What is the optimal cardiovascular medication regimen and follow‑up plan for a 75‑year‑old male with hypertension, hyperlipidemia, type 2 diabetes mellitus, benign prostatic hyperplasia, stage 4 chronic kidney disease after right nephrectomy, who is post‑transcatheter aortic valve replacement and scheduled for transurethral resection of the prostate and left total knee replacement?

Optimal Cardiovascular Management Post-TAVR with Stage 4 CKD

Blood Pressure Management

Continue amlodipine 10 mg daily as monotherapy and avoid restarting lisinopril given the patient's stage 4 CKD (GFR 26 mL/min/1.73 m², creatinine 2.53 mg/dL) following right nephrectomy. 1, 2

Rationale for Calcium Channel Blocker Monotherapy

• Calcium channel blockers are specifically favored in post-kidney transplant and advanced CKD because they improve kidney graft survival and GFR, whereas ACE inhibitors should be used with caution in this setting 1
• Amlodipine provides sustained 24-hour blood pressure control with a long half-life (35-50 hours), maintaining efficacy even with missed doses—critical for elderly patients with multiple comorbidities 3
• The patient's home blood pressure readings (120s/70s) suggest adequate control on amlodipine alone, despite elevated office readings (164/86 mmHg), indicating possible white coat hypertension 1

Why ACE Inhibitors Should Be Avoided

• ACE inhibitors and ARBs are contraindicated as first-line therapy in stage 4-5 CKD without proteinuria 2, 4
• Lisinopril was appropriately discontinued after nephrectomy to avoid nephrotoxic effects in the setting of acute-on-chronic kidney injury (creatinine elevated from baseline to 2.53 mg/dL) 2, 4
• The patient has no documented proteinuria or albuminuria, which are the primary indications for ACE inhibitor/ARB use in CKD 1, 2
• With GFR <30 mL/min, ACE inhibitors carry heightened risk of hyperkalemia and further renal deterioration 2, 4

Blood Pressure Target

• Target blood pressure <140/90 mmHg for CKD patients without proteinuria, which the patient is achieving on home monitoring 2
• Office blood pressure should be rechecked in 2 weeks as planned, but treatment decisions should prioritize home readings over isolated office elevations 1

Alternative if Blood Pressure Remains Uncontrolled

• If home blood pressure readings consistently exceed 140/90 mmHg, add chlorthalidone (thiazide-like diuretic) rather than increasing amlodipine or restarting ACE inhibitors 1, 2
• Loop diuretics (furosemide) are preferred over thiazides when GFR <30 mL/min or creatinine >2.0 mg/dL, as thiazides become ineffective at this level of renal function 4
• Consider furosemide 20-40 mg daily if additional diuresis is needed for blood pressure control in stage 4 CKD 4

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Antiplatelet and Anticoagulation Strategy

Continue aspirin 81 mg daily lifelong; clopidogrel was appropriately discontinued after 3-6 months post-TAVR. 1

Post-TAVR Antiplatelet Regimen

• Dual antiplatelet therapy (aspirin + clopidogrel) is recommended for 3-6 months post-TAVR, after which aspirin monotherapy is continued indefinitely 1
• The patient is now well beyond the 3-6 month window (TAVR performed months ago, now cleared for orthopedic surgery), so aspirin alone is appropriate 1
• Avoid adding clopidogrel back unless the patient develops atrial fibrillation or requires coronary stenting, as dual therapy increases bleeding risk in elderly post-TAVR patients 1

Perioperative Antiplatelet Management

• Aspirin should be held 7 days prior to TURP and left total knee replacement to minimize surgical bleeding risk, as was done appropriately for the TURP procedure 1
• Aspirin can be resumed 24-48 hours postoperatively once hemostasis is confirmed 1

If Atrial Fibrillation Develops

• Warfarin (INR 2.0-3.0) is preferred over direct oral anticoagulants (DOACs) in post-TAVR patients with atrial fibrillation, particularly with stage 4 CKD 5, 1
• DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) have insufficient evidence and heightened bleeding risk when GFR <30 mL/min 1, 5
• If warfarin is initiated, discontinue aspirin to avoid triple therapy and excessive bleeding risk 1, 5

