A 65-year-old man with known ischaemic heart disease is scheduled for elective right hemicolectomy. His last coronary stent was placed 4 months ago and he is on dual antiplatelet therapy. Regarding perioperative management, the MOST appropriate strategy is:

• A Proceed with surgery; withhold both aspirin and clopidogrel for 7 days preoperatively
• B Delay surgery until 12 months post-stenting; continue dual antiplatelet therapy
• C Proceed immediately with surgery; bridging with IV heparin replacing oral antiplatelets
• D Postpone elective surgery until at least 6 months post drug-eluting stent placement; continue antiplatelet therapy until that time ✓

Explanation

Guidelines recommend delaying elective surgery for at least 6 months (preferably 12 months) after drug-eluting coronary stent placement to minimise risk of stent thrombosis, which is precipitated by stopping dual antiplatelet therapy prematurely. The risk of perioperative stent thrombosis with mortality ~45% outweighs the risk of delaying most elective procedures. IV heparin does not protect against stent thrombosis (which is platelet-mediated). If surgery cannot be delayed, aspirin is typically continued while clopidogrel is withheld for 5–7 days.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.