Mayo Clin Proc. • June 2009;84(6):546-550 • www.mayoclinicproceedings.com
CLINICAL PEARLS IN PERIOPERATIVE MEDICINE
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Clinical Pearls in Perioperative Medicine
CONCISE REVIEW FOR CLINICIANS
KAREN F. MAUCK, MD, MSC, AND SCOTT C. LITIN, MD
From the Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
See end of article for correct answers to questions.
Individual reprints of this article are not available. Address correspondence
to Karen F. Mauck, MD, MSc, Division of General Internal Medicine, Mayo
Clinic, 200 First St SW, Rochester, MN (email@example.com).
© 2009 Mayo Foundation for Medical Education and Research
learning, Clinical Pearls, was introduced. Clinical Pearls is
designed with the 3 qualities of physician-learners in mind.
First, we physicians enjoy learning from cases. Second, we
like concise, practical points that we can use in our prac-
tice. Finally, we take pleasure in problem solving.
In the Clinical Pearls format, speakers present a number
of short cases in their specialty to a general internal medicine
audience. Each case is followed by a multiple-choice ques-
tion answered live by attendees using an audience response
system. The answer distribution is shown to attendees. The
correct answer is then displayed and the speaker discusses
teaching points, clarifying why one answer is most appropri-
ate. Each case presentation ends with a Clinical Pearl, de-
fined as a practical teaching point that is supported by the
literature but generally not well known to most internists.
Clinical Pearls is currently one of the most popular ses-
sions at the American College of Physicians meeting. As a
service to its readers, Mayo Clinic Proceedings has invited a
selected number of these Clinical Pearl presentations to be
published in our Concise Review for Clinicians section.
“Clinical Pearls in Perioperative Medicine” is one of them.
t the 2001 annual conference of the American College
of Physicians, a new teaching format to aid physician
A 75-year-old woman presents with a hip fracture. Her
medical history is remarkable for coronary artery disease.
Two months previously she had a non–ST-segment eleva-
tion myocardial infarction and had a drug-eluting stent
(DES) placed. She has a history of type 2 diabetes, hyper-
tension, and hyperlipidemia.
Aspirin, 81 mg/d
Clopidogrel, 75 mg/d
Atorvastatin, 20 mg/d
Metformin, 1000 mg twice daily
Enalapril, 40 mg/d
Hydrochlorothiazide, 25 mg/d
Which one of the following would be the most appropriate
recommendation to the surgeon about this patient’s anti-
platelet therapy before hip fracture repair?
a. Do not interrupt aspirin or clopidogrel therapy before
b. Stop both clopidogrel and aspirin therapy for 5 days
c. Stop both clopidogrel and aspirin therapy for 5 days
before surgery and bridge with low-molecular-weight
d. Stop clopidogrel therapy for 5 days before surgery but
do not interrupt aspirin therapy
e. Delay surgery until the 1-year anniversary of stent
Approximately 5% of patients who undergo coronary
stenting will require surgery within the year after stent place-
ment. Because of the need for uninterrupted dual antiplatelet
therapy after these stents are deployed, elective procedures
with a bleeding risk should be deferred. It is recommended
that dual antiplatelet therapy be continued without interrup-
tion for 4 to 6 weeks after the placement of a bare metal stent
(BMS) and for 12 months after a DES to minimize the risk of
stent thrombosis.1 However, unplanned urgent surgeries may
still be necessary during this critical re-endothelialization
period. The generally accepted policy is to withdraw
antiplatelet agents 7 to 10 days before a surgical or endo-
scopic procedure because of the fear of excessive bleeding.
Premature discontinuation of antiplatelet therapy markedly
increases the risk of stent thrombosis, a catastrophic event
that frequently leads to myocardial infarction and/or death.
Premature withdrawal of antiplatelet therapy is associated
with a 5- to 10-fold increase in the perioperative cardiac
death rate, with an average incidence of death of about
30%.1,2 The case fatality rate for patients who develop stent
thrombosis is 45%.2 This obviously puts the physicians,
surgeons, and patients in a difficult situation. In this case, it is
best to consider the risks and benefits of continuation vs
discontinuation of the antiplatelet therapy.
What is the risk of surgical bleeding with antiplatelet
agents? Aspirin increases the rate of bleeding complications
by 1.5 fold; however, for most surgical procedures, it does
not increase the severity of or mortality due to bleeding
complications.2 The exception would be for intracranial neu-
rosurgical and transurethral prostate procedures. Aspirin in