Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?

Kapetanakis, Emmanouil I.; Medlam, Diego A.; Boyce, Steven W.; Haile, Elizabeth; Hill, Peter C.; Dullum, Mercedes K.C.; Bafi, Ammar S.; Petro, Kathleen R.; Corso, Paul J.

doi:10.1093/eurheartj/ehi074

Cited by 160 publications

(58 citation statements)

References 31 publications

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“…In these studies, it was shown that dual antiplatelet therapy increased the risk of postoperative blood loss and receipt of blood transfusions following CABG, but there were no significant differences in terms of surgical mortality or outcomes. [22][23][24] One study showed that patients on dual antiplatelet therapy who underwent vascular, orthopaedic, and visceral surgical procedures had a higher chance of receiving a blood transfusion than controls on monotherapy (43% vs 39%). 25 These studies suggest that dual antiplatelet therapy in the perioperative period increases postoperative bleeding rates, but does not influence postoperative morbidity or mortality.…”

Section: Patients On Dual Antiplatelet Therapymentioning

confidence: 99%

Perioperative antithrombotic management in joint replacement surgeries

Chiu²,

Yiu³

et al. 2013

Hong Kong Med J

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531Objectives To determine optimal perioperative antithrombotic management for patients with cardiac diseases undergoing joint replacement surgeries.Data sources MEDLINE and PubMed database search up to January 2013.Study selection Those dealing with perioperative antithrombotic management of patients undergoing orthopaedic operations, especially joint replacement, and also those undergoing general surgery. Various combinations of the following key words were used in our search: "antiplatelet", "antithrombotic", "anticoagulant", "coronary stent", "perioperative", "venous thromboembolism", "cardiovascular", "surgery", "orthopaedic", "knee replacement", "hip replacement", "joint replacement", and "arthroplasty". Data extraction Literature review, original articles, and best practice guidelines.Data synthesis Patients should be stratified according to their risk of developing arterial thromboembolism in order to decide the most appropriate perioperative antiplatelet or anticoagulant regimen for them. After recent coronary stenting, including bare-metal stents implanted within 6 weeks and drug-eluting stents implanted within 6 months, surgery should be deferred. For venous thromboembolism prophylaxis in patients already on aspirin, the dosage should be adjusted as necessary or additional low-molecular-weight heparin administered. ConclusionThe perioperative management of patients with cardiac diseases in receipt of antithrombotic agents is based upon a delicate balance between the perceived risk of arterial thromboembolism and the perceived risk of perioperative bleeding. One must exercise good judgement in deciding the most appropriate perioperative antithrombotic regimen. Venous thromboembolism is also a common problem after joint replacement surgeries. For patients already on aspirin, optimal venous thromboembolism prophylaxis is still being debated.Perioperative antithrombotic management in joint replacement surgeries R E V I E W A R T I C L E

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Section: Patients On Dual Antiplatelet Therapymentioning

confidence: 99%

Perioperative antithrombotic management in joint replacement surgeries

Chiu²,

Yiu³

et al. 2013

Hong Kong Med J

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“…Die Therapie der KHK durch Stentimplantation mit konsekutiver, oft dualer Thrombozytenaggregationshemmung zur Reduktion der "In-stent-Thrombose" erhöht einerseits das Risiko einer postoperativen Blutung [37]. Andererseits haben Patienten mit symptomatischer KHK (neben weiteren kardiovaskulären Risiken) ein hohes Risiko für ein perioperatives akutes Koronarsyndrom (PACS; [22]).…”

Section: Perioperative Behandlung Von Patienten Mit Khk Und Koronarstunclassified

Aktuelle anästhesiologische Aspekte bei urologischen Patienten

Groll

2010

Urologe

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Patients with coronary stents should take clopidogrel and acetylsalicylic acid for 4 weeks or 12 months after stenting. Stopping this medication early, e.g., for surgery, results in a 90-fold increase in the patient's risk for myocardial infarction from stent thrombosis. The mortality due to perioperative acute coronary syndrome clearly exceeds that due to perioperative bleeding complications. If oral medication resulting in platelet inhibition has to be paused "bridging" with short-acting, intravenous GPIIb/IIIa antagonists is possible. In recent years perioperative beta-blockade has been recommended for patients with high coronary vascular risk, and recently also for those with medium or low risk. Current studies, however, indicate that patients on beta-blockers have increased perioperative mortality because of bradycardia, hypotension, and anemia. Therefore, anemia and hypotension should be rigorously avoided.Anesthetic management may have an influence on the postoperative course of cancer. Combined epidural-general anesthesia provides a benefit by minimizing the use of systemic opioids and volatile anesthetics. Presumably, this and a decreased response to surgical stress increase the ability of the patient's immune system to deal with cancer dissemination and micrometastasis.

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“…Interessanterweise konnten Operateure bei Karotisthrombendarteriektomien anhand des Blutungsverhaltens nicht zwischen Patienten unter ASS-Medikation und einer Placebo-Gruppe differenzieren [10]. Für das Blutungsrisiko unter kombinierter Thrombozytenaggregationshemmer-Therapie mit ASS und Clopidogrel liegen nur Untersuchungen bei kardiochirurgischen Eingriffen vor, die ebenfalls keine erhöhte perioperative Mortalität zeigen [8]. Für nichtkardiochirurgische Eingriffe in der Allgemein-, Gefäß-und Unfallchirurgie wurde lediglich ein um 4% erhöhter Transfusionsbedarf unter ASS und Clopidogrel beschrieben [19].…”

Section: Introductionunclassified

Perioperatives Pausieren der antithrombozytären Therapie bei Patienten mit koronaren Stents

Graw

Schwenk

Volk

2008

Chirurg

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According to the present guidelines, patients with coronary stents are to be treated with dual antiplatelet therapy. In case surgery is needed, the risk of a fatal stent thrombosis by withdrawing antithrombotics needs to be balanced in each individual case against the risk of haemorrhagic complications on continued antiplatelet medication. We present a case of fatal stent thrombosis and discuss the current evidence regarding perioperative continuation and interruption of antiplatelet therapy for this patient population. In summary the haemorrhagic risk with acetylsalicylic acid for secondary prevention seems very low, and it should be discontinued only in selected cases. Continued dual anticoagulation concepts are also discussed.

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Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?

Abstract: Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.

Cited by 160 publications

References 31 publications

Perioperative antithrombotic management in joint replacement surgeries

Perioperative antithrombotic management in joint replacement surgeries

Aktuelle anästhesiologische Aspekte bei urologischen Patienten

Perioperatives Pausieren der antithrombozytären Therapie bei Patienten mit koronaren Stents

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