May 13th, 2011
Simultaneous TIA and ACS After Aspirin Cessation for Palpebral Surgery
Jean-Pierre Usdin, MD and James Fang, MD
A 77-year-old man with metformin-treated type 2 diabetes, high blood pressure, moderate renal insufficiency, stable angina, and a history of phlebitis stopped taking aspirin in preparation for palpebral surgery. A day after the surgery, he presented to the ER with two transient ischemic attacks (TIAs) affecting the left arm.
The patient complained to the examining neurologist of epigastric discomfort. An electrocardiogram showed new abnormalities, and the man was diagnosed with ST-segment elevation acute coronary syndrome (ACS). A head CT was negative for acute thrombosis or bleed. Given the man’s recent surgery, coronary angiography was postponed for 48 hours. Aspirin was given along with other usual medical therapy.
Two days later, a few minutes before the scheduled angiogram, the patient developed a serious nosebleed and the angiogram was canceled. After another two days, the angiogram was finally performed, 300-mg clopidogrel was given, and a drug-eluting stent was placed in the left-anterior descending artery using a right femoral artery approach. A few minutes after the patient left the cath lab, the nosebleed recurred. No transfusion was necessary.
The day after the angiogram, an asymptomatic left femoral vein thrombus was detected on systematic vein Doppler imaging. This 88-kg man with a serum creatinine level of 2.5 mg/dL was discharged 3 days later on fondaparinux (5 mg/day), aspirin, and clopidogrel.
Another 10 days later, while at his country house, the patient experienced another nosebleed and was driven to the closest hospital. The attending physician decided to stop fondaparinux and start warfarin; aspirin and clopidogrel were continued. Phlebitis, again confirmed, was healing well.
Questions:
1. Was the initial delay in performing the angiogram warranted?
2. Was it appropriate to implant a drug-eluting stent?
3. Was the choice of fondaparinux a good one, would low-molecular-weight heparin have been a better choice, or would warfarin have been preferable from the start?
Response:
James Fang, MD
This complicated case represents what clinicians are increasingly encountering in practice: a patient with concomitant bleeding and thrombosis. The general approach is to consider the most life-threatening issue first and to recognize that other medical treatments for acute ischemic heart disease (short of mechanical revascularization) are often underutilized. Unfortunately, the relevance of evidence-based strategies to these situations is often limited because most clinical studies exclude such patients.
A TIA followed by a STEMI should raise concerns about brain–heart syndromes, such as embolic conditions (endocarditis, atrial fibrillation, heart failure, myxomas) and aortic syndromes (dissection, aortic plaque, vasculitis). Pre-intervention imaging is crucial in such cases because specific brain–heart diagnoses are difficult to make purely on the basis of clinical acumen.
In this particular case, an initial delay in performing coronary angiography would seem appropriate until the neurologic issues were comfortably resolved. However, the narrative does not make clear why resolution took 48 hours. Was the STEMI aborted with medical therapy? A small but significant proportion of infarcts can be aborted with aggressive medical management short of mechanical reperfusion. Although this was presumably an anterior MI, was it a “high-risk” situation? Clinical tools (e.g., the STEMI TIMI risk score) can be used to help determine the level of risk. Coronary angiography and PCI can be performed in a patient, even with a serious nosebleed (particularly if the STEMI is a high-risk one). It is not clear how the nosebleed was investigated or addressed, but being unable to control this type of bleeding is unusual.
Given the presence of both bleeding and thrombosis (and the possible need for subsequent warfarin anticoagulation), a bare-metal stent might have been a reasonable choice to avoid the need for prolonged dual antiplatelet therapy. If the vessel was quite large and the diseased segment relatively short, the risk for restenosis with a bare-metal stent might have been acceptable despite the patient’s diabetes.
With a new thrombosis, systemic anticoagulation needs to be strongly considered. However, this man has several risk factors for bleeding (older age, acute coronary syndrome, diabetes, renal insufficiency, dual antiplatelet therapy), and the use of “triple therapy” will undoubtedly be complicated by bleeding. Although some concern about hypercoagulability may be warranted without bridging antithrombin therapy to warfarin, one can make a case for initiating warfarin without the bridge. Use of a retrievable inferior vena cava filter as adjuvant therapy could even be considered.
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12 Responses to “Simultaneous TIA and ACS After Aspirin Cessation for Palpebral Surgery”
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Why did he stop aspirin before surgery? I believe that aspirin cessation before surgery is way overdone. This man had plenty of indications to keep taking aspirin. Did anyone examine the interior of his nose and see if there was an area that could have been cauterized?
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none
No ( minor surgery), probably, and no ( gfr too low). Once the DVT is documented after the DES, renal failure limits long term use of fonda and enoxaparin (I am not comfortable with the “half dose” use over 3 to 6 months). So…stuck with warfarin…but would start with unfract heparin and overlap by 2 days. Also consider TEE to exclude paradoxical emboli.
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What was the reason for the surgery. What was the cardiac status prior surgery. I would not have stopped the aspirin.
Tough case regarding the nosebleed, but I do not see the logic of stopping aspirin for minor eyelid surgery. In any case, the event was waiting to happen and the patient probably was not taking OMT anyway, given recent findings in the literature. Fortunately, he got the stent, is hopefully on OMT, and walked out of the hospital. I suggest he follow up with ENT to be sure no further bleeders lurk up his schnozz.
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I don’t belong to the HRS. None.
