Perioperative Management Of Antiplatelet Therapy Research Articles

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

ObjectiveTo summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.MethodsThis systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database’s inception to July 16, 2020. Meta-analyses were conducted when possible.ResultsIn patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE).ConclusionThis systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.

Predictors of antiplatelet cessation in a real-world patient population undergoing non-cardiac surgery after PCI

BackgroundThe optimal perioperative management of antiplatelet therapy (APT) therapy in patients undergoing noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) is unclear. We sought to identify predictors of APT cessation in a real-world cohort of patients undergoing NCS within 1 year of PCI. MethodsConsecutive patients undergoing PCI at a tertiary center between 2011 and 2018 were prospectively enrolled. Perioperative interruption of APT was defined as cessation of either aspirin or P2Y12 inhibitor between 1 and 14 days prior to NCS. Predictors of APT discontinuation were identified by multivariable Cox regression with stepwise selection of candidate variables. ResultsA total of 1092 surgeries corresponding to 747 patients were identified. Overall, there were 487 (44.6%) preoperative antiplatelet interruptions: discontinuation of either P2Y12 inhibitors only (47.4%), aspirin only (7.9%), or both agents (44.7%). Both patient-specific risk factors (prior stroke, lower BMI, anemia, MI) and procedure specific risk factors (chronic total occlusions, multivessel disease, drug-eluting stent use) affected decisions regarding APT cessation. Likelihood of APT cessation increased in higher-risk surgeries and in patients on more potent P2Y12 inhibitors (ticagrelor/prasugrel vs clopidogrel) whereas those undergoing NCS <90 days post PCI were less likely to have cessation of APT. ConclusionIn this contemporary cohort of post-PCI patients undergoing NCS, patient-, angiographic- and surgery-specific factors all affected decision-making regarding APT cessation. Our findings reflective of real-world practice, highlight the importance of a multidisciplinary team approach to individualize decision making in these patients.

Impact of aspirin discontinuation on thrombotic complications in laparoscopic colorectal cancer surgery.

The number of patients taking antiplatelet therapy is increasing. However, there is no definitive guideline for the perioperative management of antiplatelet therapy. Conventionally, the discontinuation of antiplatelet drugs has been the basic treatment as perioperative management. Therefore, we investigated the risk of discontinuing aspirin concerning thrombotic complications in laparoscopic colorectal cancer surgery. Between January 2015 and December 2019, a total of 729 patients underwent laparoscopic colorectal cancer surgery in Toyonaka Municipal Hospital. Sixty-four patients taking antithrombotic drugs aside from aspirin were excluded from this study; the remaining 665 patients were considered eligible and divided into three groups. The patients not taking aspirin were classified as the "Control group" (n = 588). Among the patients taking aspirin, those who continued preoperative aspirin were classified as the "Aspirin group" (n = 30), and those who discontinued preoperative aspirin were classified as the "No-aspirin group" (n = 47). The Aspirin, No-aspirin, and Control groups were compared retrospectively. Among the 3 groups, there were no significant difference in operative time (p = 0.14), bleeding volume (p = 0.63), or postoperative hospital stay (p = 0.06). Assessing the postoperative complication, bleeding complications were significantly more frequent in the Aspirin group (p < 0.01), although those complications were all Clavien-Dindo grade II. In contrast, thrombotic complications were significantly more frequent in the No-aspirin group (p < 0.01). Note that those complications were all Clavien-Dindo Grade III/IV. This result suggested that discontinuing aspirin increased the risk of severe thrombotic complication. Discontinuation of aspirin as perioperative management in laparoscopic colorectal cancer surgery increased the risk of severe thrombotic complications.

Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management.

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.

Perioperative management of antiplatelet therapy in noncardiac surgery.

Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.

Perioperative Management of Antiplatelet Therapy in Ophthalmic Surgery.

Supported by an unrestricted grant from Research to Prevent Blindness (Flaum Eye Institute, University of Rochester Medical Center) and NIH P30 EY001319. The authors declare that they have no conflicts of interest to disclose.

Perioperative Management of Antiplatelet Therapy in Patients With History of Coronary Artery Disease Undergoing Surgery for Esophageal Cancer: A Single-center Experience.

