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

Capodanno, Davide; Angiolillo, Dominick J.

doi:10.1161/circulationaha.113.003675

Cited by 107 publications

(95 citation statements)

References 125 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…[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.…”

Section: Discussionmentioning

confidence: 70%

“…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.…”

mentioning

confidence: 99%

See 1 more Smart Citation

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

et al. 2016

View full text Add to dashboard Cite

IMPORTANCEThe optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.OBJECTIVE To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone. DESIGN, SETTING, AND PARTICIPANTSThis prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.EXPOSURES Before surgery, patients received ticagrelor with or without aspirin or aspirin alone. MAIN OUTCOMES AND MEASURESSevere bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.RESULTS Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]. Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion . Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12. 4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group. CONCLUSIONS AND RELEVANCEIn propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

show abstract

Section: Discussionmentioning

confidence: 70%

mentioning

confidence: 99%

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

et al. 2016

View full text Add to dashboard Cite

show abstract

“…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.…”

Section: Special Considerationsmentioning

confidence: 99%

“…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.…”

Section: Special Considerationsmentioning

confidence: 99%

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

et al. 2017

Self Cite

View full text Add to dashboard Cite

Dual antiplatelet therapy with aspirin and a P2Y 12 inhibitor is the treatment of choice for the prevention of atherothrombotic events in patients with acute coronary syndromes and for those undergoing percutaneous coronary interventions. The availability of different oral P2Y 12 inhibitors (clopidogrel, prasugrel, ticagrelor) has enabled physicians to contemplate switching among therapies because of specific clinical scenarios. The recent introduction of an intravenous P2Y 12 inhibitor (cangrelor) further adds to the multitude of modalities and settings in which switching therapies may occur. In clinical practice, it is not uncommon to switch P2Y 12 inhibitor, and switching may be attributed to a variety of factors. However, concerns about the safety of switching between these agents have emerged. Practice guidelines have not fully elaborated on how to switch therapies, leaving clinicians with limited guidance on when and how to switch therapies when needed. This prompted the development of this expert consensus document by key leaders from North America and Europe with expertise in basic, translational, and clinical sciences in the field of antiplatelet therapy. This expert consensus provides an overview of the pharmacology of P2Y 12 inhibitors, different modalities and definitions of switching, and available literature and recommendations for switching between P2Y 12 inhibitors. Dual antiplatelet therapy with aspirin and a platelet P2Y 12 receptor antagonist (P2Y 12 inhibitor) is the treatment of choice for the prevention of atherothrombotic events in patients with acute coronary syndromes (ACS) and for those undergoing percutaneous coronary intervention (PCI).1,2 Clopidogrel, prasugrel, and ticagrelor are the most commonly used oral platelet P2Y 12 inhibitors; the use of ticlopidine, the first available P2Y 12 inhibitor, has been largely abandoned. 3Clopidogrel is the only oral P2Y 12 inhibitor indicated for the treatment of patients with stable coronary artery disease.1,2 Although all 3 agents have an indication for use in ACS, current guidelines support the preferential use of prasugrel and ticagrelor over clopidogrel because of their superior net clinical benefits.1,2,4-6 Nevertheless, clopidogrel remains widely prescribed. 7,8 The availability of different oral P2Y 12 inhibitors has enabled physicians to contemplate switching among therapies because of specific clinical scenarios. 9 The recent introduction of an intravenous P2Y 12 inhibitor (ie, cangrelor) further adds to the multitude of modalities and settings in which switching therapies may occur. 6 A variety of factors may contribute to the decision to switch, including the clinical setting, patient characteristics, concomitant therapies, costs, social issues, development of side effects, medication adherence, and patient/physician preference. Therefore, it is not uncommon to change P2Y 12 inhibitor. However, concerns about the safety of switching between these agents have emerged. At present, data from large-scale clinical studie...

show abstract

“…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…”

mentioning

confidence: 62%

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.

Cited by 107 publications

References 125 publications

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

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

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

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

Contact Info

Product

Resources

About

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.

Cited by 107 publications

References 125 publications

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

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

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

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

Contact Info

Product

Resources

About

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