Perioperative Bridging/Cessation of Antiplatelet Agents: 2020 Update

Abstract

Perioperative management of patients receiving antiplatelet therapy is common and must carefully balance the risk of ischemia or thrombosis with bleeding. Here we describe pathways of platelet aggregation unique to the perioperative period and mechanisms of commonly encountered antiplatelet medications, and review current literature evaluating strategies for antiplatelet management surrounding elective noncardiac and cardiac surgery. Antiplatelet therapies demonstrate unique risk profiles for stent thrombosis and bleeding that may be dependent on individual genetic polymorphisms. Use of scoring systems or point-of-care platelet function assays may identify patients especially vulnerable to alterations in perioperative antiplatelet management, and guide timing of surgery. Prior guidelines, which recommend a minimum 6-month delay in elective surgery for patients receiving dual-antiplatelet therapy following percutaneous coronary intervention (PCI), may be amended to 3 months in certain cases in which newer generation antiplatelet therapies are administered. While use of intravenous bridging agents may reduce platelet reactivity during cardiac surgery, there is no single antiplatelet strategy which consistently reduces rates of major bleeding or cardiovascular events. There is insufficient evidence to support any specific perioperative antiplatelet strategy. Cases should be individualized to balance the risks of stent thrombosis and bleeding. Current recommendations may be modified if the risk of delaying surgery outweighs the risk of stent thrombosis. It is reasonable to guide management by utilizing scoring systems and point-of-care platelet function assays.