Patient Suffers Myocardial Infarction After Stopping Plavix

The case involves an elderly female patient with an extensive cardiac history and family history, who was to undergo kidney stone surgery. The cardiologist advised that he would need to stop Plavix and Aspirin 1 week prior to surgery and for 2 weeks after surgery (but continue other cardiac medications throughout). The surgery was performed and two days later, the patient suffered an acute MI with stent placement followed by placement of a defibrillator.

Question(s) For Expert Witness

1. Do you perform angioplasty? If so, how often?

2. What is the standard preoperative and post-operative advice given to patients undergoing angioplasty regarding medications?

3. Is it possible that discontinuing Plavix and aspirin for that length of time could have caused the patient's MI?

Expert Witness Response E-007419

I will be able to render an opinion as to whether or not discontinuation of the Plavix and aspirin was related to the patient's myocardial infarction. Essential additional information in this particular case would include the date that the previous stent was inserted, the specific type of stent which had previously been placed, i.e. a bare-metal or drug-eluting stent, and information regarding the specific infarct related artery and if the infarction was related to an in-stent thrombosis of the previously placed stent. If they infarction was related to an acute thrombus formation within the previously placed stent and that stent was a drug eluded stent, discontinuation of antiplatelet therapy preoperatively could certainly and most probably would be related to the myocardial infarction. It is well known that in-stent thrombosis can occur as a result of discontinuation of antiplatelet therapy in patients who have had previously placed drug-eluting stents. The time that the initial stent was inserted is also important in this case as guidelines state that antiplatelet therapy should not be discontinued within one year after a drug-eluting stent is inserted unless the patient requires emergent surgery. It is unclear to me as to the indications for the surgery and the sense of urgency for this patient's surgery. If the patient had a drug eluded stent and that the stent is placed over a year ago, discontinuation of Plavix one week prior to the procedure is not a deviation of standard of care. Current guidelines suggest continuation of low-dose aspirin throughout the perioperative period or surgical procedures other than those related to the spine or brain. I generally recommend continuation of low-dose aspirin for all non-cardiac surgical cases except for those related to the brain or spine or unless the surgeon feels that there is extremely high risk of bleeding should low-dose aspirin be continued.