2012 Update to the Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and Noncardiac Operations

Study Questions:

What are recommended guidelines for the use of antiplatelet medications in patients undergoing surgical operations?

Methods:

The Society of Thoracic Surgeons Workforce on Evidence Based Surgery provided updated recommendations based on recent literature regarding the use of antiplatelet medications during surgery.

Results:

The major points of this article include:

1. The bleeding risk of patients requiring cardiovascular procedures should be assessed; established risk factors for bleeding include: advanced age, reduced red blood cell volume, complex operations, urgent operations, preoperative antiplatelet and anticoagulant drugs, and chronic comorbidities.

2. Especially in patients at high risk of bleeding, P2Y12 inhibitors should be discontinued for a few days prior to cardiovascular surgery; this practice is associated with reduced bleeding and reoperation, but not with a difference in death, myocardial infarction, or stroke. Stopping aspirin before cardiovascular surgery reduces bleeding, but the risk of other adverse events in patients with an acute coronary syndrome is not known.

3. It is reasonable to continue antiplatelet monotherapy (either clopidogrel or aspirin) in patients undergoing most noncardiac surgeries regardless of urgency.

4. Antiplatelet therapy should be started soon after coronary artery bypass surgery.

5. In patients on dual antiplatelet therapy requiring urgent operation, a delay of 1-2 days is reasonable in patients with an acute coronary syndrome; platelet inhibition testing may be useful to determine the optimal delay. Evidence suggests that aspirin should be continued until the operation.

6. The provider team should coordinate their approach in the use of perioperative antiplatelet medications.

Conclusions:

A multidisciplinary and evidence-based approach to antiplatelet therapy is important in patients undergoing surgery.

Perspective:

These guidelines synthesize recent literature and provide evidence-based recommendations for the perioperative use of these drugs in common clinical scenarios. While we have an improved level of evidence in some scenarios, there is still much that is unknown, such as the relative risk and benefit of surgery in patients with coronary stents who are on dual antiplatelet therapy. Further, the data suggest that real-world practice is frequently at odds with guidelines, suggesting a need to improve the penetrance of evidence and guidelines into clinical practice patterns.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Arrhythmias, Interventions and ACS

Keywords: Myocardial Infarction, Stroke, Acute Coronary Syndrome, Platelet Aggregation Inhibitors, Erythrocytes, Comorbidity, Ticlopidine, Risk Factors, Thoracic Surgery, Stents, Reoperation, Platelet Aggregation, Cardiovascular Diseases, Coronary Artery Bypass, Hemorrhage


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