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Recent drug-eluting stent for spinal decompression56-year-old man, 92 kg, with progressing leg weakness from thoracic cord compression

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Know this first

  • After a stent for ACS, waiting 12 months is ideal; past 3 months, time-sensitive surgery can be reasonable.
  • Stent thrombosis risk peaks in the 3 months after a DES.
  • Platelet function returns 3–5 days after ticagrelor, 5–7 after clopidogrel, 7–10 after prasugrel.
  • Aspirin continues whenever possible.

The patient

56-year-old man, 92 kg, with progressing leg weakness from thoracic cord compression, for decompression within the next few days. NSTEMI treated with a drug-eluting stent 4 months ago, angina-free since; hypertension; climbed two flights before the weakness. Drugs: aspirin, ticagrelor, atorvastatin, bisoprolol, perindopril. Vitals: BP 146/88, HR 64, SpO2 97%, RR 14.

The examiner asks

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  1. Consider

    What concerns you?

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    • A 56-year-old, 4 months after a stent for NSTEMI, needing time-sensitive spinal decompression. Patient
    • Urgency: time-sensitive; delay costs leg function, yet bleeding near his cord would be devastating. Stem trigger
    • Active cardiac conditions? None: his NSTEMI was 4 months ago, past 60 days, and he's angina-free. Disease
    • Risk score: ischaemic heart disease is his only RCRI item; spine surgery isn't on the list. RCRI 1.
    • Functional capacity: two flights before the weakness, over 4 METs.
    • Decision: RCRI 1, so no further cardiac testing; his antiplatelet plan is the real issue.
    • Stented for ACS, so 12 months is ideal; after 3 months surgery may proceed if benefit outweighs risk.

  2. Prepare

    How do you manage his antiplatelets?

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    • A joint decision with him, his cardiologist and the surgeon before stopping anything. (Disease)
    • Aspirin continues through surgery whenever possible.
    • Ticagrelor stops 3–5 days before, the window for platelet recovery.
    • Surgery in a hospital with a 24-hour cath lab.
    • Bisoprolol and atorvastatin continue; perindopril is withheld for 24 hours.

  3. Plan

    Your anaesthetic plan?

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    • Arterial line before induction; five-lead ECG with ST-segment trends. Disease
    • MAP kept at 85–90 for his compressed cord; no tachycardia.
    • Platelets available; transfuse if he bleeds while antiplatelet effect lingers. Crisis
    • Ticagrelor restarts as soon as the surgeon accepts the bleeding risk. After surgery

  4. Crisis

    Two hours in, prone, ST elevation appears in II, III and aVF; BP 78/46, HR 52. What do you do?

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    • Likely stent thrombosis: tell the surgeon and call cardiology now. Crisis
    • Noradrenaline first, plus atropine 1 mg IV and a fluid bolus.
    • Not phenylephrine: its reflex slowing would worsen his bradycardia.
    • Close rapidly, turn him supine, 12-lead ECG and echo.
    • Activate the cath lab; primary PCI is the treatment for STEMI.
    • Anticoagulation for PCI is weighed with the surgeon against his fresh spinal wound. After surgery

Fatal mistakes

  • Stopping both antiplatelet drugs without cardiology.
  • Operating where emergency PCI isn't available.
  • Treating ST elevation with vasopressors alone.

Checked against: AHA/ACC 2024 · Miller 10e

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