Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery

Abstract

UrologyTotal and partial nephrectomy, percutaneous nephrostomy, percutaneous lithotripsy, radical cystectomy and prostatectomy, prostatic endoscopic resection, endoscopic bladder interventions, penectomy, partial orchiectomyAdapted from Rossini et al 42 with permission of the publisher.

Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting

“…[5][6][7]11 Although current guidelines recommend that administration of ticagrelor should be withheld for at least 5 days before CABG, unstable conditions do not allow waiting for washout of this potent antiplatelet agent. 8,9,11 One of the most clinically important observations in this study was that discontinuation of ticagrelor therapy more than 24 hours before surgery in the group receiving ticagrelor with or without aspirin was not associated with an increased risk of major bleeding complications compared with patients receiving aspirin alone. These findings suggest that it may be safe to operate on patients treated with ticagrelor earlier after its discontinuation, leading to possible clinical and economic benefits.…”

“…8 Concern exists that a discontinuation of several days may be associated with an increased risk of cardiovascular events while awaiting surgery. 9,10 Indeed, in the Platelet Inhibition and Patient Outcomes (PLATO) trial, 3 it was recommended that, in patients undergoing CABG, administration of ticagrelor should be withheld for 24 to 72 hours, and prior guidelines suggested a shorter discontinuation of treatment in patients requiring urgent CABG. 10,11 The absence of randomized studies makes it difficult to establish the exact risk of bleeding complications after perioperative ticagrelor administration and its optimal timing of discontinuation before surgery.…”

International Expert Consensus on Switching Platelet P2Y 12 Receptor–Inhibiting Therapies

“…Preoperative and postoperative management of antiplatelet therapy is described in detail elsewhere. 95 The decision to withdraw P2Y 12 -inhibiting therapy should take into account the thrombotic and bleeding risks of the individual patient according to the specific surgery being performed and timing from PCI. 96 Similarly, the need for bridging should be individualized as described previously.…”

“…96 Similarly, the need for bridging should be individualized as described previously. 95,96 For patients with ACS requiring coronary artery bypass surgery, unless recent PCI was conducted, P2Y 12 -inhibiting therapy should be withdrawn before surgery but restarted postoperatively if the bleeding risk is low. For both cardiac and noncardiac surgery, if withdrawal of P2Y 12 -inhibiting therapy is warranted, clopidogrel and ticagrelor should be discontinued for 5 days and prasugrel for 7 days.…”

Preoperative Fibrinogen and Morbidity in Patients With Residual Platelet Inhibition Undergoing Off-Pump Coronary Artery Bypass Grafting

“…1 However, discontinuation of antiplatelet therapy (DAPT) before surgery may come at the expense of an increased risk of ischemic events in the perioperative period. 2 Irrespective of any bleeding consideration, increased residual antiplatelet effects were shown to be associated with a significant reduction in the risk of early mortality in patients treated with more potent antiplatelet agents than clopidogrel (ie, prasugrel and ticagrelor), 3,4 mirroring similar prior observations with clopidogrel and abciximab. 1,5…”