What is the optimal management of antiplatelet agents, such as Aspirin (acetylsalicylic acid), in the perioperative period of non-cardiac surgery for patients with high thrombotic risk and high bleeding risk?

From the Guidelines

Aspirin should be continued in selected patients with high thrombotic risk and high bleeding risk undergoing non-cardiac surgery when the risk of cardiac events outweighs the risk of bleeding, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1. The management of antiplatelet agents in the perioperative period for non-cardiac surgery requires careful consideration of both thrombotic and bleeding risks.

• For patients with high thrombotic risk, such as those with recent coronary stents, acute coronary syndrome, or stroke, and high bleeding risk, the decision to continue or discontinue antiplatelet therapy should be individualized.
• The 2024 guideline suggests that in patients with coronary artery disease (CAD) without prior percutaneous coronary intervention (PCI) undergoing elective non-cardiac surgery, it may be reasonable to continue aspirin in selected patients when the risk of cardiac events outweighs the risk of bleeding 1.
• In general, P2Y12 inhibitors, such as clopidogrel, ticagrelor, and prasugrel, should be discontinued before surgery, with the exact timing depending on the specific medication and the patient's individual risk factors.
• For patients with drug-eluting stents placed within the past 6 months or bare metal stents within 30 days, surgery should be postponed if possible, and a multidisciplinary approach involving cardiology, anesthesiology, and surgery is essential if surgery is urgent.
• Bridging therapy with cangrelor or glycoprotein IIb/IIIa inhibitors may be considered in extremely high-risk patients, and P2Y12 inhibitors should be resumed as soon as hemostasis is achieved, typically within 24-48 hours post-surgery.
• The 2014 ACC/AHA guideline also provides recommendations for the management of perioperative antiplatelet therapy, including the importance of individualizing treatment decisions and considering the risks and benefits of continuing or discontinuing antiplatelet therapy 1. However, the 2024 guideline 1 takes precedence due to its more recent publication and higher quality evidence. Overall, the key to managing antiplatelet agents in the perioperative period is to carefully balance the risks of thrombosis and bleeding, and to individualize treatment decisions based on each patient's unique risk factors and clinical circumstances.

From the Research

Management of Antiplatelet Agents in Non-Cardiac Surgery

The management of antiplatelet agents in the perioperative period of non-cardiac surgery is crucial, especially in patients with high thrombotic risk and high bleeding risk.

• Patients undergoing non-cardiac surgery within 1 year of percutaneous coronary intervention (PCI) are at increased risk of both major adverse cardiac events (MACE) and bleeding 2.
• The risk of MACE and bleeding depends on the estimated surgical risk and urgency of the procedure, which are increased early after PCI 2.
• Preoperative interruption of antiplatelet therapy is not associated with an increased risk of cardiac events 2.

Perioperative Antiplatelet Management

• Antithrombotic agents are the cornerstone of secondary prevention of ischemic events but substantially increase the risk of bleeding 3.
• Perioperative management of antiplatelet therapy poses a recurring dilemma in clinical practice, requiring concomitant evaluation of individual thrombotic and bleeding risks related to both clinical and procedural factors 3.
• Current guidelines do not provide detailed recommendations on perioperative antiplatelet management, and the optimal approach in these patients is yet to be determined 3.

Risk Assessment and Management

• Patients at high bleeding risk undergoing PCI can be assessed using prognostic models to identify individual patients' risk of major coronary thrombotic and bleeding events 4.
• These models can help clinicians choose the most appropriate revascularization strategy and tailor the duration and intensity of antithrombotic regimens 4.
• The use of low aspirin doses (75 to 160 mg/day) is consistently favored for short- and long-term use due to the lack of a dose-response relationship between increasing aspirin dose and improved efficacy, and a higher incidence of gastrointestinal bleeding with increasing aspirin dose 5.

Antiplatelet and Anticoagulation Agents

• Aspirin is the foundation antiplatelet agent, and new P2Y12 receptor inhibitors (prasugrel and ticagrelor) have clear benefits compared with clopidogrel for dual antiplatelet therapy 6.
• Anticoagulation uses one of four choices: bivalirudin, unfractionated heparin, enoxaparin, and fondaparinux, and some patients require triple therapy with aspirin, clopidogrel, plus an anticoagulant 6.
• New oral anticoagulants have been shown to be at least as effective as vitamin K antagonists in atrial fibrillation and led to fewer bleeding complications 6.