To present the experience of the upper Gastrointestinal Unit of the Surgical Department of National and Kapodistrian University of Athens in order to inform surgeons of the exact harms and benefits associated with their decisions concerning management of antiplatelet therapy. This was a single-center study of patients who underwent surgery for esophageal cancer and had concomitant coronary artery disease from 1/1/2005 to 31/7/2017. Patients were divided into two cohorts based on when their antiplatelet therapy was stopped (<7 vs. ≥7 days). Esophageal cancer was classified as esophageal only or as Siewert type I, II, or III based on tumor location at the gastroesophageal junction. A univariate logistic regression model was developed to assess the relationship between baseline variables and myocardial infraction, mortality, bleeding and stroke after the operation. For all tests, differences with a value of p<0.05 were considered significant. During the study period, 135 esophagectomies were performed for esophageal cancer. Almost 17% of them had concomitant coronary artery disease medically managed with antiplatelet therapy. No difference was found in terms of myocardial infarction, stroke or severe bleeding events between patients that stopped antiplatelet therapy for more or less than 7 days before esophagectomy. It is a reasonable approach to discontinue antiplatelet therapy for more than 7 days before surgery, especially in such a population of patients with esophageal cancer that require complex operations with high bleeding risk.

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

BackgroundThe perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). MethodsOccurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. ResultsA total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. ConclusionsOBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI.

Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review

BackgroundThe correct perioperative management of antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) is often debated by clinicians. American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend postponing elective NCS at least 3 months after stent implantation. Regardless of the timing of surgery, ACC/AHA guidelines recommend continuing at least ASA throughout the perioperative period and ideally continuing dual APT (DAPT) therapy “unless surgery demands discontinuation.” The objective of this review was to ascertain the risks and benefits of APT in the perioperative period, to assess how these risks and benefits vary by APT management, and the significance of length of time since stent implantation before operative intervention.MethodsPubMed, Web of Science, and Scopus were searched from inception through October 2017. Articles were included if patients were post PCI with stent placement (bare metal [BMS] or drug eluting [DES]), underwent elective NCS, and had rates of major adverse cardiac events (MACE) or bleeding events associated with pre and perioperative APT therapy.ResultsOf 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small (< 50: n = 5, 51–150: n = 5, >150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (< 6 months: n = 3, 6–12 months: n = 1, > 12 months: n = 6). At least six different APT strategies were described. Six studies further utilized bridging protocols using three different pharmacologic agents. Studies typically included multiple surgical fields with varying degrees of invasiveness. Across all APT strategies, rates of MACE/bleeding ranged from 0 to 21% and 0 to 22%. There was no visible trend in MACE/bleeding rates within a given APT strategy. Stratifying the articles by type of surgery, timing of discontinuation of APT therapy, bridging vs. no bridging, and time since stent placement did not help explain the heterogeneity.ConclusionsEvidence regarding perioperative APT management in patients with cardiac stents undergoing NCS is insufficient to guide practice. Other clinical factors may have a greater impact than perioperative APT management on MACE and bleeding events.Systematic review registrationPROSPERO CRD42016036607

Preoperative Evaluation of the Ophthalmology Patient

Ophthalmologic surgeries, particularly cataract surgeries, are amongst the most frequently performed procedures in the United States and worldwide. These procedures are generally associated with a low risk of major adverse complications and are well-tolerated. Traditional scoring systems used to calculate the risk of perioperative complications are not applicable to ophthalmologic surgeries and may overestimate risk, potentially leading to unnecessary development of worsened vision or vision loss. Conversely, while these surgeries are generally associated with a low risk, outcomes are improved when comorbid conditions are identified, communicated to the ophthalmologist, and effectively managed. Additionally, routine preoperative testing is frequently ordered, but rarely indicated. A reduction in unnecessary preoperative testing has substantial potential to reduce the economic impact on healthcare costs in this patient population. Of particular note, the perioperative management of antiplatelet therapy and anticoagulation in the patient undergoing ophthalmologic surgery can be confusing. Internists may not have an adequate understanding of the bleeding risks associated with common ophthalmologic surgeries, and ophthalmologists may not have an adequate understanding of which patient populations are at highest risk of adverse events from an interruption of therapy. A better understanding of the bleeding risks associated with common ophthalmologic surgeries can help the internists provide more accurate recommendations to the ophthalmologist to allow for a more appropriate treatment plan in the perioperative setting and help determine optimal timing of surgical intervention.

