NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on Thursday in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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November 22, 2022
MKSAP 19 General Internal Medicine 2: Item 100
Stem:
A 72-year-old woman is seen for a preoperative medical evaluation prior to a hemicolectomy for newly diagnosed stage II colon cancer. Five months ago, she underwent drug-eluting coronary artery stent placement for stable ischemic heart disease and is now asymptomatic. Medications are metoprolol, aspirin, clopidogrel, benazepril, and atorvastatin.
Physical examination findings, including vital signs, are normal.
Which of the following is the most appropriate preoperative management of this patient's dual antiplatelet therapy?
Responses Received from Members (679 Responses):
The Correct Answer is: B. Continue aspirin and withhold clopidogrel
Educational Objective
Manage perioperative dual antiplatelet therapy for a patient undergoing urgent noncardiac surgery.
Critique
The most appropriate preoperative management of this patient's dual antiplatelet therapy (DAPT) is to continue aspirin and withhold clopidogrel (Option B). In patients with coronary stents, guidelines recommend that DAPT should be continued uninterrupted for 14 to 30 days after bare metal stent placement and 3 to 6 months after drug-eluting stent placement. Elective surgery should be postponed during these time frames. However, if the risk of surgical delay exceeds the risk for stent thrombosis, discontinuation of the P2Y12 inhibitor can be considered after a minimum of 3 months in patients with a drug-eluting stent. Low-dose aspirin should be continued if at all possible, and DAPT should be restarted as soon as bleeding risk has sufficiently diminished. Clopidogrel should be withheld 5 days before surgery.
Precise data on the risk for serious DAPT-related bleeding are lacking except in patients undergoing coronary artery bypass graft surgery. Studies have shown that DAPT in these patients increases the incidence of bleeding, reoperation, and transfusion. On the basis of these data, experts recommend discontinuation of P2Y12 receptor blockers at least 5 days before surgery for clopidogrel, 7 days for prasugrel, and 3 to 5 days for ticagrelor. Continuing both aspirin and a P2Y12 inhibitor (Option A) is not recommended.
Decisions regarding perioperative antiplatelet therapy are informed in part by a randomized controlled study of patients with previous coronary artery stenting who subsequently had surgery. The data suggested that patients who continued aspirin throughout the perioperative period had the lowest rate of a major cardiac adverse event. Withholding perioperative aspirin either with or without a P2Y12 inhibitor (Options C, D) is not recommended. Withholding both aspirin and clopidogrel may be reasonable if the risk for bleeding is extreme or the consequences catastrophic, such as those associated with neurosurgery.
Surgery is associated with proinflammatory effects that may increase the risk for thrombosis, particularly coronary artery thrombosis and stent thrombosis. Aspirin, clopidogrel, and other P2Y12 inhibitors are antiplatelet agents, which can mitigate this risk. Balancing the risk for bleeding and thrombosis is key, and continuation of both agents may lead to unacceptable bleeding risk. In general, bleeding risk with aspirin is lower than that with clopidogrel in the perioperative period, so continuing aspirin alone is recommended during this time frame.
Key Points
In patients with coronary stents, guidelines recommend that dual antiplatelet therapy should be continued uninterrupted for 14 to 30 days after bare metal stent placement and a minimum of 3 to 6 months after drug-eluting stent placement.
In patients with an urgent need for surgery, discontinuation of a P2Y12 inhibitor can be considered after a minimum of 3 months in patients with a drug-eluting stent; aspirin should be continued if at all possible.
Bibliography
Banerjee S, Angiolillo DJ, Boden WE, et al. Use of antiplatelet therapy/DAPT for post-PCI patients undergoing noncardiac surgery. J Am Coll Cardiol. 2017;69:1861-70. [PMID: 28385315] doi:10.1016/j.jacc.2017.02.012
Copyright 2019, American College of Physicians.
November 8, 2022
MKSAP 19 General Internal Medicine 2: Item 23
Stem:
A 65-year-old man is seen for a preoperative medical evaluation 2 weeks before total left shoulder arthroplasty. Medical history is significant for COPD. He was hospitalized 6 months ago for COPD exacerbation. He reports no changes in cough or sputum production. He has no shortness of breath or fever. Screening for obstructive sleep apnea (OSA) with the STOP-BANG questionnaire categorizes the patient as low risk for OSA. He has a 30–pack-year history of cigarette smoking but quit smoking 6 years ago. Medications are inhaled tiotropium, beclomethasone, and albuterol.
On physical examination, vital signs are normal. Oxygen saturation is 94% breathing ambient air. There are decreased breath sounds throughout and an increased expiratory phase. Left shoulder range of motion is painful and restricted. The remainder of the examination is normal.
Which of the following is the most appropriate perioperative pulmonary assessment?
Responses Received from Members (894 responses):
The Correct Answer is: D. No further testing
Educational Objective
Perform perioperative pulmonary assessment in a patient with COPD.
Critique
No further testing is required for this patient (Option D). Perioperative pulmonary complications include pneumonia, respiratory failure, and exacerbation of underlying lung disease. There is a limited role for routine perioperative pulmonary testing in patients with COPD. Patients with COPD should be screened preoperatively for signs and symptoms of COPD exacerbation. Patients should also be screened for obstructive sleep apnea, which is associated with adverse perioperative outcomes, including cardiac events, pulmonary complications, and ICU admissions. A validated screening tool for OSA is the 8-item STOP-BANG questionnaire. One point is assigned for each “yes” response about Snoring, Tiredness, Observed apneas, elevated blood Pressure, BMI >35, Age >50 years, Neck circumference >40 cm, and male Gender. Cumulative points determine the risk for OSA: low risk, 0 to 2 points; intermediate risk, 3 to 5 points; high risk, 5 points.
Evidence for the benefit of preoperative arterial blood gas analysis (Option A) is lacking. The results are rarely helpful in managing patients with stable chronic lung disease or predicting clinical outcomes.
Routine preoperative chest radiography (Option B) is not recommended in patients with chronic lung disease unless clinical examination or history suggests a change in pulmonary status. In only approximately 2% of cases does screening chest radiography lead to changes in perioperative management, and abnormal findings can usually be predicted on the basis of clinical examination. It may be reasonable, but not necessary, to obtain chest radiographs in patients older than 70 years with chronic cardiopulmonary disease if they have not had chest radiography in the previous 6 months. Preoperative chest radiography may be indicated in patients undergoing thoracic or mediastinal surgery, which this patient is not.
Although spirometry (Option C) may help delineate progression of airflow obstruction due to worsening COPD, results do not change perioperative management in patients such as this one. There is no absolute value of FEV1 or FEV1/FVC that precludes surgery, nor do these values help predict perioperative pulmonary complications.
Key Points
Patients with COPD should be screened preoperatively for signs and symptoms of COPD exacerbation.
Chest radiography, arterial blood gas analysis, or spirometry is not routinely indicated in the preoperative evaluation of patients with chronic lung disease.
Bibliography
Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118:317-34. [PMID: 28186222] doi:10.1093/bja/aex002
Copyright 2019, American College of Physicians.