For a 50‑year‑old man with compensated heart failure with reduced ejection fraction on sacubitril/valsartan (Entresto), empagliflozin, carvedilol, spironolactone and chronic atrial fibrillation anticoagulated with apixaban, who is scheduled for a fistulotomy tomorrow, how should I stratify his pre‑operative cardiac risk and which medications should be continued or held, particularly regarding the apixaban dose taken today?

Preoperative Cardiac Risk Stratification and Medication Management

Cardiac Risk Stratification

This patient is at low cardiac risk for fistulotomy, and the procedure should proceed as scheduled without delay. 1, 2

Fistulotomy is a low-risk surgical procedure (estimated cardiac risk <1%) that does not require extensive preoperative cardiac testing or medication adjustments in compensated heart failure patients. 1, 2 Your patient demonstrates:

• Compensated HFrEF with no signs of decompensation (no congestion, normal creatinine, stable functional status) 2
• Optimized guideline-directed medical therapy (GDMT) with all four foundational medication classes 1, 2
• Controlled atrial fibrillation on appropriate anticoagulation 3
• NYHA Class I-II status based on clinical description (no physical exam findings of heart failure) 2

The combination of low surgical risk and stable cardiac status places this patient in the lowest risk category for perioperative cardiac complications. 1, 2

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Medication Management: Continue All Heart Failure Medications

All heart failure medications (Entresto, empagliflozin, carvedilol, spironolactone) must be continued through the perioperative period without interruption. 1, 2

Rationale for Continuation:

• Entresto (sacubitril/valsartan) provides at least 20% mortality reduction and should never be interrupted for low-risk procedures 1, 2
• Empagliflozin reduces cardiovascular death and heart failure hospitalization with benefits occurring within weeks; interruption increases risk of decompensation 3, 4
• Carvedilol provides 34% mortality reduction (the highest among GDMT classes) and prevents perioperative tachycardia and arrhythmias 2
• Spironolactone provides at least 20% mortality reduction and reduces sudden cardiac death risk 2

Critical principle: Discontinuing GDMT for even brief periods in HFrEF patients is associated with two to fourfold higher risk of adverse cardiovascular events. 2 The risk of withholding these medications far exceeds any theoretical perioperative concern for low-risk surgery. 1, 2

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Apixaban Management: Defer Surgery 24-48 Hours

Yes, you should defer the fistulotomy because the patient took apixaban today. 5

Specific Timing Recommendations:

For fistulotomy (moderate bleeding risk procedure):

• Discontinue apixaban at least 48 hours prior to surgery 5
• Since the patient took apixaban today, reschedule the procedure for 48-72 hours from now 5
• No bridging anticoagulation is required during this brief interruption 5

Bleeding Risk Classification:

Fistulotomy carries moderate bleeding risk because:

• It involves incision of perianal tissue with rich vascular supply
• Bleeding in this location, while controllable, would be clinically significant
• The procedure is elective, allowing time for proper anticoagulation management 5

Resumption of Anticoagulation:

• Restart apixaban as soon as adequate hemostasis is established (typically 12-24 hours post-procedure for fistulotomy) 5
• Resume at the patient's usual dose of 5 mg twice daily (he does not meet criteria for dose reduction: age <80, weight likely >60 kg, creatinine normal at 1.1 mg/dL which is <1.5 mg/dL) 5

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Perioperative Monitoring

Blood Pressure Management:

• Do not hold GDMT for asymptomatic hypotension 2
• GDMT medications maintain efficacy and safety even with systolic BP <110 mmHg 2
• If symptomatic hypotension occurs perioperatively, address reversible causes first (hypovolemia, infection) before adjusting GDMT 2

Renal Function and Electrolytes:

• Monitor serum creatinine and potassium within 1-2 weeks post-procedure, especially given combination of Entresto + spironolactone 1, 2
• Modest creatinine increases (up to 30% above baseline) are acceptable and should not prompt medication discontinuation 2
• Potassium levels require close monitoring with MRAs; caution when K+ >5.0 mEq/L 2

Atrial Fibrillation Management:

• Continue carvedilol for rate control throughout the perioperative period 2
• Empagliflozin may reduce incident atrial fibrillation and does not adversely affect outcomes in patients with existing AF 3

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Common Pitfalls to Avoid

• Never discontinue GDMT for low-risk elective procedures – the cardiovascular risk of medication interruption exceeds surgical risk 1, 2
• Do not bridge anticoagulation for the 48-hour apixaban interruption – bridging is not generally required for brief interruptions before low-to-moderate risk procedures 5
• Do not reduce GDMT doses due to unfounded concerns about perioperative hypotension in stable patients 2
• Do not delay restarting apixaban beyond 24 hours post-procedure once hemostasis is adequate – prolonged interruption increases stroke risk 5

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Summary Algorithm

1. Defer surgery 48-72 hours to allow apixaban washout 5
2. Continue all HF medications (Entresto, empagliflozin, carvedilol, spironolactone) without interruption 1, 2
3. Perform fistulotomy once 48 hours have elapsed since last apixaban dose 5
4. Restart apixaban 12-24 hours post-procedure once hemostasis is confirmed 5
5. Monitor renal function and electrolytes within 1-2 weeks 2