A patient with a recently placed coronary artery drug-eluting stent (DES) 3 months ago on dual antiplatelet therapy (DAPT: aspirin + clopidogrel) requires elective hip replacement. What is the recommended management of antiplatelet therapy?
- A Stop both aspirin and clopidogrel 7 days before surgery
- B Bridge with IV heparin after stopping DAPT 5 days preoperatively
- C Postpone surgery until 12 months post-DES if at all possible; if surgery cannot be delayed, continue aspirin and consult cardiology regarding clopidogrel bridging strategy ✓
- D Switch to warfarin for bridging anticoagulation
Explanation
Drug-eluting stents require DAPT for 12 months to prevent in-stent thrombosis (which carries ~45% mortality). Elective surgery should be postponed until 12 months post-DES if possible. If surgery cannot be delayed beyond 6 months post-DES, aspirin should be continued perioperatively whenever possible (bleeding risk tolerable), and the decision on clopidogrel should be made with cardiology input — abrupt DAPT cessation carries 30-fold increased risk of stent thrombosis. Heparin bridging does not protect against platelet-mediated stent thrombosis. Warfarin does not substitute for antiplatelet agents.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
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