Ask Dr. Keith Roach M.D EDm, KAk EoMidln MJD)
Drug-eluting stent makes knee surgery a no-go for now
DEAR DR. ROACH: I need an objective opinion. I'm an active 75-year-old male who had two drug-eluting stents placed in my heart approximately seven months ago. I have noticed no difference. I have low blood pressure and feel just fine. As a result of the stents, I have been taking 90 mg of Brilinta twice a day since the procedure. Recently, an old injury to my knee flared up, creating a great deal of pain and discomfort. It has not gone away as it usually does.
My orthopedist ordered a CT scan that showed I have a complex tear in my medial meniscus that needs surgery to repair. Even though I am in pain, unable to walk without a cane and suffer throbbing pain in my knee at night, the orthopedist will not operate unless I come off the Brilinta five days prior to the surgery. My cardiologist refuses to agree to succession of the Brilinta with what I consider a cavalier attitude, and offers no alternative suggestions. — G.N.
ANSWER: I understand your frustration, and I hope I can explain why your cardiologist and orthopedic surgeon may have the positions they do.
The stent is a metal device that holds open an artery after it has been unblocked. Some stents are bare metal, but a drug-eluting stent has medication that slowly dissolves over many months, to help keep the blood from clotting inside the stent. A clot often leads to a heart attack and may lead to death.
It takes at least 6-12 months for the artery to fully heal with a drug-eluting stent, during which time the person needs to be protected with both aspirin and another drug, such as clopidogrel (Plavix) or ticagrelor (Brilinta). Stopping these drugs before a year puts the person at greater risk for this catastrophic event. With a drug-eluting stent, if the medication is stopped in the first month, there is a 25 percent risk of heart attack. If it is stopped in the first 11 months, the risk of death is 7.5 percent among those who stopped compared with 0.7 percent for those who didn't. If a cardiologist knows the patient may need surgery within six to 12 months after the heart procedure, a bare-metal stent -which has less risk of clotting the artery — usually is used instead of a drug-eluting one.
From the surgeon's perspective, the risk of serious bleeding with both Brilinta and aspirin is high enough that he or she doesn't want to operate, and I have to trust the surgeon on that decision.
If the surgery is absolutely necessary, the cardiologist likely would put you on a different medication, such as heparin, that would both protect the artery with the stent and could be stopped the day before surgery. In case of an elective surgery, the risk of you having a heart attack and dying is best reduced by waiting the full year.
Finally, recent studies suggest that, at least for most people, physical therapy is as effective as surgery for a meniscal tear, but obviously there are going to be some exceptions.
I am sorry your cardiologist didn't take the time to explain this to you. You are the most important person to make decisions about your care. You need to know enough to make an informed decision. *** Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell. edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.