Clinical practice guidelines for management of dual antiplatelet therapy in patients with noncardiac surgery: A critical appraisal using the AGREE II instrument

Abstract

What is known and objective: Despite the availability of clinical practice guidelines (CPGs), there are considerable differences in their recommendations in the perioperative management of stented patients who need elective noncardiac surgery. Our aim was to systematically review the quality of CPGs for perioperative management of dual antiplatelet therapy (DAPT) and summarize the recommendations. Methods: A systematic search for perioperative DAPT guidelines was conducted on PubMed, Embase and websites of guideline organizations and professional societies until 4 February 2021. Independently, two assessors appraised the quality of CPGs using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument and extracted the data. Recommendations were summarized, and a comparative study was conducted to analyse the consistency among guidelines. Results and discussion: A total of 10 guidelines fulfilled our inclusion criteria. The domain of scope and purpose and clarity of presentation obtained the highest median scores, while the domain of stakeholder involvement and rigour of development obtained the lowest median scores. Three guidelines (ACCP, ESC/ESA and ACC/ AHA) with a score of at least 60% in most AGREE II domains were recommended. Recommendations across perioperative management of DAPT guidelines were inconsistent. What is new and conclusion:The ACCP, ESC/ESA and ACC/AHA CPGs were recommended. There is a need for high-quality prospective studies assessing different management strategies on this issue. Given the lack of consensus, the results of this study will help to guide perioperative dual antiplatelet management strategies for patients with coronary stents who are undergoing noncardiac surgery.

Effect of perioperative aspirin continuation on bleeding after pneumonectomy

“…8 In most clinical situations, continuous aspirin provided benefit that outweighed the bleeding risk, so most guidelines recommend that aspirin is continued perioperatively. 3 However, aspirin cessation should be considered when it comes to the procedures associated with a very high risk of hemorrhagic complications, such as a surgical procedure for pulmonary abscess with empyema or pulmonary resection for destructive pneumonophthisis, for which the American Clinical Practice Guidelines suggest stopping aspirin ≤7 days before the surgery, and resuming an antiplatelet agent ≤24 h after the surgery. 4 There was a lack of consensus in a previous study with regard to the use of bridging therapy with heparin or intravenous antiplatelet agents during perioperative antiplatelet cessation, as the bridging therapy demonstrated no clear benefits.…”

“…Available studies report that the effect of perioperative aspirin continuation on thromboembolic and major bleeding events were varied. 2 , 3 With the rapid development of minimally invasive surgical techniques, when patients receiving aspirin are undergoing elective noncardiac surgery, the American Clinical Practice Guidelines suggest aspirin continuation over aspirin interruption. 4 The 2021 Chinese expert collaboration stated that aspirin should not be discontinued during the perioperative period for major tumor surgery and major thoracic surgery for patients with atherosclerotic cardiovascular disease with high or very high risk of ischemic cardiovascular events.…”

“…The majority of thoracic surgeons have advocated stopping antiplatelet drugs one week before surgery in past decades. Available studies report that the effect of perioperative aspirin continuation on thromboembolic and major bleeding events were varied 2,3 . With the rapid development of minimally invasive surgical techniques, when patients receiving aspirin are undergoing elective noncardiac surgery, the American Clinical Practice Guidelines suggest aspirin continuation over aspirin interruption 4 .…”

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

“…A systematic evaluation of 10 guidelines for perioperative management of dual antiplatelet therapy has demonstrated limited rigor and lack of evidence and consensus. 55 The strengths of this systematic review relate to the close working relationship with experts from CHEST/ACCP who developed a priori clinical question and inclusion criteria and. A panel from CHEST/ACCP will use this evidence along with other contextual and implementation factors, such as patients’ values and preferences, feasibility, and acceptability, to develop practical advice for clinicians.…”

Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool

“…We found that stakeholder involvement regarding the experience and expectations of the target population in development of the guidelines was lacking, a limitation also found in the appraisals of other perioperative guidelines. [30][31][32] Consultation with patients helps ensure that values, preferences, and topics of priority have been considered. There has been an increased shift toward a patient-centered approach in the perioperative care setting that aims to take into account the holistic needs and goals of the patient as a means to improve satisfaction, functional status, and well-being.…”