Guidance on antiplatelet agents remains less than comprehensive, with ACC offering recommendations on certain but not all situations. Evidence is complex and unclear in many situations. Much guidance is intertwined with guidance on timing and delay of surgery so as to continue antiplatelet therapy after cardiac intervention like cath and stent. I've tried to separate timing of surgery and mgmt of antiplatelet therapy. I find ACC guidance on this topic sparse, with more from ACCP, so I'm presenting both. First, guidance from ACC 2024, then guidance from ACCP 2022.
ACC-AHA 2024 GUIDANCE
For patients who have undergone PCl (cardiac cath with angioplasty +/- stent):
- In patients with prior PCl undergoing NCS (non-cardiac surgery), it is recommended to continue aspirin, if possible, to reduce the risk of cardiac events (1, B)
- In patients with CAD who require time- sensitive NCS within 30 days of PCl with BMS or months of PCl with DES, DAPT should be continued unless the risk of bleeding outweighs the benefit of the prevention of stent thrombosis (1, B)
- In select patients after PCl who have a high thrombotic risk, perioperative bridging with intravenous antiplatelet therapy (IV cangrelor) may be considered <6 months after DES or days after BMS if NCS cannot be deferred (2b, B)
- In patients with a recent ('30 days) bare- metal stent (BMS) or DES-PCI, elective NCS requiring interruption of 21 antiplatelet agents is potentially harmful due to a high risk of stent thrombosis and ischemic complications (3H, B)
- In patients with prior PCl in whom OAC monotherapy must be discontinued before NCS, aspirin should be substituted when feasible in the perioperative period until OAC can be safely reinitiated (1, B)
For patients who have not undergone PCI:
- In patients with CCD (chronic coronary disease) without prior PCl undergoing elective NCS, it may be reasonable to continue aspirin in selected patients when the risk of cardiac events outweighs the risk of bleeding (2b, B)
- In patients with CAD but without prior PCl who are undergoing elective non-carotid NCS, routine initiation of aspirin is not beneficial (3NB, B)
For all CAD patients:
- Periop antiplatelet therapy mgmt and timing of surgery should be determined by a multidisciplinary team with shared decision- making to weigh the risks of bleeding, thrombosis, and consequences of delayed surgery (1, B)
ACCP 2022 GUIDANCE
- In patients receiving ASA who are undergoing elective NCS, ASA continuation is suggested over ASA interruption (Conditional rec, Mod certainty). When surgery has high bleeding risk, interrupt ASA for 7 days.
- When interrupting ASA for surgery, stop 7 days ahead of surgery (cond, very low)
- When interrupting clopidogrel, stop 5 days ahead (cond, very low)
- When interrupting ticagrelor, stop 3-5 days ahead (cond, very low)
- When interrupting prasugrel, stop 7 days ahead (cond, very low)
- Resume interrupted antiplatelet agents within 24 hours of surgery (cond, very low)
- In patients receiving DAPT with coronary stents placed within the last 6 to 12 weeks who are undergoing an elective surgery/procedure, it is suggested to either continue DAPT or stop one antiplatelet agent within 7 to 10 days of surgery (cond, very low). No preference for which to stop is evinced.
- In patients receiving DAPT who had coronary stents placed within the last 3 to 12 months and are undergoing an elective surgery/ procedure, it is suggested to stop the P2Y12 inhibitor prior to surgery over continuation of the P2Y12 inhibitor (cond, very low). Rec can be modified by the particulars of the case.
- When interrupting antiplatelet drugs for elective surgery, it is suggested not to bridge with a glycoprotein llb/llla inhibitor, cangrelor (an IV P2Y12 inh), or LMWH (cond, low)
- In patients with coronary stents who require continued DAP T, it is suggested to delay an elective surgery/procedure over not delaying the surgery/procedure (cond, very low). Delay should be considered on a case-by-case basis.
- In patients on antiplatelet therapy undergoing minor dental procedures, minor dermatologic procedures, and minor ophthalmologic procedures, it is suggested to continue antiplatelet therapy (cond, very low, very low, and low, respectively). In each case, continuation of ASA and interruption of P2Y12 inhibitor is also an option.
Minimum time for return of platelet function per ACC:
- aspirin: 4 d
- clopidogrel: 5-7 d
- prasugrel: 7-10 d
- ticagrelor: 3-5 d
I would love to develop a nice clean clear decision tree. Let me know if you find one.