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    Perioperative Management of Antiplatelet Therapy 04july2021

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    Isabel Arcangel

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    Perioperative Management of Antiplatelet Therapy 04july2021

    Uploaded by

    Isabel Arcangel
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    36. Perioperative Management of Antiplatelet Therapy 04July2021

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    2 views5 pages

    Perioperative Management of Antiplatelet Therapy 04july2021

    Uploaded by

    Isabel Arcangel

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    PERIOPERATIVE MANAGEMENT

    OF ANTIPLATELET THERAPY

    OBJECTIVE:
    To provide guidance to clinicians, based on the Canadian Cardiovascular Society recommendations,
    for the perioperative management of patients on antiplatelet therapy who require non-cardiac or
    cardiac surgery.

    BACKGROUND:
    Antiplatelet drugs are commonly used in the primary and secondary prevention of cardiovascular
    disease. Patients receiving antiplatelet therapy have a broad range of cardiovascular risk depending
    on the clinical indication for treatment.

    With over 200 million noncardiac surgical procedures performed worldwide each year, clinicians face
    unique challenges regarding the perioperative management of patients with coronary artery disease
    who are receiving acetylsalicylic acid (ASA) alone; clopidogrel alone; or any combination of ASA and a
    P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor). Clinicians must balance the risks of major adverse
    cardiovascular events associated with interrupting these therapies against the risk of bleeding from
    continuing these therapies in the perioperative period. Additionally, other factors including the
    pharmacokinetic actions of antiplatelet drugs and the optimal timing of surgery in patients with
    coronary stenting must be considered. The latter group of patients requires special consideration due
    to the increased risks and significant mortality of stent thrombosis.

    RISK STRATIFICATION FOR PERIOPERATIVE THROMBOSIS AND BLEEDING


    Risk stratification for thrombosis and bleeding is largely empiric in patients who are receiving
    antiplatelet therapy. Patients considered at highest risk for cardiovascular events in the perioperative
    period include those with recently (i.e. within one year) implanted bare metal stents (BMS) or drug-
    eluting stents (DES), recent myocardial infarction (MI), those with carotid ulcerating plaque and
    stroke or aortic ulcerating plaque and systemic embolism. Patients at low risk for perioperative
    cardiovascular events are those taking antiplatelet therapy for primary prevention of MI, limb
    ischemia or stroke (although this is rarely indicated). Clinicians must balance these risks against the
    associated risks of perioperative bleeding (listed in Table 1).

    DIAGNOSTIC TESTING, ARTHROCENTESIS, AND MINOR DENTAL, SKIN AND EYE PROCEDURES
    Patients undergoing arthrocentesis, minor dental (extraction, root canal), eye (cataract) or skin
    (biopsy, skin cancer excision) procedures, as well as low bleeding risk diagnostic procedures, can
    continue ASA without interruption. Less is known about the safety of continuing P2Y12 inhibitors
    (clopidogrel, ticagrelor, prasugrel) around minor procedures when taken as monotherapy. It is
    reasonable to discontinue them for a short period (3-4 days) before the procedure. If patients are also

    © 2021 Thrombosis Canada Page 1 of 5


    taking ASA (dual antiplatelet therapy), the P2Y12 should be discontinued prior to surgery (clopidogrel
    and ticagrelor for 5-7 days, prasugrel for 7-10 days) while ASA is continued.

    Patients having a diagnostic test associated with a higher risk for bleeding should be managed like
    higher risk surgeries, as outlined below.

    MANAGEMENT OF PATIENTS WITHOUT CORONARY STENTS UNDERGOING ELECTIVE OR NON-URGENT


    NONCARDIAC SURGERY
    The Perioperative Ischemic Evaluation (POISE) 2 trial is the only randomized trial in noncardiac
    surgery to assess perioperative antiplatelet drug management. It demonstrated that continuing ASA
    did not have an effect on the incidence of major adverse cardiovascular events or mortality but
    increased the risk of major bleeding. Only 4% of patients in this study had a coronary stent and it
    excluded patients who underwent carotid endarterectomy, received a BMS in the 6 weeks before
    surgery, or a DES in the 12 months before surgery.

    Initiating ASA before surgery to reduce perioperative cardiovascular events is not recommended.

    ASA should be discontinued 5-7 days prior to elective or non-urgent non-cardiac surgery except in
    patients undergoing carotid endarterectomy or with recent coronary artery stenting (see below for
    approach). Perioperative ASA continuation might also be reasonable for some surgical interventions
    to prevent local thrombosis (e.g. lower extremity bypass or arterial aneurysm repair).

