1. An MI, a Stent, Bleeding, and Surgery! What Do I Do? COPYRIGHT © 2016, ALL RIGHTS RESERVED From the Publishers of

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3. Dear Consult Guys: We have a tough case and if anyone can help us it is the two of you. Here goes: We are caring for a patient in the hospital who needs a right colectomy. He is 85 years old and had a NSTEMI 5 months ago. He underwent cardiac cath on the day following the NSTEMI and was found to have a 95% stenosis of the proximal left anterior descending coronary artery. He underwent successful angioplasty of this stenosis with placement of a drug eluting stent. We’ve sent the cath films for your review. He now presents with fatigue. He was found to have heme (+) stool. His Hgb is 9.0 (was 10.8 at time of cath) and Cr 2.1. He is diabetic and Hb A1c is 9. His medications are aspirin 81mg daily, clopidogrel 75 mg daily, and a beta blocker. His cholesterol is 250 (LDL 160). His activity is decreased due to fatigue but he is able to walk a flight of stairs without difficulty. Colonoscopy revealed a fungating mass of the right colon at the hepatic flexure. Pathology identified adenocarcinoma. How should we proceed? Dear Consult Guys: We have a tough case and if anyone can help us it is the two of you. Here goes: We are caring for a patient in the hospital who needs a right colectomy. He is 85 years old and had a NSTEMI 5 months ago. He underwent cardiac cath on the day following the NSTEMI and was found to have a 95% stenosis of the proximal left anterior descending coronary artery. He underwent successful angioplasty of this stenosis with placement of a drug eluting stent. We’ve sent the cath films for your review. He now presents with fatigue. He was found to have heme (+) stool. His Hgb is 9.0 (was 10.8 at time of cath) and Cr 2.1. He is diabetic and Hb A1c is 9. His medications are aspirin 81mg daily, clopidogrel 75 mg daily, and a beta blocker. His cholesterol is 250 (LDL 160). His activity is decreased due to fatigue but he is able to walk a flight of stairs without difficulty. Colonoscopy revealed a fungating mass of the right colon at the hepatic flexure. Pathology identified adenocarcinoma. How should we proceed?

4. Patient Copyright © 2016

5. Patient Copyright © 2016

6. Cardiac cath post NSTEMI 5 months ago *Reproduced with permission from Howard Weitz, MD

7. Copyright © 2016 PTCA post NSTEMI 5 months ago *Reproduced with permission from Howard Weitz, MD

9. Clear for Surgery? Our Concerns:  Perioperative Risk  Antiplatelet management in the perioperative period Copyright © 2016

10. How to Determine Risk of MACE Low risk (<1%) Increased risk ( > 1%) Copyright © 2016

11. 211,410 + 257,385 = 468,795 patients *Gupta PK et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery. Circulation. 2011;124:381-387, published online before print July 5 2011, doi:10.1161/CIRCULATIONAHA.110.015701

12. Patient Age: 85 Cr: > 1.5 ASA Class: III (severe systemic disease) Functional: Independent Surgery: Intestinal Risk probability for perioperative MI or cardiac arrest: 2.3% Copyright © 2016

13. *Lee TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation. 1999;100:1043-1049, doi:10.1161/01.CIR.100.10.1043 4315 + 1422 = 5737 patients Risk predictors High risk OR Hx CAD Hx CHF Cerebrovasc dx Diabetic insulin Cr > 2

14. Revised Cardiac Index High risk surgery: intraperitoneal CAD: prior MI CHF: No Cerebrovascular disease: No Diabetes on insulin: Yes Serum creatinine > 2mg/dl: Yes Risk of MI, pulmonary edema, ventricular fibrillation, cardiac arrest, complete heart block: > 11% Copyright © 2016

15. Perioperative Risk Risk of major cardiac event or death: 2.3 - > 11% Risk of not performing the surgery:  Continued GI bleed  Cancer growth  Bowel obstruction Copyright © 2016

16. Stent Bleeding risk vs stent thrombosis Second generation DES since 2008  Less stent thrombosis Copyright © 2016

17. ACC AHA 2014 Guideline Delay elective surgery after stent Balloon angioplasty without stent: 14 days Bare metal stent: 30 days Drug eluting stent: 365 days Drug eluting stent: 180 days  If risk of delaying surgery is greater than the risk of stent thrombosis – myocardial ischemia consider NCS after 180 days *Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944.

18. European Society of Cardiology 2014 Guideline Delay elective surgery after stent Bare metal stent: 4 week minimum, 3 months ideal Drug eluting stent (new generation): 6 months  A minimum of 3 months might be acceptable *The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). 2014 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2014) 35, 2541–2619.

20. NCS during the 2 years following stent Risk of MI or need for coronary revascularization VA retrospective – older men Stents placed 2000 - 2010 Risk highest (3.5%) immediately after stent Risk stabilizes (1.0%) at 6 months post stent Especially true for drug eluting stent *Holcomb CN, Graham LA, Richman JS, et al. The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following Coronary Stenting. J Am Coll Cardiol. 2014;64(25):2730-2739. doi:10.1016/j.jacc.2014.09.072.

22. Perioperative Cardiovascular Risk NSQIP database Mayo Clinic 1120 patients with stents then NCS  2006 to 2011 Risk of major adverse cardiac event and bleeding elevated for 1 year post stent *Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2016;67(9):1038-1049. doi:10.1016/j.jacc.2015.11.063.

24. Time to stent thrombosis Stop ASA, stop thienopyridine Median 7 days Continue ASA, stop thienopyridine Median 122 days (6% within 10 d) *Eisenberg MJ et al. Safety of Short-Term Discontinuation of Antiplatelet Therapy in Patients With Drug-Eluting Stents. Circulation. 2009; 119: 1634-1642.

25. 85-year-old man right colectomy Continue aspirin Discontinue clopidogrel 5 days preop Resume clopidogrel asap postop  Loading dose 300mg Heightened surveillance for postop stent thrombosis Copyright © 2016

26. 85-year-old man right colectomy Don’t forget other agents to decrease risk  Statin  Continue beta blocker His anemia at time of NSTEMI should have raised concern about drug eluting stent committing him to long term asa + clopidogrel Copyright © 2016

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