Perioperative Outcomes of Patients Undergoing Lobectomy on Clopidogrel

Perioperative management of antiplatelet therapy for patients undergoing pulmonary resection must balance the risk of cardiovascular events with that of hemorrhage. An optimal approach has not been defined in this population. We sought to characterize outcomes of patients undergoing pulmonary lobectomy on antiplatelet therapy with clopidogrel. A prospective institutional database was retrospectively reviewed to identify all patients undergoing pulmonary lobectomy from 2007 to 2015 who received perioperative clopidogrel. Patients were grouped according to the timing of clopidogrel discontinuation before operation: group I, 5 days or less; group II, 6 to 14 days; and group III, more than 14 days. Analyses were performed to assess the effect of timing of discontinuation on adverse events. Sixty-two patients were identified and included in the analysis. The indication for clopidogrel was coronary artery disease in 44 patients (71%), 35 (56%) of whom had prior stent placement. The overall incidences of transfusion and major cardiovascular events were 16% (10 of 62) and 6.5% (4 of 62), respectively. Non-ST elevation myocardial infarctions occurred in 4 patients. Three were in patients with stents, all placed more than 1 year before the operation. There were no significant differences identified in estimated blood loss, operative duration, or perioperative deaths. No significant outcome differences in perioperative cardiovascular or hemorrhagic events were identified among the groups. Although these findings suggest that clopidogrel may be discontinued shortly before the operation with limited risk of bleeding, we also found that holding therapy for more than 14 days preoperatively may be safe in appropriately selected patients.

P3.04-023 Perioperative Management of Antiplatelet Therapy in Patients with Coronary Stent Who Need Thoracic Surgery: Topic: Miscellaneous I

Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 6 -12 months after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). It is often replaced by bridging heparin for the prevention of perioperative stent thrombosis in Japan, although there is no evidence for heparin replacement. The aim of this study was to investigate the perioperative complication between the patients with continuation of antiplatelet therapy (APT) and that with substitution of heparin after interruption of APT in thoracic surgery. A retrospective study was done on 75 patients after coronary stent procedures performed thoracic surgery with APT or bridging heparin in perioperative from June 2008 to October 2015. We evaluated the perioperative outcomes between the patients with APT (APT group) and that with bridging heparin interrupting APT (non APT group). Males were 13 cases (76%) and median age was 73.5 years in APT group. Fifteen cases (88%) with APT had angina in past history. The type of stent was drug eluting stent (71%), bare metal stent (24%) and biological absorption stent (6%) in APT group. Surgical procedures with wide wedge resection (12%), segmentectomy (12%), lobectomy (71%), and others (6%) were performed in APT group. Median operative time was 119 minutes and median operative blood loss was 18ml in APT group. There was no difference with operative time and blood loss in APT group compared in non APT group (p=0.128 and p=0.923). Cardiovascular events was not observed in both groups. One case had Hemothorax and reoperation in APT group and one case had hemosputum in non APT group. There was no difference in complication in both groups. Perioperative death was not observed in both groups. There was no difference between the patients with and without the discontinuation of antiplatelet agent in perioperative cardiovascular and embolic events. On the other hand, it seems that the compensatory of bleeding to continue antiplatelet agent is too large, because a few cases were forced completion pneumonectomy and acute exacerbation of interstitial pneumonia due to bleeding. Among the patients with coronary stent undergoing thoracic surgery, it might be less the benefits of the surgery with continuation of antiplatelet agent.

Coronary stenting and surgery: perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation

The management of antiplatelet therapy in patients with coronary stents undergoing surgery is a growing clinical problem and often represents a matter of debate between cardiologists and surgeons. It has been estimated that about 4-8% of patients undergoing coronary stenting need to undergo surgery within the next year. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. In addition, surgery confers an additional risk of perioperative cardiac ischemic events, being high in these patients because of the pro-inflammatory and pro-thrombotic effects of surgery. Current international guidelines recommend to postpone non-urgent surgery for at least 6 weeks after bare metal stent implantation and for 6-12 months after drug-eluting stent implantation. However, these recommendations provide little support with regard to managing antiplatelet therapy in the perioperative phase in case of urgent operations and/or high hemorrhagic risk. Furthermore, ischemic and hemorrhagic risk is not defined in detail on the basis of clinical and procedural characteristics. Finally, guidelines shared with cardiologists and surgeons are lacking. The present consensus document provides practical recommendations on the management of antiplatelet therapy in the perioperative period in patients with coronary stents undergoing surgery. Cardiologists and surgeons contributed equally to its creation. An ischemic risk stratification has been provided on the basis of clinical and procedural data. All surgical interventions have been defined on the basis of the hemorrhagic risk. A consensus on the most appropriate antiplatelet regimen in the perioperative phase has been reached on the basis of the ischemic and hemorrhagic risk. Dual antiplatelet therapy should not be withdrawn for surgery at low bleeding risk, whereas aspirin should be continued perioperatively in the majority of surgical operations. In the event of interventions at high risk for both bleeding and ischemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be considered.

