Question of the Week # 408

408)  A 52 year old post-menopausal woman with history of  hypertension, coronary artery disease and early stage breast cancer is evaluated in your office prior to breast reconstruction surgery. She was diagnosed with left breast invasive ductal carcinoma one year ago and has undergone left modified radical mastectomy followed by chemotherapy. Her history is significant for cardiac catheterization 3 months ago with coronary stent placement. Medications include Aspirin, Clopidogrel, metoprolol, lisinopril and anastrozole.  She is physically active and walks about 3 blocks per day with out any chest pain or shortness of breath.  Physical examination is unremarkable except fore evidence of left mastectomy. A resting electrocardiogram, chest x-ray , complete blood count and electrolytes are normal. Which of the following is the most appropriate recommendation at this time?

A) Schedule exercise stress test  and if normal, clear for surgery

B) Discontinue Clopidogrel and clear for surgery

C) Obtain 2D echo and if normal, clear for surgery

D) Admit, discontinue clopidogrel, start heparin and then, proceed with surgery

E) Recommend delaying surgery at least another 8 months

15 Responses

  1. A

  2. e

  3. E) Recommend delaying surgery at least another 8 months

    • d

  4. e

  5. C

  6. B) Discontinue Clopidogrel and clear for surgery

  7. c

  8. C

  9. e

  10. d

  11. e
    Needs continuous Clopidogrel to keep open the stent, as the surgery is elective, we should postpne the elective surgery. If no h/o stent we shoud stop Clopedogrel 1 week prior to surgery.

  12. D-

  13. C, as long as cardiac is clear pt is ready to go, antiplt is necessary for cad

  14. Ans.. E

    I will paste an answer from someone who posted it on the usmle Forum

    ” First of all what type of stent: bare metal or drug eluting? the way this question is asked. I assume DES.
    So, ANswer is E.

    I have never seen such a thing like using heparin to bridge for stents. Heparin has nothing to do with antiplatelets therapy in term of stents. Rather, you WILL CONTINUE antiplatelets therapy around the surgery if you cannot hold them. For CABG you continue ASA and stop the other antiplatelet 5 days before.

    Breast surgery a consider a low risk surgery

    Periop cardiac eval:
    step 1 : is the surgery emergent >> yes: do surgery No: go to step 2
    Step 2: Are there any red flags= active cardiac conditions (acte CHF, acute coronary syndrome >cardiac eval and optimization. if No, go to step3
    Step3: Is the pt undergoing low risk surgery? yes>> surgery. No: step 4
    Step4: does the pt have good functionnal capacity >> evaluate METS (metabolic equivalent). Pt should have > 4 Mets.4 Mets are qivalent to carry grocery upstairs.
    Step 5: you get here if pt has poor fnctionnal status or you cannot determine the funct status >> check clinical risk factors. Cardiac eval (echo, stress test…)

    For stents: Hold off on elective non cardiac surgery if :
    – within 4-6 wks of BMS (baremetal stent)
    – Within 12 months of DES (drug eluting stent)
    – within 4 weeks of ballon angioplasty (was 14 days in previous guidelines) “

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