Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend? (original) (raw)
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Perioperative management of antiplatelet therapy
British Journal of Anaesthesia, 2013
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.
Arquivos Brasileiros de Cardiologia, 2018
Background: The current guidelines dispose recommendations to manage antiplatelet agents in the perioperative period; however, the daily medical practices lack standardization. Objectives: To asses factors associated with inadequate management of antiplatelet agents in the perioperative period of non-cardiac surgeries. Methods: Cross-sectional Study conducted in hospital from October 2014 to October 2016. The study dependent variable was a therapy that did not comply with the recommendations in the Brazilian Association of Cardiology (SBC) guidelines. The independent variables included some characteristics, the people in charge of the management and causes of lack of adherence to those guidelines. Variables were included in the multivariate model. Analysis was based on the odds ratio (OR) value and its respective 95% confidence interval (CI) estimated by means of logistic regression with 5% significance level. Results: The sample was composed of adult patients submitted to non-cardiac surgeries and who would use acetylsalicylic acid (aspirin) or clopidogrel (n = 161). The management failed to comply with the recommendations in the guidelines in 80.75% of the sample. Surgeons had the highest number of noncomplying orientations (n = 63). After multivariate analysis it was observed that patients with a higher level of schooling (OR = 0.24; CI95% 0.07-0.78) and those with a previous episode of acute myocardial infarction (AMI) (OR = 0.18; CI95% 0.04-0.95) had a higher probability of using a therapy complying with the guidelines. Conclusion: Positive association between patients' schooling level, or those with a history of previous AMI, with management of the use of aspirin and clopidogrel in the perioperative period of non-cardiac surgeries. However, diverging conducts stress the need of having internal protocol defined.
Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery
Journal of the American College of Cardiology, 2017
Dual antiplatelet therapy (DAPT) is prescribed to millions of patients worldwide following coronary stenting. DAPT is indicated to lower the risk of ischemic events, such as myocardial infarction, including stent thrombosis, ischemic stroke, or death from cardiovascular causes. A significant number of these patients undergo noncardiac surgery and may require DAPT interruption. This poses a significant clinical dilemma because DAPT interruption exposes patients to the potential risk of stent thrombosis, perioperative myocardial infarction, or both. Conversely, continuing DAPT may be associated with excess bleeding complications. Observational data in this area are conflicting, and there are no randomized clinical trials to guide practitioner decision making. On the basis of predominantly consensus recommendations, various strategies for managing DAPT during the perioperative period have been proposed. This review presents 3 commonly encountered clinical scenarios that lead into an ev...
Guideline on antiplatelet and anticoagulation management in cardiac surgery
European Journal of Cardio-Thoracic Surgery, 2008
This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor Vlla to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).
Comparison of Two Strategies for the Management of Antiplatelet Therapy During Urgent Surgery
Annals of Thoracic Surgery, 2005
The optimal management of aspirin and clopidogrel therapy before surgery in patients with acute coronary syndrome is uncertain. Aspirin and clopidogrel within 5 days of surgery increases postoperative bleeding and reexploration. However, in acute coronary syndrome patients the risk of bleeding must be balanced against the risks of discontinuing the treatment and delaying surgery.From June 2002 to July 2003, patients undergoing urgent coronary artery bypass graft surgery (CABG) for acute coronary syndrome were randomly assigned to one of two groups. The treatment group remained on aspirin and clopidogrel therapy till surgery, receiving intraoperative aprotinin. The placebo group received placebo for 5 days before surgery and received placebo infusions intraoperatively. Platelet reactivity in response to adenosine diphosphate was assessed by whole blood single-platelet counting. Of the 88 patients eligible, 50 entered the study.Postoperative blood loss was significantly greater in the placebo group than in the treatment group (702 ± 120 mL versus 446 ± 62 mL, p = 0.004). This difference was observed as early as 8 hours postoperatively (385 ± 66 mL versus 266 ± 36 mL, p = 0.03). Patients in the placebo group also required more blood transfusions (1 ± 0.3 units versus 0.3 ± 0.2 units, p = 0.03). Three patients in each group underwent surgical reexploration for bleeding.The strategy of continuing aspirin and clopidogrel therapy with intraoperative aprotinin reduces postoperative blood loss, transfusion requirements, prevents delay to surgical treatment, and may prevent major adverse cardiac events before surgery.
Antiplatelet Therapy, Cardiac Surgery, and the Risk of Bleeding: The Surgeon's Perspective
Reviews in Cardiovascular Medicine, 2011
Antiplatelet therapy is widely accepted in the contemporary management of patients with coronary syndromes. Effective platelet inhibition can cause an increased risk of bleeding, which is more evident when patients are referred to surgical coronary revascularization. The cardiac surgeon should be familiar with all new antiplatelet drugs. In this article we compile the latest information about antiplatelet therapy and its impact on cardiac surgery.