Dual antiplatelet therapy and non-cardiac surgery: evolving issues and anesthetic implications

Abstract

Dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is imperative for the treatment of acute coronary syndrome, particularly during the re-endothelialization period after percutaneous coronary intervention (PCI). When patients undergo surgery during this period, the consequences of stent thrombosis are far more serious than those of bleeding complications, except in cases of intracranial surgery. The recommendations for perioperative DAPT have changed with emerging evidence regarding the improved efficacy of non-first-generation drug (everolimus, zotarolimus)-eluting stents (DES). The mandatory interval of 1 year for elective surgery after DES implantation was shortened to 6 months (3 months if surgery cannot be further delayed). After this period, it is generally recommended that the P2Y12 inhibitor be stopped for the amount of time necessary for platelet function recovery (clopidogrel 5–7 days, prasugrel 7–10 days, ticagrelor 3–5 days), and that aspirin be continued during the perioperative period. In emergent or urgent surgeries that cannot be delayed beyond the recommended period after PCI, proceeding to surgery with continued DAPT should be considered. For intracranial procedures or other selected surgeries in which increased bleeding risk may also be fatal, cessation of DAPT (possibly with continuation or minimized interruption [3–4 days] of aspirin) with bridge therapy using short-acting, reversible intravenous antiplatelet agents such as cangrelor (P2Y12 inhibitor) or glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) may be contemplated. Such a critical decision should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic and bleeding risks.

Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms

“…Derived from the cardiologists' practice for the management of stents in coronary diseases 3 , interventional neuroradiologists usually use dual antiplatelet therapy (aspirin plus a P2Y12 receptor inhibitor [clopidogrel, prasugrel or ticagrelor]) during the first weeks/months after stenting (with no consensus between the different teams around the world), and then switch for a single anti-platelet therapy (for a total of at least one year in our Institution). The drawback of this strategy is that most of the antiplatelet agents used in the field of interventional neuroradiology have a slow onset of action (2-8 hours for clopidogrel, for instance) 4 , thus requiring a loading dose before the endovascular treatment. Additionally, the long duration of platelet inhibition induced by P2Y12 inhibitors 4 is challenging for the management of hemorrhagic complications or unplanned high bleeding risk procedures, including ventricular drainage setting.…”

“…The drawback of this strategy is that most of the antiplatelet agents used in the field of interventional neuroradiology have a slow onset of action (2-8 hours for clopidogrel, for instance) 4 , thus requiring a loading dose before the endovascular treatment. Additionally, the long duration of platelet inhibition induced by P2Y12 inhibitors 4 is challenging for the management of hemorrhagic complications or unplanned high bleeding risk procedures, including ventricular drainage setting. Moreover, platelet inhibition induced by some antiplatelet agents, like ticagrelor, is difficult to neutralize, which may lead to dramatic complication in case of hemorrhage 5 .…”

Knowledge About the Stents and Post Pci Pharmacotherapy Among Patients Undergoing Pci

“…This percentage increased to 30 to 50% with the use of dual antiplatelet therapy. 21,22 Our study is the pioneer work showing a general lack of medical awareness with regards to antiplatelet therapy and stents among patients who go through PCI. 23 The results from our study showed that only 15% of the total patients had an adequate level of awareness about stents and pharmacotherapy therapy after PCI.…”

Preoperative platelet transfusions to reverse antiplatelet therapy for urgent non‐cardiac surgery: an observational cohort study

“…Only a few studies assessed the perioperative bleeding risk in patients with APT undergoing non‐cardiac surgery . The prospective POISE‐2 trial reported an overall bleeding rate of 4.6% in nearly 5000 patients left on aspirin throughout elective non‐cardiac surgery .…”