Should a patient with a history of stroke, currently on dipyridamole (Persantine) and aspirin (acetylsalicylic acid), discontinue dipyridamole and continue aspirin alone prior to undergoing cochlear implant surgery?

From the Guidelines

I strongly recommend temporarily discontinuing dipyridamole 7 days before the cochlear implant surgery while continuing aspirin, as this approach balances bleeding risk during surgery with stroke prevention, based on the guidelines from the American Heart Association/American Stroke Association 1. The patient's history of stroke and current regimen of dipyridamole and aspirin indicate a high risk of recurrent stroke, and the decision to stop dipyridamole and continue aspirin during the perioperative period should be made with caution.

• The European Stroke Prevention Study (ESPS-1) and ESPS-2 trials demonstrated that the combination of aspirin and dipyridamole is at least as effective as aspirin alone for secondary stroke prevention, but with more side effects 1.
• The guidelines for the prevention of stroke in patients with stroke or transient ischemic attack recommend the use of antiplatelet agents, including aspirin, dipyridamole, and clopidogrel, to reduce the risk of recurrent stroke and other cardiovascular events 1.
• Aspirin should be continued throughout without interruption at the current dose, as it provides continued antiplatelet protection with less bleeding risk than dual therapy.
• After surgery, the patient should return to the dual antiplatelet regimen of dipyridamole plus aspirin for secondary stroke prevention, as dipyridamole's reversible antiplatelet effects diminish within 24-48 hours after discontinuation.
• The surgical team should be prepared for potentially increased bleeding during the procedure despite dipyridamole discontinuation, and meticulous hemostasis techniques should be employed.
• The patient should be monitored closely for both bleeding complications and signs of thrombotic events during this transition period. The ENT team's plan to proceed with aspirin monotherapy during the perioperative period is reasonable, but it is crucial to weigh the benefits of stroke prevention against the risks of bleeding, and to individualize the selection of antiplatelet agents based on patient risk factor profiles, cost, tolerance, and other clinical characteristics 1.

From the FDA Drug Label

PRECAUTIONS General Coronary Artery Disease: Dipyridamole has a vasodilatory effect and should be used with caution in patients with severe coronary artery disease (e.g., unstable angina or recently sustained myocardial infarction). Hypotension: Dipyridamole should be used with caution in patients with hypotension since it can produce peripheral vasodilation.

The patient is on dipyridamole and aspirin due to a previous stroke. The ENT team wants to stop dipyridamole and continue with aspirin only for a cochlear implant surgery.

• Stopping dipyridamole may increase the risk of stroke, as it is an antiplatelet agent used to prevent stroke.
• Continuing aspirin may not be sufficient to prevent stroke, as the patient was previously on a combination of dipyridamole and aspirin.
• The FDA drug label does not provide specific guidance on the management of dipyridamole in patients undergoing cochlear implant surgery.
• A conservative approach would be to consult with the patient's cardiologist or neurologist to determine the best course of action, as the risk of stroke may outweigh the risk of bleeding during surgery 2.

From the Research

Patient Management

• The patient is currently on dipyridamole and aspirin due to a previous stroke and is scheduled for a cochlear implant surgery.
• The ENT team wants to stop dipyridamole and continue with aspirin only before proceeding with the surgery.

Antiplatelet Therapy Considerations

• According to 3, aspirin is the most widely studied and prescribed antiplatelet drug for patients at high risk of vascular disease, but it provides incomplete protection against cardiovascular events.
• The combination of aspirin and dipyridamole has been shown to be more effective than aspirin alone in reducing serious vascular events in patients at high risk 3, 4.
• However, the use of dual antiplatelet therapy, such as aspirin and clopidogrel, is associated with an increased risk of major bleeding, particularly when the treatment is extended for more than 30 days 5, 6.

Surgical Considerations

• The risk of bleeding during surgery is a concern when using antiplatelet therapy.
• Stopping dipyridamole and continuing with aspirin only may reduce the risk of bleeding during surgery, but it may also increase the risk of recurrent stroke.

Recommendations

• Based on the available evidence, it is recommended to weigh the benefits and risks of continuing or stopping antiplatelet therapy before surgery 5, 6.
• The decision to stop dipyridamole and continue with aspirin only should be made on a case-by-case basis, taking into account the patient's individual risk factors and the surgical procedure 7, 4.
• Close monitoring of the patient's condition and adjustment of the antiplatelet therapy regimen as needed is crucial to minimize the risk of bleeding and recurrent stroke.