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Lipid Management

Continue ezetimibe 10 mg daily; consider adding a moderate-intensity statin if LDL remains elevated above goal. 6

Ezetimibe in CKD

• Ezetimibe is safe in advanced CKD, with only a 1.5-fold increase in AUC in severe renal impairment (CrCl ≤30 mL/min), requiring no dose adjustment 6
• The patient was appropriately started on ezetimibe to lower LDL post-TAVR 6

Statin Considerations

• If LDL remains >70 mg/dL, add atorvastatin 20-40 mg daily or rosuvastatin 10 mg daily (moderate-intensity statin) for secondary prevention in a patient with aortic stenosis requiring TAVR 1
• Statins are safe in CKD and do not require dose adjustment until dialysis is initiated 1

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Antibiotic Prophylaxis for Dental Procedures

Prescribe amoxicillin 2 grams orally 1 hour before invasive dental procedures; if penicillin-allergic, use azithromycin 500 mg. 5

• All patients with prosthetic heart valves, including TAVR, require antibiotic prophylaxis for dental work involving manipulation of gingival tissue or periapical region of teeth 5
• This was appropriately discussed with the patient 5

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Cardiovascular Follow-Up and Surveillance

Schedule cardiology follow-up annually for TAVR surveillance with echocardiography; primary care visits every 3 months for blood pressure, renal function, and diabetes management. 1

Post-TAVR Surveillance Schedule

• Echocardiography should be performed annually to monitor TAVR valve function, paravalvular regurgitation, and left ventricular function 1
• The patient's most recent echocardiogram showed normal prosthetic valve function, so annual surveillance is appropriate 1
• Increase frequency of echocardiography if symptoms develop (dyspnea, chest pain, syncope) or if significant paravalvular leak is detected 1

Renal Function Monitoring

• Check basic metabolic panel (creatinine, GFR, potassium) every 2-4 weeks initially after nephrectomy, then every 3 months once stable 2, 4
• The patient should be referred to nephrology for co-management of stage 4 CKD, as was appropriately recommended 2, 4

Blood Pressure Monitoring

• Home blood pressure monitoring should continue daily, with office visits every 2-4 weeks until blood pressure is stable, then every 3 months 1
• Patients on amlodipine monotherapy should be followed monthly until blood pressure is controlled 1

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Perioperative Cardiovascular Clearance

The patient is cleared for left total knee replacement from a cardiovascular standpoint, provided aspirin is held 7 days preoperatively and blood pressure is controlled. 1

Timing of Surgery Post-TAVR

• Elective non-cardiac surgery should be delayed at least 3 months post-TAVR to allow for dual antiplatelet therapy completion and valve stabilization 1
• The patient is well beyond this window and has been appropriately cleared 1

Perioperative Medication Management

• Hold aspirin 7 days prior to surgery; resume 24-48 hours postoperatively 1
• Continue amlodipine throughout the perioperative period to maintain blood pressure control 1
• Hold ezetimibe on the day of surgery; resume when oral intake is tolerated 6

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Common Pitfalls to Avoid

• Do not restart ACE inhibitors or ARBs in stage 4 CKD without proteinuria, as they provide no benefit and increase risk of hyperkalemia and acute kidney injury 2, 4
• Do not use thiazide diuretics (hydrochlorothiazide, chlorthalidone) as monotherapy when GFR <30 mL/min, as they are ineffective; use loop diuretics instead 4
• Do not combine aspirin with warfarin in post-TAVR patients unless there is a compelling indication (e.g., recent coronary stent), as this markedly increases bleeding risk 1, 5
• Do not use DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) in stage 4-5 CKD, as they lack evidence and carry heightened bleeding risk 1, 5
• Do not delay nephrology referral in a patient with stage 4 CKD post-nephrectomy, as early co-management improves outcomes 2, 4
• Do not ignore home blood pressure readings in favor of office readings, as white coat hypertension is common in elderly patients and can lead to overtreatment 1