For this patient who underwent percutaneous coronary intervention and stenting with an everolimus-eluting coronary stent 4 months ago, the optimal preoperative management is to delay surgery. The American College of Cardiology and American Heart Association (ACC/AHA) previously recommended delaying elective noncardiac surgery for a minimum of 12 months after placement of a drug-eluting stent (DES) due to the increased risk of cardiovascular complications, regardless of the type of antiplatelet therapy; however, according to the 2016 Guideline Focused Update on Duration of Dual Antiplatelet Therapy, the ACC/AHA now recommends that elective noncardiac surgery be optimally delayed at least 6 months after DES implantation. The updated ACC/AHA guideline states that noncardiac surgery can be considered 3 months after DES placement if the benefits outweigh the risks. This requires collaborative decision making with the patient's cardiologist. Patients with bare metal coronary stenting require a minimum noncardiac surgical delay of 30 days.
In patients treated with percutaneous coronary intervention who are undergoing elective noncardiac surgery, dual antiplatelet therapy should optimally not be discontinued within 6 months of DES placement. For patients who must undergo noncardiac surgery before the minimum duration of DAPT, either continuation of both antiplatelet agents or aspirin alone may be considered based on discussions between all members of the perioperative care team. However, in this patient's case, surgery is elective and optimally should be delayed.
Antiplatelet management in elective surgical patients with a previous history of coronary intervention who have surpassed the minimum duration of DAPT is also controversial. The ACC/AHA recommends consensus decision making between a patient's clinicians to provide an individualized antiplatelet management plan, whereas the American College of Chest Physicians advises that patients on aspirin who are at moderate to high risk for cardiovascular events should remain on aspirin throughout surgery. Those at moderate to high cardiovascular risk include patients with ischemic heart disease, heart failure, diabetes mellitus, prior stroke, kidney disease, or undergoing vascular procedures.