    In patients with an indication for chronic ASA, this medication should be resumed when the risk of
    bleeding related to surgery has passed, usually between 8-10 days after major noncardiac surgery or
    after venous thromboembolism prophylaxis has stopped.

    MANAGEMENT OF PATIENTS WITH CORONARY STENTS UNDERGOING ELECTIVE OR NON-URGENT


    NONCARDIAC SURGERY
    A sub-study of the POISE-2 trial involving 470 patients with previous percutaneous coronary
    intervention (PCI) and cardiac stents revealed that for every 1000 patients with prior PCI,
    perioperative ASA will prevent 59 myocardial infarctions but cause 8 major bleeds. It is, therefore,
    viewed that in patients with prior PCI undergoing noncardiac surgery, perioperative ASA may be more
    likely to benefit than harm patients.

    Clinicians must consider the timing of surgery and perioperative dual antiplatelet (DAPT)
    management in patients being treated with DAPT after PCI with a BMS or DES.

    © 2021 Thrombosis Canada Page 2 of 5


    Timing of Non-cardiac
    Perioperative Antiplatelet Management
    Surgery
    PCI Patients with a Recommended to delay ASA should be continued perioperatively.
    Bare Metal Stent surgery for at least 1 month Clopidogrel and ticagrelor should be
    after PCI withheld 5-7 days preoperatively, and
    prasugrel 7-10 days preoperatively
    P2Y12 inhibitor should be restarted as
    soon as it is deemed safe by the surgeon

    PCI Patients with a Recommended to delay ASA should be continued perioperatively.


    Drug Eluting Stent surgery for at least 3 Clopidogrel and ticagrelor should be
    months after PCI. If semi- withheld 5-7 days preoperatively, and
    urgent surgery is required, prasugrel 7-10 days preoperatively
    surgery should be delayed
    at least 1 month after PCI P2Y12 inhibitor should be restarted as
    with a DES. soon as it is deemed safe by the surgeon

    MANAGEMENT OF PATIENTS REQUIRING ELECTIVE OR SEMI-URGENT CABG AFTER ACUTE CORONARY


    SYNDROME (ACS)
    Coronary artery bypass grafting is associated with a high risk of bleeding with potentially significant
    consequences (i.e. cardiac tamponade, death). An interdisciplinary assessment of the risks of
    coronary thrombotic complications and risk of perioperative bleeding should be performed with the
    surgeon, interventional cardiologist, attending physician / cardiologist and the patient.

    Treatment Semi-urgent CABG Elective CABG


    ASA ASA should be continued in all patients with ACS who require CABG
    Ticagrelor Suggested to discontinue a minimum of 48-72 Recommended to be
    hours prior to surgery to minimize the risk of discontinued ideally 5 days
    bleeding. prior to surgery.
    Clopidogrel Suggested to discontinue a minimum of 48-72 Recommended to be
    hours prior to surgery to minimize the risk of discontinued ideally 5 days
    bleeding. prior to surgery.
    Prasugrel Suggested to discontinue a minimum of 5 days Recommended to be
    prior to surgery to minimize the risk of discontinued ideally 7 days
    bleeding. prior to surgery.

    Table 1: Risk of Perioperative Bleeding

    © 2021 Thrombosis Canada Page 3 of 5


    OTHER RELEVANT THROMBOSIS CANADA CLINICAL GUIDES

    • Acetylsalicylic Acid (ASA®)


    • Clopidogrel (Plavix®)
    • Prasugrel (Effient®)
    • Ticagrelor (Brilinta®)

    REFERENCES
    Devereaux PJ, et al. Aspirin in patients undergoing noncardiac surgery. New Engl J Med 2014; 370:
    1494-1503.

    Graham M et al. Aspirin in patients with previous percutaneous coronary intervention undergoing
    noncardiac surgery. Ann Intern Med 2018;168(4):237-244.

    Mehta SR, et al. 2018 Canadian Cardiovascular Society/Canadian Association of Interventional


    Cardiology focused update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol
    2018;34(3):214-233.

    Date of Version: 04July2021

    Please note that the information contained herein is not to be interpreted as an alternative to medical advice
    from your doctor or other professional healthcare provider. If you have any specific questions about any

    © 2021 Thrombosis Canada Page 4 of 5


    medical matter, you should consult your doctor or other professional healthcare providers, and as such you
    should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because
    of the information contained herein.

    © 2021 Thrombosis Canada Page 5 of 5

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