DAPT for non cardiac elective surgery

[anbuitachi]

Just curious what you tell your surgeons for these totally elective cases.

hypothetical case. 78 yr old comes in for lipoma excision under general anesthesia. MI 7 months ago w DES to LAD on DAPT. Comes in today on aspirin, off plavix for a week. Proceed with the case? Postpone for until 1 year?

Im curious because i find the AHA guidelines to be a bit vague.. possibly due to lack of amazing data. The recommendation for DAPT after stents after ACS is 1 year (class 1 data). However its recommenation for DAPT for elective non cardiac surgery is at least 6 months, and it didn't even differentiate ACS vs SIHD. I find it odd that the recommendation for someone NOT having surgery is 12 months, yet if you have surgery it's reduced to 6 months (isn't surgery supposed to be pro inflammatory??). Do you people all go by 6 months??

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[Psai]

Well, a lipoma excision is a local case. Mac at the most.

The data with first generation stents showed that there were fewer and fewer events the longer you waited after stent placement (I think it was something like 9% -> 4% -> 3% for 1 month, 6 month, 1 year but I may be just pulling numbers out of my ass)

I think with the second generation like tacrolimus and everlimus eluting stents, outcomes are better and the interval is shorter. I think people agree on 1 month for BMS and 6 months for DES although if you have to go earlier, you go earlier

Second-Generation Drug-Eluting Stent Implantation Followed by 6- Versus 12-Month Dual Antiplatelet Therapy
Security trial JACC randomized multicenter noninferiority study 6 months and 12 months for cardiac death, mi, stroke, stent thrombosis, bleeding 4.5% vs 3.7% not statistically significant difference

Six months versus 12 months dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): randomised, multicentre, non-inferiority trial
bmj 6 months is noninferior to 12 months in composite outcome of mortality, stroke, mi, in stent thrombosis, revasc

 

[Mman]

Do you people all go by 6 months??

I go by whatever the cardiologist who put the stent in tells the patient.

 

[anbuitachi]

I go by whatever the cardiologist who put the stent in tells the patient.

That varies a lot depending on cardiologist. We've all seen stupid clearances.

 

[dannyboy1]

6 months seems to be the new 1 year. That being said, if a patient had stents I am sending them for cardiac clearance prior to elective surgery so whatever cards says....

 

[eagle0990]

totally elective cases (lipoma excision) wait 1 year. This is unless they have documentation from their cardiologist that they can come off their DAPT at 6 months. I have alternatively seen these cases go after 6 months, but before the year, and they are kept on their DAPT throughout the peri-op period.

Additionally, I have had patients come in for surgery with a note from their internist OK'ing holding DAPT for a week. I then call the cardiologist and they have no idea the patient is getting an operation. Per the cardiologist's rec I give the patient plavix and ASA in the pre-op area and send them home without an operation.

 

[Hork Bajir]

Cangrelor (ultra-short acting P2Y12 inhibitor) is also a game changer that isn’t really addressed in any of the new guidelines.

Patient with a DES 2 months ago found to have cancer that needs surgery sooner rather than later (or pick your intermediate urgency scenario)? Admit, hold plavix and start cangrelor infusion, shut it off 5 minutes before induction. Do the case, and then depending on the location of surgery/hemostasis/surgeons’s judgement/etc, restart cangrelor X number of hrs later. Everything good, minimal drain output, transition back to PO DAPT. Bleeding problems or need to return to OR, stop cangrelor and it’s gone within minutes.

Not sure what the data out there is like, or what people’s experience with this drug is, but seems very useful (albeit EXPENSIVE). Being off DAPT for 7+ days is a different risk profile than being off DAPT for 7 hours.

 

[anbuitachi]

does anyone remember the study on heparin? i know they are different mechanisms, one platelet one not. but is there any benefit in starting heparin infusion while off plavix and shutting it off shortly before surgery then restarting DAPT?

 

[Mman]

Cangrelor (ultra-short acting P2Y12 inhibitor) is also a game changer that isn’t really addressed in any of the new guidelines.

Patient with a DES 2 months ago found to have cancer that needs surgery sooner rather than later (or pick your intermediate urgency scenario)? Admit, hold plavix and start cangrelor infusion, shut it off 5 minutes before induction. Do the case, and then depending on the location of surgery/hemostasis/surgeons’s judgement/etc, restart cangrelor X number of hrs later. Everything good, minimal drain output, transition back to PO DAPT. Bleeding problems or need to return to OR, stop cangrelor and it’s gone within minutes.

Not sure what the data out there is like, or what people’s experience with this drug is, but seems very useful (albeit EXPENSIVE). Being off DAPT for 7+ days is a different risk profile than being off DAPT for 7 hours.

While that sounds like a neat trick to use in some of these patients, I'd bet interested in seeing data. Patients rarely just drop dead because they skipped their DAPT for a couple days. When they do die is in the immediate postop period when they just sat in the OR releasing a bunch of tissue factor and becoming hypercoagulable and I'm not sure having that drug is going to change that.

 

[AdmiralChz]

Not sure what the data out there is like, or what people’s experience with this drug is, but seems very useful (albeit EXPENSIVE). Being off DAPT for 7+ days is a different risk profile than being off DAPT for 7 hours.

How expensive we talkin’? Our hospital won’t approve Andexxxa or Praxbind, and gave us endless crap over using IV Tylenol. Neat trick, but until there’s some data on it and it’s use becomes more widespread might just be a fun idea for some of us...

