Elective noncardiac surgery in stented patients — In order to minimize adverse cardiovascular events, we suggest that elective noncardiac surgery be deferred until after the minimal recommended duration of DAPT for each type of stent. For patients treated with either BMS or DES who are not at high risk of bleeding, we suggest one year of DAPT. In patients at high risk of bleeding, our recommended duration of therapy is one and six months, respectively. (See
"Antiplatelet therapy after coronary artery stenting", section on 'Noncardiac surgery or GI endoscopy'.)
While the optimal duration of DAPT for stented patients is not known, we are concerned that the proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT if a significant percent of struts are not endothelialized. In addition, one cannot predict the possibility that DAPT might have to be stopped due to unexpected major bleeding. Thus, we recommend caution in performing elective noncardiac surgery prior to the minimal recommended duration of such therapy. Although the minimal duration of such therapy is four weeks for BMS, we recommend waiting six weeks given our concerns about the possible increased risk of stent thrombosis in the perioperative period.
The final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and the patient has taken place. Some surgeons are not fully aware of the risk of prematurely discontinuing antiplatelet therapy in patients with recent PCI with stenting. In many cases, DAPT can be continued in the perioperative period, although for some surgeries such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis.
Our recommendations for the timing of surgery are based on observations presented above regarding the rates of stent thrombosis in patients with premature cessation of DAPT and rates of adverse cardiovascular events found in studies of patients undergoing noncardiac surgery. (See
'Timing, incidence, and clinical predictors' above.) No randomized trials comparing different times for surgery after PCI or differing antiplatelet strategies have been performed. These recommendations attempt to take into account what is known about the risk of perioperative bleeding on one or two antiplatelet agents.
If surgery must be performed before the minimum time period for DAPT (generally one year in patients not at high bleeding risk), we suggest that an attempt be made to defer it for at least six weeks after placement of a BMS and at least six months after a DES. In these patients, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible.
Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and
clopidogrel and surgery can usually be safely performed on aspirin. (See
"Perioperative medication management", section on 'Aspirin'.)
Additional points to consider include:
●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy
●
Clopidogrel,
prasugrel, and
ticagrelor should be stopped five, seven, and three to five days, respectively, before surgery. Some experts are willing to recommend shorter discontinuation periods, for procedures less likely to be associated with major bleeding.
●
Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps even later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting [
26].
●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage [
26]. (See
"Management of cardiac risk for noncardiac surgery", section on 'Revascularization before surgery'.)
Urgent or emergent noncardiac surgery — For patients who require surgery prior to the minimal duration of DAPT discussed above, such as those who require urgent or emergent noncardiac surgery, two issues need to be discussed among all managing practitioners:
●The relative risks and benefits of continuing DAPT
●Role of platelet transfusion. For patients who are at increased risk of bleeding, there will not be time to discontinue one or both antiplatelet agents. While platelet transfusion may be necessary for excessive bleeding after surgery, the role of prophylactic platelet transfusion has not been well studied. (See
"Congenital and acquired disorders of platelet function", section on 'Platelet transfusion'.)