Severe Aortic Stenosis, a Fractured Hip, and Dual Antiplatelet Therapy
A 78-year-old woman (52 kg) is admitted at 22:00 with a displaced femoral neck fracture after a fall. She reports two episodes of exertional syncope in the past month. Echocardiography three weeks ago showed an aortic valve area of 0.7 cm², mean gradient 46 mmHg, ejection fraction 60%, and moderate concentric hypertrophy. Five months ago she had a drug-eluting stent placed in the LAD after an NSTEMI and takes aspirin 81 mg plus clopidogrel 75 mg daily; eGFR is 38 mL/min/1.73 m². The orthopedic surgeon wants to operate at 07:00 the next morning and asks whether the antiplatelet drugs can simply be continued. She is comfortable at rest, BP 138/70, HR 68, with a grade 3/6 crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids.
1. Which findings drive this patient's operative risk, and what do you need to establish before an anesthetic plan can be made?
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Two independent, competing risks exist and neither can be ignored.
Aortic stenosis: valve area 0.7 cm² and mean gradient 46 mmHg meet criteria for severe stenosis, and exertional syncope makes her symptomatic - the highest-risk symptom short of heart failure. Symptomatic severe AS carries a substantial perioperative mortality for noncardiac surgery because stroke volume is fixed: hypotension or tachycardia reduces coronary perfusion and can produce ischemia, arrhythmia, and arrest. Her ejection fraction of 60% is falsely reassuring; the hypertrophy and small cavity mean the ventricle is preload-dependent and poorly tolerant of vasodilation.
Hip fracture: each day of delay beyond 24–48 hours increases mortality and morbidity from immobilization, delirium, and pressure injury, so indefinite delay is not benign either.
Before planning, establish:
- Whether the syncope is truly from AS - ECG and rhythm to exclude heart block and arrhythmia, orthostatic vitals, and whether there was a prodrome or exertion.
- Current volume status and any signs of heart failure.
- Cardiac surgery or structural heart team availability for balloon aortic valvuloplasty or expedited TAVR as a bridge; this conversation should start tonight, not in the morning.
- Baseline hemoglobin, renal function, and the exact date and complexity of the stent.
2. The surgeon asks whether the antiplatelet drugs can simply be continued. How do you weigh stent thrombosis, surgical bleeding, and neuraxial hematoma?
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This is not a single drug question - it is a question about which anesthetic technique you are willing to pair with which antiplatelet strategy.
- Stent thrombosis: a drug-eluting stent five months old sits in the highest-risk window; premature clopidogrel discontinuation risks a catastrophic infarction. Guidelines favor delaying elective surgery six months after a drug-eluting stent, and this fracture is not elective.
- Surgical bleeding: continuing dual therapy increases blood loss in hip fracture surgery, but this is generally manageable bleeding, not the catastrophic and irreversible event that stent thrombosis is.
- Neuraxial hematoma: clopidogrel must be stopped 5–7 days before neuraxial puncture. Aspirin alone is acceptable. If dual therapy continues, spinal and epidural techniques are off the table.
The defensible resolution is to continue dual antiplatelet therapy, avoid neuraxial anesthesia, and use general anesthesia or a peripheral fascia iliaca or femoral nerve block for analgesia - peripheral blocks are safe on dual therapy. Stopping clopidogrel is an option only with explicit cardiology concurrence and a documented shared decision with the patient, and it would then be timed with the surgical delay. Involve cardiology tonight and document the reasoning, whatever is chosen.
3. Assuming surgery proceeds tomorrow, describe your intraoperative hemodynamic goals and how the antiplatelet decision shapes the anesthetic technique.
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Because dual antiplatelet therapy continues, neuraxial anesthesia is excluded; plan general anesthesia with an arterial line placed before induction, or a peripheral block plus careful general anesthesia.
Hemodynamic goals in severe AS:
- Keep the patient in sinus rhythm. Atrial fibrillation or nodal rhythm loses the atrial contribution to a stiff ventricle and can cause abrupt hypotension; treat aggressively.
- Maintain preload - the ventricle is small and stiff and needs filling pressure; do not dry her out preoperatively.
- Preserve afterload and systemic vascular resistance; avoid vasodilators and deep volatile anesthesia before the airway is secure and the line is in.
- Keep heart rate in the normal-to-low-normal range (roughly 60–80) to allow diastolic coronary filling.
- Treat hypotension with a vasoconstrictor such as phenylephrine boluses first, not with fluid alone and not with a vasodilator.
- Avoid tachycardia from light anesthesia, pain, or anemia.
For the block, use a peripheral technique with diluted local anesthetic and incremental dosing under monitoring, or perform it after induction if you prefer. Postoperatively, plan for monitored or intensive care beds, continuous rhythm and blood pressure monitoring, and early involvement of the structural heart team for definitive valve therapy during the same admission.