Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction

Abstract

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considered.

Non-ST Elevation Myocardial Infarction and Coronary Artery Stenting in Pregnancy in a Woman with Resistant Familial Hyperlipidaemia

“…For perioperative management of caesarean section, the risk of intraoperative bleeding if antiplatelet therapy was continued had to be balanced against the risk of stent thrombosis if antiplatelet therapy was stopped. It had been 3 months post-NSTEMI and stent insertion, and therefore risk of another coronary event and stent thrombosis was not increased [5]. However, available data are based on non-pregnant patients, while pregnancy is a hypercoagulable state.…”

Gestion péri-opératoire des patients traités par antithrombotiques en chirurgie orale. Argumentaire

“…S32 patients ayant interrompu leur traitement par aspirine durant la période postopératoire immédiate et dans le mois suivant [25,30,60,64,65,102,103,112,116,127,214,277]. Dans une méta-analyse [40], l'arrêt de l'aspirine chez un patient sous aspirine au long cours est associé une augmentation du risque d'évènement thrombotique (cardiaque ou neurologique) d'un facteur trois (OR 3,14 , IC à 95 % de 1,75 à 5,61, p < 0,05).…”

“…Par ailleurs, des études [165,166] ont montré chez des patients porteurs de stents, la survenue d'événement thrombotique dans une période de 1 à 3 mois suite à l'arrêt de la bithérapie (arrêt du clopidogrel et poursuite de l'aspirine). Ceci soulève la question d'un possible « phénomène de rebond prothrombotique » à l'arrêt du clopidogrel [257], effet délétère également évoqué avec l'aspirine [60,102,103] mais dont la physiopathologie n'est toujours pas élucidée [18].…”

“…Pour ce type de chirurgie, comme le risque de saignement est plus élevé ou plus difficilement contrô-lable, le maintien de la thérapeutique antiplaquettaire doit être discuté au cas par cas, en tenant compte de la balance bénéfice/risque (thrombotique et hémorragique) entre le praticien et le médecin prescripteur. Deux stratégies de gestion de la bithérapie peuvent être proposées : maintien de la bithérapie ou arrêt partiel de la bithérapie (arrêt du S33 clopidogrel ou prasugrel ou ticagrelor et poursuite de l'aspirine) [8,60,127,162,163].…”

Ureteroscopy in patients with coagulopathies is associated with lower stone-free rate and increased risk of clinically significant hematuria

“…may result from a rebound increase in clotting factors after discontinuation of these drugs (3). Withdrawal of antiplatelet agents in the perioperative period is associated with higher risks than the maintenance of these medications (4). Several studies have reported coronary stent thrombosis after premature discontinuation of antiplatelet agents (5-7), resulting in increased post-operative myocardial infarction, peri-operative cardiac mortality, and overall mortality (5,6,8).…”