What is the optimal perioperative management of antiplatelet therapy?

What is the optimal perioperative management of antiplatelet therapy?

Coronary stents and non-cardiac surgery: to bridge or not to bridge?

Haemost 2015; 114: 423-431. Patients with coronary stents need antiplatelet therapy to reduce the risk of stent thrombosis. The standard therapy is lifelong low-dose aspirin with supplementary P2Y12-inhibitor treatment during the first months. In patients who have suffered from an acute coronary syndrome (ACS), the P2Y12-inhibitor is usually given for 12 months (1–3). In these patients, the new and stronger P2Y12-inhibitors ticagrelor or prasugrel are preferred over clopidogel, unless the patient is at high risk of bleeding (1–3). In stable coronary patients undergoing elective stenting, clopidogrel is used (3), and the recommended treatment duration depends on the type of stent: bare metal stents 1–3 months, first-generation drug-eluting stents (DES) 12 months and second-generation DES usually six months (3). Earlier cessation of dual antiplatelet therapy (DAPT) carries a high risk for stent thrombosis (4, 5). A need for elective or acute surgery for cardiac or non-cardiac disease is not uncommon in patients with recent stent implantation (6–8). This clearly puts the clinician in a difficult dilemma as an operation is associated with bleeding: should surgery be performed during dual or mono antiplatelet therapy or maybe even without any antiplatelet therapy at all? As the risk of stent thrombosis is highest in the weeks after stent implantation, postponing the operation is an attractive option. Surgery in patients on low-dose aspirin is associated with increased risk of bleeding (9), and bleeding rates are higher when surgery is performed on DAPT (10). Bleeding is a particular problem in some surgical scenarios such as spinal and brain surgery, but also in less extensive procedures such as percutaneous organ biopsies, where neither compression nor direct surgical haemostasis can be performed, are major challenges. In these situations, the surgeon may prefer to stop all antithrombotic medication, whereas individualised perioperative management of antiplatelet therapy guided by platelet function testing might be possible in selected patients undergoing elective surgery (11). Difficult dilemmas should be discussed at a multidisciplinary team conference with participation of a cardiologist, a surgeon, an anaesthesiologist and sometimes also other experts (12). As mentioned, postponing surgery in patients on dual antiplatelets is advised if at all possible. Indeed, DES are most often used and the duration of DAPT is usually for 6–12 months, although with newer generation DES, it might be possible to shorten the time interval to three months (3). In life-threatening acute conditions, surgery may have to be performed on ongoing/uninterrupted DAPT. In other cases (e.g. operations for malignancies), surgery cannot be postponed for several months and given that these cases are particularly challenging they would need to be discussed in the multidisciplinary team. The management of antithrombotic therapy in patients with coronary stents undergoing surgery is thus a major challenge and should be based on a balanced decision weighing the risk of perand postoperative bleeding against the risk of stent thrombosis. If surgery on DAPT is considered too risky and the presumed risk of stent thrombosis is low, the operation is performed on low-dose aspirin after stopping the P2Y12 inhibitor prior to surgery: 3–5 days for ticagrelor and 5 days for clopidogrel and prasugrel (1–3, 12). A difficult clinical dilemma arises if surgery has to be performed without any antiplatelet therapy at all, in particular in the first month(s) after coronary stenting, and especially if the P2Y12 inhibitor has to be stopped within the first days or weeks after stenting (13). The latter situation is not uncommon and the risk of adverse cardiac events is very high and might be further enhanced by the proinflammatory and prothrombotic state associated with surgery (14, 15). Patients with recent ACS, diabetes, low ejection fraction, renal failure and patients who have been undergoing extensive stenting for three vessel disease or left main disease are at particularly high risk (16, 17). In such situations, particular attention is needed and it is recommended that these patients are admitted to a hospital with 24/7 PCI facilities (12). In cases where the risk of stent thrombosis is assumed to be very high, initiation of parenteral antithrombotic bridging therapy should be considered (12, 18).

