Perioperative Management of DAPT Post-PCI

Authors:
Banerjee S, Angiolillo DJ, Boden WE, et al.
Citation:
Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2017;69:1861-1870.

The following are key points to remember from this review about the use of dual antiplatelet therapy (DAPT) for post-percutaneous coronary intervention (PCI) patients undergoing noncardiac surgery:

  1. A significant number of patients following coronary stenting undergo noncardiac surgery and may require DAPT interruption. This poses a significant clinical dilemma, as DAPT interruption exposes patients to the potential risk of stent thrombosis, perioperative myocardial infarction, or both. Conversely, continuing DAPT may be associated with excess bleeding complications.
  2. Decision making regarding perioperative management of antiplatelet therapy involves a complex interplay of various clinical variables and requires an individualized approach.
  3. Based on contemporary evidence, the prior Class I recommendation that elective noncardiac surgery in drug-eluting stent recipients be delayed for 1 year has been modified and reduced to at least 6 months in the 2016 guideline and the prior Class IIb recommendation to consider noncardiac surgery after 180 days has been modified and reduced to 3 months.
  4. In this review article, the authors suggest a framework for perioperative management of DAPT. In general, for patients at low thrombotic and low hemorrhagic risk, they suggest that clinicians continue aspirin (ASA) and discontinue P2Y12 receptor inhibitor; and resume within 24-72 hours with a loading dose.
  5. For patients at intermediate thrombotic and low hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, then the suggestion is to continue ASA, to discontinue P2Y12 receptor inhibitor, and resume within 24-72 hours with a loading dose.
  6. For patients at high thrombotic and low hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, they suggest continuing ASA and P2Y12 receptor inhibitor perioperatively.
  7. For patients at low thrombotic and intermediate hemorrhagic risk, they recommend continuing ASA, discontinuing P2Y12 receptor inhibitor, and resuming within 24-72 hours with a loading dose.
  8. For patients at intermediate thrombotic and intermediate hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, continue ASA, discontinue P2Y12 receptor inhibitor, and resume within 24-72 hours with a loading dose.
  9. For patients at high thrombotic and intermediate hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, continue ASA, discontinue P2Y12 receptor inhibitor, resume within 24-72 hours with a loading dose, and consider bridging with a short-acting intravenous antiplatelet therapy.
  10. For patients at low thrombotic and high hemorrhagic risk, they recommend continuing ASA, discontinuing P2Y12 receptor inhibitor, and resuming within 24-72 hours with a loading dose.
  11. For patients at intermediate thrombotic and high hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, continue ASA, discontinue P2Y12 receptor inhibitor, and resume within 24-72 hours with a loading dose.
  12. For patients at high thrombotic and high hemorrhagic risk, they suggest postponing elective surgery. If surgery cannot be deferred, continue ASA, discontinue P2Y12 receptor inhibitor, resume within 24-72 hours with a loading dose, and consider bridging with a short-acting intravenous antiplatelet therapy.
  13. The suggestions outlined above are expert opinions, which highlight the need for a highly individualized and collaborative approach to patient care, and multidisciplinary team-based decision making. The lack of high-quality evidence in this important therapeutic area also underscores a need for well-designed clinical studies to guide and inform physician practice.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Aspirin, Drug-Eluting Stents, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Perioperative Period, Platelet Aggregation Inhibitors, Primary Prevention, Risk, Stents, Surgical Procedures, Operative, Thrombosis


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