When Occam's Razor Doesn't Apply

Patient’s can have as many diseases as they damn well please.
— Hickam's dictum, attributed to John Hickam, MD

Today Dr. Mayo presented a case in a "choose your own adventure" style report where the audience participated to help the case unfold. Through the process we saw a patient 5 days post-esophagectomy for adenocarcinoma present with acute shortness of breath and hypoxia. Ultimately found to have segmental pulmonary emboli, sepsis with GNR bactermia and dynamic EKG changes with mid-LAD stenosis requiring DES placement. Whew! Let's walk through a few learning points.

Perioperative Risk Assessment 

While we do not manage many post-operative patients, we are often asked to comment on the patient's perioperative risk of major adverse cardiac events (MACE). There are several tools to do this. The Revised Cardiac Risk Index (RCRI) is one of the most commonly used given its relatively simplicity. Patients are given 1 point for each: high risk surgery (intrathoracic, intraperitoneal, suprainguinal vascular), ischemic heart disease, heart failure, diabetes mellitus (on insulin), cerebrovascular disease, chronic kidney disease (sCr >2 mg per dL). As points accumulate so to do does the risk of MACE: 0 = 0.5%, 1 = 2.6%, 2 = 7.2%, greater than 3 = 14.4% risk. For those with MACE greater than 1%, an estimated functional capacity of less than 4 METs suggests that pharmacologic stress testing may be useful if it would change management. Other calculators include the Gupta Perioperative Cardiac Risk which includes more variables. A conservative recommendation is to utilize both models to inform decision making.

Post-Esophagectomy Complications

Post-operatively, it is important to recall that complications can be systemic or disease specific. For example, post-esophagectomy one might be concerned with not only ACS (MI risk 1.1-3.8%), AFib (as high as 20%), PE (DVT rates 1.5-2.4%), pulmonary disease with pneumonia, ARDS, bronchospasm or COPD exacerbation but also procedure specific complications such as anastomotic leak, conduit ischemic, stricture, recurrent laryngeal nerve injury, chylothorax, diaphragmatic hernia, pneumomediastinum etc.

Triple Therapy?

This case also lead to discussion of triple therapy for management post-DES while treating for segmental pulmonary emboli. Dr. Mayo reviewed a recent article in the International Heart Journal by Amano et al. in Japan looking at DAPT + VKA vs. DAPT + DOAC. The study only had 280 patients however, it found that there was no major difference in terms of bleeding, outcomes and thromboembolism. This trial was limited in that it was single center, retrospective and non-randomized. However, it suggests that more studies should be done and that DOACs may be an alternative to VKA in this setting as well.