eP283 - The Heart or the Colon: Risks of Dual Antiplatelet Therapy versus Delayed Colectomy for Cancer

Purpose/Background: An 83-year-old woman with a history of hypertension, hyperlipidemia, abdominal aortic aneurysm, recent stroke, and diverticulitis requiring sigmoid colectomy presented with anemia and dyspnea. Given her extensive cardiac history, she underwent stress electrocardiography which demonstrated ischemia. She subsequently underwent left heart catheterization which revealed 70% stenosis of her left anterior descending artery. This was treated with percutaneous coronary intervention (PCI) by drug-eluting stent (DES) placement. She was discharged home on aspirin and clopidogrel (dual antiplatelet therapy; DAPT) but re-presented two weeks later with symptomatic anemia.Methods/Interventions: Gastroenterology was consulted given persistent anemia. Though colonoscopy 4 years ago was negative, repeat colonoscopy at this time demonstrated a large cecal mass with biopsy showing adenocarcinoma with intact mismatch repair proteins. She was discharged the following day, but again readmitted one week later for bright red blood per rectum and anemia. Staging CT chest/abdomen/pelvis was negative for metastatic disease. Colorectal surgery was consulted for possible surgical intervention in the setting of bleeding cecal mass and symptomatic anemia.Results/Outcomes: A multidisciplinary cardiology, gastroenterology, and colorectal surgery review of treatment options was conducted. Cardiology recommended delay of surgical intervention for at least 8 weeks after DES placement with supportive care via intermittent transfusions.Conclusion/

Discussion: With continued medical advances, average life span continues to increase and a greater proportion of colectomies are currently performed in geriatric patients with more complex comorbidities. Previous research demonstrates that patients readmitted for bleeding after PCI are more likely to have colon cancer without metastasis (OR 5.44, 95% CI 3.29-8.99, p < 0.001). Thus, elderly patients who present with anemia or bleeding after PCI should be evaluated for colonic adenocarcinoma, even with a remote history of negative colonoscopy.

With regards to duration of DAPT in patients requiring noncardiac surgery, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines published recommendations in 2016. The risk of in-stent thrombosis following PCI with DES is highest in the first 4-6 weeks following the procedure, but can remain elevated up to 1 year. However, newer studies have demonstrated no significant difference in rates of in-stent thrombosis for patients treated with 3 versus 6 months of DAPT. For patients who require nonelective noncardiac surgery, such as a colectomy, after PCI with DES on DAPT, treating clinicians should reach consensus weighing the risks of in-stent thrombosis and major cardiovascular perioperative events versus the risk of delaying definitive cancer treatment.Figure 1Staging CT chest/abdomen/pelvis with evidence of 3.7 cm cecal polyp