI, emphasizing the importance of hemodynamic stability and echocardiographic assessment 2. No high-quality randomized trials specifically address arthroscopy timing post-MI, so recommendations are extrapolated from cardiac surgery data and general perioperative risk principles.