Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Abstract

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93e3.88), P¼0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31e 3.46), P¼0.96. Bleeding was more frequent with DAPT 6.55 (2.3e17.96) P¼0.0002. In a propensity matched analysis of

Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion

“…The maintenance of aspirin or clopidogrel until surgery was not found to be significantly associated with MACCE in our results, which does not agree with the previous guidelines [26]. However, the protective role of an antiplatelet agent against the major adverse cardiovascular event was reported to be insignificant by a recent prospective observational study [44]. Another recent retrospective study of patients with second-generation DES reported that the incidence of major adverse cardiac events was not influenced by antiplatelet therapy [45].…”

Withholding antiplatelet therapy before noncardiac surgery might increase the risk of major adverse cardiovascular events: numbers often hide the truth (Comment on BJA 2019; 122:170-179)

“…Those results tended to persist when patients who continued dual APT (DAPT) were excluded from the analysis, suggesting that the risk of MACE is also linked to discontinuation of aspirin monotherapy. However, the results by Hong and colleagues 2 discontinuation of APT for <7 days in their study did not lead to adverse outcomes. Even after taking note of these limitations, this study does highlight the dilemma of routine protracted discontinuation of APT.…”

“…EditordWe are grateful to Karim and colleagues 1 for their thoughtful comments on the Occurrence of Bleeding and Thrombosis during Antiplatelet therapy in Noncardiac surgery (OBTAIN) study. 2 They expressed concern that the results of OBTAIN might be used to advocate the discontinuation of dual antiplatelet therapy (DAPT) in all patients who have undergone percutaneous coronary intervention (PCI) and now require noncardiac surgery. We agree that this clinical problem requires a nuanced approach.…”

The clinical dilemma of managing patients who are on dual antiplatelet therapy and require major non-cardiac surgery

“…1 In this context, Howell et al, conducted the OBTAIN multicentre prospective cohort study to better delineate the risks and benefits of continuing or interrupting DAPT in patients undergoing non-cardiac surgery after PCI within the 4 yrs preceding the index non-cardiac surgery. 8 identified as part of routine care included cardiac (myocardial infarction or PCI for cardiac event) and bleeding (reoperation for bleeding, gastrointestinal or intracranial haemorrhage, and spinal or epidural haematoma) events. Importantly, there was no standardised postoperative surveillance (i.e.…”