ACC reviews evidence for non-stented patients showing no benefit to aspirin
started or continued for surgery. Thus their perioperative aspirin
recommendations are much less pushy than previously, except for
post-stent, as follows:
- initiation or continuation of aspirin is
not beneficial in patients undergoing elective noncardiac noncarotid
surgery who have not had previous coronary stenting (III:NB, B), unless
the risk of ischemic events outweighs the risk of surgical bleeding
(III:NB, C).
- for patients having urgent surgery during the first
4 to 6 weeks after BMS or DES implantation, DAPT (dual antiplatelet
therapy) should be continued unless the relative risk of bleeding
outweighs the benefit of the prevention of stent thrombosis (I, C).
-
for patients who have received coronary stents and must undergo
surgical procedures that mandate the discontinuation of P2Y12-inhibitor
(Clopidogrel and similar) therapy, continue the aspirin if possible and
restart the P2Y12-inhibitor as soon as possible after surgery (I,C).
-
mgmt of perioperative antiplatelet therapy should be determined by a
consensus of the surgeon, anesthesiologist, cardiologist, and patient,
who should weight the relative risk of bleeding versus prevention of
stent thrombosis (I, C).
- ACC offers a new proposed algorithm on
surgery timing and medical mgmt decisions for post-stent patients on
DAPT. But humbly this editor finds that the algorithm leaves too many
situations and questions unanswered to be useful for inclusion here. We
all should away further clarification.
ASCCP gives detailed Aspirin guidance.
-
for patients with low risk of cardiac event, stop Aspirin (and other
antiplatelet agents in 2008 guideline) 7-10 days before surgery.
-
for patients with higher risk of cardiac event (those with ischemic
heard disease, compensated or prior CHF, diabetes, renal insufficiency,
or stroke, exclusive of stents), continue Aspirin (and other
antiplatelet agents per 2008 guideline) during surgery, with caution for
prostate and intracranial procedures well-known for bleeding risk.
-
for patients on dual antiplatelet therapy who received bare metal stent
within 6 weeks or drug-eluting stent within 6 months, deferral of
surgery is recommended, but if surgery must be undertaken, continue dual
antiplatelet therapy.
- for patients with stents whose
antiplatelet agents will be stopped, data is insufficient to support use
of bridging heparins, direct thrombin inhibitors and thus they are not
recommended.
- when stopping Aspirin, do so 7-10 days before surgery.
- for patients whose Aspirin has been stopped, resume 24 hours post-op or next morning if surgical hemostasis good.
- continue Aspirin through minor dental, dermatologic, and cataract procedures.