Unfractionated Heparin during the Interruption of Antiplatelet Therapy for Non-cardiac Surgery after Drug-eluting Stent Implantation

Abstract

Objective Heparin is not recommended to be administered during the interruption of antiplatelet therapy for non-cardiac surgery. However, there are insufficient data to determine the value. The purpose of the present study was to evaluate the clinical results of the administration of unfractionated heparin during the interruption of antiplatelet therapy in non-cardiac surgery patients who had previously undergone drug-eluting stent (DES) implantation. Methods We retrospectively identified 210 elective non-cardiac surgical procedures that were performed with the administration of unfractionated heparin during interruption of all antiplatelet therapies in patients who had previously undergone DES implantation. Heparin was administered during the perioperative period in accordance with the local practice guideline at out institution. We examined the clinical outcomes within 30 days of surgery. Results The mean number of implanted DESs was 2.1±1.3. No major adverse cardiac events (including cardiac death, definite stent thrombosis, and non-fatal myocardial infarction) occurred in any of the 210 cases within 30 days of surgery. Four of the 210 cases (1.9%) required reoperation for bleeding within 30 days of surgery. Conclusion Our data showed the potential for the perioperative management with unfractionated heparin administration in Japanese patients who had previously undergone DES implantation who required noncardiac surgery with the interruption of all antiplatelet therapies.

Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review

“…No two studies used the same strategy. Bridging agents included glycoprotein IIb/IIIa inhibitors [ 19 – 21 ], low molecular weight heparin [ 20 , 22 ], and unfractionated heparin [ 23 , 24 ]. APT management varied within the bridging studies: some included just DAPT while others included DAPT or SAPT.…”

“…Ten studies provided a measure of average time from PCI to NCS. Three studies averaged less than 6 months (“early”) [ 15 , 21 , 25 ], one was six to 12 months (“mid”) [ 26 ], and six were greater than 12 months (“late”) [ 16 , 17 , 19 , 23 , 24 , 27 ]. Seven of these studies had outcomes associated with pre and perioperative APT strategies providing nine MACE data points and eight bleeding data points (Fig.…”

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“…Así mismo, algunos estudios que exploraron la estrategia de suspensión de la DAP con terapia puente o "bridging" con cangrelor (un inhibidor P2Y12 reversible de acción ultracorta), inhibidores de los receptores IIbIIIa (tirofiban o eptifibatide) o anticoagulantes pre cirugía de revascularización miocárdica, no demostraron disminuir el riesgo de eventos isquémicos o hemorrágicos (122)(123)(124)(125)(126) aunque se evidenciaron bajas tasas de eventos en general, y el cangrelor demostró un mantenimiento adecuado de la actividad antiplaquetaria durante el puente. Un estudio observacional en Argentina encontró una baja tasa de eventos isquémicos con la estrategia de puente con tirofiban, y una tasa de sangrado de 8%, en su mayoría BARC 2 (127).…”

“…(127,128) -En pacientes de muy alto riesgo isquémico, podría considerarse la terapia puente con heparinas ante la necesidad de suspensión de la DAP temprana luego de la angioplastia. (122,123) -En pacientes sometidos a cirugía no cardíaca se recomienda reiniciar la DAP dentro de las 24 h posoperatorias, si se ha controlado el sangrado.…”