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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

Selected in EuroIntervention by S. Brugaletta

References

Authors

Rossini R Musumeci G Visconti L Bramucci E Castiglioni B, De Servi S, Lettieri C, Lettino M, Piccaluga E, Savonitto S, Trabattoni D, Capodanno D, Buffoli F, Parolari A, Dionigi G, Boni L, Biglioli F, Valdatta L, Droghetti A, Bozzani A, Setacci C, Ravelli P, Crescini C, Staurenghi G, Pietro Scarone P, Francetti L, D’Angelo F, Gadda F, Comel A, Salvi L, Lorini L, Antonelli M, Bovenzi F, Cremonesi A, Angiolillo D, Guagliumi G

Reference

EuroIntervention 2014;10:38-46

Published

May 2014

Link

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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be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk.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.

My Comment

What is known   

The number of patients with coronary stents undergoing surgery is increasing significantly. Premature discontinuation of antiplatelet therapy, especially if it occurs within the first months after stent implantation, is associated with a higher risk of stent thrombosis, a feared complication that might have dramatic clinical consequences. On the other hand, antiplatelet therapy can significantly raise intraoperative hemorrhagic risk in surgical or endoscopic procedures. Little support is provided with regard to managing antiplatelet therapy in the perioperative phase in case of semi-elective or urgent surgical or endoscopic procedures. The purpose of this paper is to provide practical recommendations for a tailored and standardized antiplatelet treatment management, specific for each type of surgery.

Major findings 

  • 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 risks.
  • Aspirin should be continued peri-operatively in the majority of surgical operations.
  • 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.

My comments

The present consensus represents a first attempt to guide antiplatelet treatment of those patients who received double antiplatelet therapy after stent implantation and who need to undergo a cardiac or non-cardiac surgery. Of value is that it has been developed by a consensus between the three medical doctors usually involved in such decision (cardiologists, surgeons and anaesthesiologists). Every kind of surgery has been evaluated and classified according to bleeding risk and balanced with the ischemic risk of the patients. As such guidelines are still missing at European level, it would be important that this consensus could push an European consensus on this matter.

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