What is the likelihood of a 62-year-old male with a history of myocardial infarction (heart attack) 7 years ago, currently managed with medications and Continuous Positive Airway Pressure (CPAP) therapy for obstructive sleep apnea, experiencing a cardiovascular event within 2 weeks after stopping CPAP and anticoagulant (blood thinner) therapy due to surgery?

Risk of Cardiovascular Event During 2-Week Perioperative Interruption

The risk of a major cardiovascular event within 2 weeks of stopping CPAP and anticoagulation for surgery in this patient is relatively low (estimated 1-3%), but the temporary discontinuation of anticoagulation poses a greater immediate risk than CPAP interruption. 1

Understanding the Two Separate Risks

Anticoagulation Interruption Risk

The primary concern in this scenario is the temporary cessation of anticoagulation ("blood thinners"), not the CPAP interruption:

• For patients with prior MI (7 years ago) who are on anticoagulation, the perioperative thrombotic risk depends on the indication for anticoagulation 1
• If anticoagulation is for atrial fibrillation with a CHA2DS2-VASc score ≤4, this represents "low risk" (<4% annual stroke risk), translating to approximately 0.6-0.8% risk over 2 weeks 1
• If anticoagulation is for recent venous thromboembolism or mechanical heart valve, the risk profile differs significantly 1
• The 2022 CHEST guidelines recommend that for most patients with stable coronary disease, anticoagulation can be safely interrupted for 5-7 days perioperatively without bridging therapy 1

CPAP Interruption Risk

The cardiovascular risk from short-term CPAP withdrawal is minimal:

• The 2016 SAVE trial demonstrated that CPAP therapy in patients with moderate-to-severe OSA and established cardiovascular disease did NOT prevent cardiovascular events (hazard ratio 1.10,95% CI 0.91-1.32, P=0.34) 2
• A 2016 randomized controlled trial showed that 2-week CPAP withdrawal caused blood pressure increases (+9.1 mmHg) but did NOT impair coronary endothelial function or myocardial perfusion 3
• These findings indicate that short-term CPAP interruption (2 weeks) does not acutely increase cardiovascular event risk, despite causing blood pressure elevation 3

Quantifying the 2-Week Risk

The combined estimated risk of a major cardiovascular event (MI, stroke, cardiovascular death) during this 2-week period is approximately 1-3%, based on the following:

• Baseline annual cardiovascular risk in patients with prior MI and well-controlled risk factors is approximately 3-5% per year 1
• This translates to roughly 0.3-0.5% over 2 weeks under normal circumstances
• Perioperative stress increases this baseline risk by 2-4 fold during the immediate perioperative period 1
• The anticoagulation interruption adds additional thrombotic risk depending on the indication (0.5-1% for most indications over 2 weeks) 1
• CPAP interruption adds minimal additional acute risk based on current evidence 2, 3

Critical Protective Factors in This Patient

This patient has several factors that LOWER his risk:

• 7 years post-MI with "great cholesterol numbers" and medication control suggests optimal secondary prevention 1
• Long-term medical therapy including statins, antiplatelet agents, and blood pressure control significantly reduces long-term cardiovascular mortality 1
• The temporal distance from the index MI (7 years) places him in a lower-risk category compared to recent MI patients 1

Perioperative Management Recommendations

The key is proper perioperative medication management, not CPAP continuation:

• Antiplatelet therapy (aspirin) should be continued perioperatively unless the surgery has extremely high bleeding risk 1
• P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) should be stopped 5-7 days before surgery and restarted as soon as bleeding risk permits 1
• Anticoagulation timing depends on the specific agent: warfarin stopped 5 days before, DOACs stopped 1-2 days before based on renal function 1
• Beta-blockers and statins should be continued throughout the perioperative period 1

Common Pitfalls to Avoid

• Do not assume CPAP interruption is a major cardiovascular risk factor—current evidence does not support this 2, 3
• Do not restart anticoagulation too early postoperatively before surgical hemostasis is secure 1
• Do not discontinue aspirin unnecessarily—it should be continued in most cases 1
• Ensure blood pressure is monitored closely during CPAP interruption, as hypertension may worsen 3

Post-Surgical Resumption

• Anticoagulation should be restarted within 24-72 hours postoperatively once hemostasis is secure 1
• CPAP should be resumed immediately postoperatively as it improves oxygenation and may reduce pulmonary complications 1
• P2Y12 inhibitors should be restarted within 24-48 hours unless contraindicated by bleeding 1