The combination of arterial and venous thrombosis is suggestive for aquired thrombophylia ( LAC, deficit C or S proteins..). Probably will be helpful to exclude this problem.
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None
I agree with Dr Salvatore Petrina . the repeated epistaxix ( and I would have liked to understand whether it was anterior or posterior one ) with the DVT resulting after PTCA and evidence of TIA , suggests one should rule out a hypercoagulability state .
The delay in angiogram is raccomanded while clinically the patient did not need an urgent PCI ( neither had he ACS )and had moderate epistaxis.
The implantation of a drug-eluting stent is not to me to decide , the cardiologist performing the PTCA is usually deciding while operating the procedure .Still there is a controversy whether balloonig , non drug eluting or drug eluting stent is better for one patient or anothre . there is no concluded guideline , so the decision is done in time of the catheterization.
The choice which anticoagulation treatment is better for this patient -personally I would start with low-molecular weight heparin and afterwards moving to coumadine. I do not have experience with fondaparinux .
Yes, angiogram had to be done, yes a drug diluting stent is the best choice, this patient may have been treated with LMWH, and continued on it until DVT resolves and D-Dimer is within normal limits. A tight BP control, either with a Calcium-channel blocking agent such as Manidipine, or a combination of ACEI and diuretic, such as Perindopril plus Indapamide is to be implemented. I have the hunch that the most up-to-date opinions point that Aspirin continues being the drug of choice for a TIA, Clopidogrel may add a bit, but Dipyridamole can also be considered. Stenting for coronary artery disease is right, but not for above the chest circulation. A cholesterol lowering drug is mandatory in this context, and Pravastatin is a good choice, as it has shown in RCT some specific protection against stroke. The combination of Warfarin, Aspirin and Clopidogrel may pose the patient in a too high bleeding risk, evenmore, we are dealing with a TIA, and although TIA have a tendency to relapse, there are predictive scales for this risk, and it’s just a risk, not a sure event. An epistaxis is not a serious bleeding, but just a warning.
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None
I dont se the indication for palpebral surgery in this mman, and in any case I would’nt stop aspirin
I agree with Drs, Petrina & Cohen to rule out thronbofilia
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none
Thank you to all my colleagues for these comments.
The Aspirin was stopped by the attending cardiologist considering the the ophtalmologist’wishes.
I would not personally stop the antithrombotic for a minor surgery furthermore the patient was stable and well treated by his physician.
The surgery was performed because the ptosis of superior eyelids which provoked a serious discomfort in this still professionally active patient.
The nose bleeding was anterior and the EENT specialist did a cauterization after the first event. Unfortunately the oxygen nasal canula (which was not totally necessary) placed by the anesthesiologist was partly the cause of recurrent bleeding.
We did not perform specific tests for thrombophilia, the age of the patient and the lack of really histories of recurrent thrombosis is not, in my opinion, in favor of a genetic problem of coagulation.
I agree with the fact that choosing LMWH or Fondaparinus was not a good idea; in fact Coumadin plus aspirin is a better option but we remain with an active stent and a diabetic patient so Clopidogrel…
We can speculate on the following idea:” if Aspirin had not been stopped, possibly all these successive events will not happen”
difficult choice between thrombosis and hemorrhage is our daily problem.
dr Jean-Pierre Usdin
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No conflicts of interests
An intriguing case and a lively debate. Most agree that stopping aspirin was problematic in a diabetic hypertensive patient with “stable” angina — I would argue that stopping aspirin in a patient with known coronary artery disease to perform a provocative elective procedure was the mistake. However troublesome the eye issue for a professional, the more important medical issue was the CAD which should have been investigated and remedied first. Dye load was obviously an issue for a patient with chronic kidney disease, but with adequate hydration, delineation of coronary anatomy and exclusion of a PFO accomplished. Fondaparinux, like enoxaparin, has no approved indication in renal failure, but can certainly be used with decreased dosing frequency and monitoring of drug levels (easily done in most laboratories), and, I would argue, that in a setting of mild-to-moderate renal failure, might well be safer than institution of warfarin in this patient without a bridging strategy or coupling warfarin with aspirin and clopidogrel.
Competing interests pertaining specifically to this post, comment, or both:
On advisory panel for and have received honoraria from GlaxoSmithKline.
Dear doctor Andersen I agree with the fact that Aspirin should not be stopped before the eyelid surgery. It was a minor surgery and I do not know or understand the reasons of this stopping. I could not have an explanation from the surgeon or the attending cardiologist.
I think however that the evaluation of the status of the CAD before this surgery was not necessary low operative risk, no emergency, stable patient.
I was really concerned about all the comments this case provoked. This patient’s case was discussed in our peer review and the same discussions with agreements and non agreements were made.
many thanks to CardioExchange for accepting this case.
dr Usdin.
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no conflicts of interest.
Thank you, Dr Usdin. I may simply reveal myself for the pedant I am, but I’m still stuck on “stable” angina and “low operative risk” in a diabetic patient with hypertension and chronic kidney disease. Any procedure or injury that involves activation of the hemostatic system in such a patient ( with elevated factor VIII, vWF, fibrinogen, PAI-1 levels and acquired platelet hyperfunction, etc.) provides an opportunity for trouble in compromised cardiac or cerebral vessels — known by coronary symptomatology and serum creatinine levels to be present in this patient. Thank you for letting me participate in the discussion. Judith
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None relevant to this comment.