Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies

Abstract

Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.

Risk of Adverse Cardiac and Bleeding Events Following Cardiac and Noncardiac Surgery in Patients With Coronary Stent

“…Considering the fact that SBEs were numerically higher than cardiac death and MI, a standardized bleeding classification of surgical procedures seems helpful, and interesting attempts in this direction are ongoing. 13 In our study, thrombotic risk stratification on the basis of stent type (DES versus BMS) and time from PCI showed a good correlation with the incidence of cardiac death/MI within 30 days after surgery ( Figure 3A). Patients with intermediate thrombotic risk exhibited a 50% higher risk of cardiac death and MI, and patients classified at high risk showed a risk of cardiac death/MI 2.17× higher than patients at low thrombotic risk.…”

“…3 Bleeding risk associated with each procedure was classified into low, intermediate, or high on the basis of available literature coupled with expert opinion (Table II in the Data Supplement). 13 For this purpose, a large number of surgeons were previously involved, and the result of this multidisciplinary collaboration have been summarized in an intersociety consensus document on perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation. The document was endorsed by 16 national societies of cardiology, anaesthesiology, and surgery.…”

“…Stent thrombosis risk was defined low >6 months after BMS and >12 months after DES; intermediate 1 to 6 months after BMS or 6 to 12 months after DES; and high <1 month after BMS or <6 months after DES (Table 1). 13 For patients with multiple PCI procedures, only the procedure carrying the highest thrombotic risk based on the classification above was selected for the analysis. Patients with DES were further differentiated between old-generation DES (oDES; Cypher and Cypher Select [ In patients undergoing surgery, the incidence of cardiovascular death, myocardial infarction (MI), and serious bleeding event (SBE) was assessed at 30 days.…”

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

“…However, all these documents lacked a clear definition of perioperative bleeding risk, advocating tailored treatment decided within a multidisciplinary team but without providing clear guidance. Recently, Rossini et al proposed a multidisciplinary document, endorsed by 16 Italian national societies of cardiology, anaesthesiology and surgery, on perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation (24). This document has been recently updated on the basis of new scientific data and is awaiting publication (Rossini R. et al submitted).…”

Preoperative Evaluation Before Non-Cardiac Surgery in Patients with Percutaneous Coronary Intervention: Review

“…29 Bunun yanı sıra kanama sonrasında yapı-lacak kan transfüzyonu da stent trombozunu artırmaktadır. 30 Kanama durumlarında Aspirin ve klopidogrelin etkisini önleyecek ilaç yoktur. Ancak etkilerini azaltmak amacıyla trombosit transfüz-yonu, desmopressin veya Faktör VII verilebilir.…”