Perspectives on the management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery.

To provide an updated overview on the management of antiplatelet therapy in patients with coronary stents undergoing cardiac and noncardiac surgery. Surgical procedures are frequently performed in patients with coronary stents and are associated with an increased risk of ischemic and bleeding complications in the perioperative period. Given the lack of well-designed prospective randomized trials, guidelines recommendations are currently derived from observational studies and expert consensus. Defining the optimal balance between the risk of thrombotic events following discontinuation of antiplatelet therapy and the risk of hemorrhagic complications of having a surgical procedure while on antiplatelet therapy is pivotal. Elective surgery should be postponed for at least 4 weeks after bare metal stent implantation and 6-12 months after drug-eluting stent. If this is not possible, aspirin should be continued in the perioperative period, although the management of P2Y₁₂ inhibitors should be individualized according to the individual patient and type of surgery. In the absence of well-defined recommendations deriving from prospective randomized clinical trials, the perioperative management of antiplatelet therapy should be based on the balance between the specific thrombotic and hemorrhagic risks that characterize each patient and each surgical procedure.

Preoperative management of antiplatelet drugs for a coronary artery stent: how can we hit a moving target?

BackgroundWith the advent of percutaneous coronary intervention, specifically the bare metal stent and subsequently, the drug-eluting stent, the scope of interventional cardiology has greatly increased. Aspirin, in combination with a thienopyridine is the present-day cornerstone of oral antiplatelet therapy after coronary artery stent placement. Continuing this chronic antiplatelet therapy, to mitigate a perioperative major adverse cardiac event, can be challenging and remains controversial in patients with a coronary artery stent undergoing non-cardiac surgery. We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.DiscussionA recent systematic review identified 11 clinical practice guidelines for the perioperative management of antiplatelet therapy in patients with a coronary stent who need non-cardiac surgery. However, there is significant variance and inadequacy with these current applicable professional society guidelines. Moreover, persistently variable success has been experienced in translating even well-grounded national clinical guidelines into local practice, including in the perioperative setting. Under the auspices of a broadly multidisciplinary institutional task force and applying the Consensus-Oriented Decision-Making model, we created two evidence-informed and local expert opinion-supported standardized clinical assessment and management plans for the preoperative management of antiplatelet therapy in patients with a coronary artery stent.SummaryPatient care can be optimized via evidence-based, yet locally developed and reiterative standardized clinical assessment and management plans for patients with coronary artery stents undergoing surgical procedures. Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

Perioperative management of antiplatelet therapy

Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.

Pre‐operative medication and proximal femoral fractures

We would like to express some concerns regarding the guidance on antiplatelet therapy in the new AAGBI guidelines on fractured neck of femur [1]. According to the guidelines, ‘aspirin may be withheld during inpatient stay, unless indicated for unstable angina or recent/frequent transient ischaemic attacks’, while ‘clopidogrel is generally not stopped on admission, especially in patients with drug eluting coronary stents’. In our opinion, this advice is contrary to previously published guidance on peri-operative management of antiplatelet therapy. While treatment with aspirin and clopidogrel has been shown to increase transfusion requirements in non-cardiac surgery, there is no evidence that this increases morbidity and mortality [2–4]. In contrast, the risks of stopping antiplatelet medication peri-operatively have been well demonstrated, particularly in those patients with coronary stents, in whom stent thrombosis is frequently a fatal event [5, 6]. Our understanding is that aspirin should be continued throughout the peri-operative period. Clopidogrel should be stopped on admission except in high-risk patients: bare metal stent insertion within 6 months; acute coronary syndrome or stroke within 6 weeks; and drug eluting stent insertion within 6–12 months [3, 4, 7]. In these situations, the decision to stop clopidogrel should be made in conjunction with a cardiologist or the prescribing practitioner. Stopping clopidogrel on admission allows surgery to take place at least 24 hours after the last dose, thereby increasing the effectiveness of any transfused platelets, while still within a 48-hour target. It can be restarted on the morning following surgery, assuming adequate haemostasis [7]. We welcome the statement that antiplatelet therapy should not delay surgery in these patients.