Korean J Anesthesiol.  2017 Feb;70(1):13-21. 10.4097/kjae.2017.70.1.13.

Dual antiplatelet therapy and non-cardiac surgery: evolving issues and anesthetic implications

• Song JW
• Soh S
• Shim JK

• KMID: 2402889
• DOI: http://doi.org/10.4097/kjae.2017.70.1.13

Abstract

Dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y₁₂ inhibitor (clopidogrel, prasugrel, or ticagrelor) is imperative for the treatment of acute coronary syndrome, particularly during the re-endothelialization period after percutaneous coronary intervention (PCI). When patients undergo surgery during this period, the consequences of stent thrombosis are far more serious than those of bleeding complications, except in cases of intracranial surgery. The recommendations for perioperative DAPT have changed with emerging evidence regarding the improved efficacy of non-first-generation drug (everolimus, zotarolimus)-eluting stents (DES). The mandatory interval of 1 year for elective surgery after DES implantation was shortened to 6 months (3 months if surgery cannot be further delayed). After this period, it is generally recommended that the P2Y₁₂ inhibitor be stopped for the amount of time necessary for platelet function recovery (clopidogrel 5-7 days, prasugrel 7-10 days, ticagrelor 3-5 days), and that aspirin be continued during the perioperative period. In emergent or urgent surgeries that cannot be delayed beyond the recommended period after PCI, proceeding to surgery with continued DAPT should be considered. For intracranial procedures or other selected surgeries in which increased bleeding risk may also be fatal, cessation of DAPT (possibly with continuation or minimized interruption [3-4 days] of aspirin) with bridge therapy using short-acting, reversible intravenous antiplatelet agents such as cangrelor (P2Y₁₂ inhibitor) or glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) may be contemplated. Such a critical decision should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic and bleeding risks.

Keyword

Acute coronary syndrome; Antiplatelet therapy; Percutaneous coronary intervention; Surgery

MeSH Terms

Acute Coronary Syndrome
Aspirin
Blood Platelets
Consensus
Glycoproteins
Hemorrhage
Humans
Percutaneous Coronary Intervention
Perioperative Period
Platelet Aggregation Inhibitors
Prasugrel Hydrochloride
Recovery of Function
Stents
Thrombosis
Aspirin
Glycoproteins
Platelet Aggregation Inhibitors
Prasugrel Hydrochloride