I agree with many of the above. Most patients do fine off DAPT even for a week with the newer generation of DES.

 

[anbuitachi]

How expensive we talkin’? Our hospital won’t approve Andexxxa or Praxbind, and gave us endless crap over using IV Tylenol. Neat trick, but until there’s some data on it and it’s use becomes more widespread might just be a fun idea for some of us...

I agree with many of the above. Most patients do fine off DAPT even for a week with the newer generation of DES.

yea i think its the pro inflammatory status postop that messes them up. not being on DAPT for a week is not a huge deal without the surgery part.

i think the IV tylenol problem is b/c PO tylenol works just as well, and is 100x cheaper. the IV tylenol cost adds up when ordered so frequently.

 

[anes121508]

Just curious what you tell your surgeons for these totally elective cases.

hypothetical case. 78 yr old comes in for lipoma excision under general anesthesia. MI 7 months ago w DES to LAD on DAPT. Comes in today on aspirin, off plavix for a week. Proceed with the case? Postpone for until 1 year?

Im curious because i find the AHA guidelines to be a bit vague.. possibly due to lack of amazing data. The recommendation for DAPT after stents after ACS is 1 year (class 1 data). However its recommenation for DAPT for elective non cardiac surgery is at least 6 months, and it didn't even differentiate ACS vs SIHD. I find it odd that the recommendation for someone NOT having surgery is 12 months, yet if you have surgery it's reduced to 6 months (isn't surgery supposed to be pro inflammatory??). Do you people all go by 6 months??

I believe some of the newer generation stents are 3 months. I’ve seen several cases scheduled on the exact 3 month date. I’ll look for the aha statement...

How do you guys handle patients that are beyond the reccomended time for their stent to come off duapt but stay on asa and are now having some elective procedure...feel like our surgeons just take everyone off asa. We don’t have a preop clinic so when I see the guy DOS they are already off asa x 7 days for a superficial procedure and history of a DES 14 months again.

 

[anes121508]

I believe some of the newer generation stents are 3 months. I’ve seen several cases scheduled on the exact 3 month date. I’ll look for the aha statement...

How do you guys handle patients that are beyond the reccomended time for their stent to come off duapt but stay on asa and are now having some elective procedure...feel like our surgeons just take everyone off asa. We don’t have a preop clinic so when I see the guy DOS they are already off asa x 7 days for a superficial procedure and history of a DES 14 months again.

To clarify thats procedures that need to be done sooner than later ...

 

[BobLoblaw78]

Cangrelor (ultra-short acting P2Y12 inhibitor) is also a game changer that isn’t really addressed in any of the new guidelines.

Patient with a DES 2 months ago found to have cancer that needs surgery sooner rather than later (or pick your intermediate urgency scenario)? Admit, hold plavix and start cangrelor infusion, shut it off 5 minutes before induction. Do the case, and then depending on the location of surgery/hemostasis/surgeons’s judgement/etc, restart cangrelor X number of hrs later. Everything good, minimal drain output, transition back to PO DAPT. Bleeding problems or need to return to OR, stop cangrelor and it’s gone within minutes.

Not sure what the data out there is like, or what people’s experience with this drug is, but seems very useful (albeit EXPENSIVE). Being off DAPT for 7+ days is a different risk profile than being off DAPT for 7 hours.

Just had consult for two patients with MI and subsequent stent within 3 months. Approved by cardiologist that didn't place stent to come off DAPT at 2-3 months for surgery utilizing a Integrilin bridge protocol. And will restart with Plavix loading dose when surgeon deems acceptable bleeding risk. One surgery is laparoscopic biopsy for cancer and second I am not so sure. We do not have a cardiac cath lab location within 1 hour.

I have not seen the patients yet, but my recommendation is to perform at facility with or close vicinity of cardiac cath lab in case of restent thrombosis. I would consider proceeding if patient fully understands risks and has great objection to going elsewhere. Change My Mind. lol

 

[anbuitachi]

I believe some of the newer generation stents are 3 months. I’ve seen several cases scheduled on the exact 3 month date. I’ll look for the aha statement...

How do you guys handle patients that are beyond the reccomended time for their stent to come off duapt but stay on asa and are now having some elective procedure...feel like our surgeons just take everyone off asa. We don’t have a preop clinic so when I see the guy DOS they are already off asa x 7 days for a superficial procedure and history of a DES 14 months again.

for totally elective cases? im not aware of 3 months

 

[Hork Bajir]

One surgery is laparoscopic biopsy for cancer

Should be an outpatient thing, no? In which case they’ll go home and have their postop MI on day 3, presumably far from a cath lab, regardless of where they get the procedure done

 

[kmurp]

Per a conversation recently with one of our cardiologists, the answer is “it depends”. It’s not only the type of stent and time interval, but also, for this cardiologist, the size of the stent and it’s location. I think based on this, it’s best to get an individualized recommendation from the cardiologist based not only on the need for the surgery but also on the patients specific stent situation.

 

[BobLoblaw78]

I think there is also a difference between the cardiologists. I would prefer the recommendation be from the cardiologist that placed the stent and not another. He knows better the conditions that it was placed under and whether it was high risk or not.

The question remains. Should patients within 6 months or even 12 months stop DAPT if a cath lab is not available within 2 hours? 1 hour? I think this is where patient autonomy and a clear conversation involving the risks including stent thrombosis is needed.

 

[drimranhussain]

AHA Guidelines DAPT

 

[drimranhussain]

 

[drimranhussain]

DAPT S/P Stent