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Expert Opinion

Jun 15, 2018

JOURNAL：American College of Cardiology

ACS Management in a Patient in Need of Noncardiac Surgery
D Narcisse

KEYWORDS
Acute Coronary Syndrome; Adenocarcinoma; Anemia; Angina Pectoris; Angina; Unstable; Angiotensin-Converting Enzyme Inhibitors, Aspirin, Biopsy, Bradycardia, Cardiac Catheterization, Comorbidity, Coronary Angiography, Coronary Artery Disease, Drug-Eluting Stents; Endoscopy; Erythrocyte Indices, Esophagus, Factor X, Fibrinolytic Agents; Follow-Up Studies; Gastroenterology; Hemoglobins, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex, Positron-Emission Tomography; Postoperative Complications; Purinergic P2Y Receptor Antagonists, Rectal Neoplasms, Retrospective Studies, Risk Assessment, Stents; Thrombosis; Ticlopidine; Tomography; Troponin I

INTRODUCTION - Patients with acute coronary syndrome (ACS) benefit from potent antithrombotic therapy and, for those with high-risk clinical features, early invasive risk stratification. This strategy reduces short- and long-term major adverse cardiac events, but it also increases the risk for bleeding. In some scenarios, the risk of bleeding may be particularly acute and predictable. For example, the care of patients who require noncardiac surgery and develop ACS preoperatively involves a careful balance between ischemia and bleeding.1

CASE REPORT - A 70-year-old male patient with a history significant for T4N2 rectal cancer treated with resection, radiation, and chemotherapy presented with melena for 3 weeks and intermittent chest pain for 2 weeks. On arrival, the troponin I was 0.24 ng/mL (upper limit of normal 0.04 ng/mL). The patient's hemoglobin was 8.3 g/dL, significantly decreased from his baseline of 12 g/dL 3 months prior to presentation. The mean corpuscular volume was consistent with microcytic anemia. The patient was admitted to the hospital for further workup of gastrointestinal bleeding and non-ST-segment elevation myocardial infarction (MI).

Due to the gastrointestinal bleeding and anemia, P2Y12 inhibition and antithrombin therapy was withheld. Gastroenterology performed upper endoscopy, which revealed a 5-cm friable mass in the esophagus. Biopsies were consistent with esophageal adenocarcinoma. An oncology evaluation indicated that this was a second primary malignancy. Computed tomography and positron emission tomography scans were negative for metastasis. Prior to treatment, which included surgical resection, chemotherapy, and radiation therapy, it was recommended that the patient undergo coronary angiography to define the burden of coronary artery disease (CAD).

Subsequent left heart catheterization revealed two-vessel CAD with disease located in the left anterior descending and left circumflex arteries with a low SYNTAX score of 11 (Figures 1-2). Due to the requirement for impending surgery, the decision was made to attempt optimal medical therapy including aspirin, statin, angiotensin-converting enzyme inhibitor, nitrates, and ranolazine. Beta-blocker therapy was held due to bradycardia. P2Y12 inhibition was not prescribed to reduce bleeding risk because surgery may be required. Unfortunately, the patient continued to have exertional and rest angina.

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