From the Guidelines
Discontinuing aspirin and prasugrel 12 weeks after percutaneous coronary intervention (PCI) for non-cardiac surgery is not universally safe for all patients and should be individualized based on the type of stent, indication for PCI, and patient-specific risk factors for bleeding and thrombosis. Generally, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor like prasugrel or clopidogrel should be continued for at least 6-12 months after PCI with drug-eluting stents, and at least 1 month (but ideally 3 months) for bare-metal stents 1. If surgery is urgent and cannot be delayed, consultation with both the cardiologist who performed the PCI and the surgeon is essential. For high bleeding risk surgeries, it may be reasonable to continue aspirin alone while temporarily discontinuing the P2Y12 inhibitor. The timing of discontinuation matters significantly - stopping these medications too early increases the risk of stent thrombosis, which can be catastrophic with mortality rates of 20-45% 1.
Some key considerations include:
- The type of stent used: drug-eluting stents require longer durations of DAPT compared to bare-metal stents 1
- Indication for PCI: stable coronary disease versus acute coronary syndrome 1
- Patient-specific risk factors for bleeding and thrombosis: including age, weight, and history of bleeding or thrombotic events 1
- The need for individualized assessment and a multidisciplinary approach involving cardiology, anesthesiology, and surgery 1
In terms of specific guidance, the 2014 ESC/ESA guidelines on non-cardiac surgery recommend delaying elective non-cardiac surgery until completion of the full course of DAPT and, whenever possible, performing surgery without discontinuation of aspirin 1. The ACCF/AHA guidelines also provide recommendations for the management of antiplatelet therapy in patients undergoing non-cardiac surgery after PCI 1.
Ultimately, the decision to discontinue aspirin and prasugrel 12 weeks after PCI for non-cardiac surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of continuing or discontinuing DAPT. The most recent and highest quality study, the 2014 ESC/ESA guidelines, should be prioritized in making this decision 1.
From the FDA Drug Label
The optimal duration of thienopyridine therapy is unknown In patients who are managed with PCI and stent placement, premature discontinuation of any antiplatelet medication, including thienopyridines, conveys an increased risk of stent thrombosis, myocardial infarction, and death. Discontinue thienopyridines, including prasugrel, for active bleeding, elective surgery, stroke, or TIA.
It is not safe to discontinue aspirin and prasugrel 12 weeks after PCI for non-cardiac surgery, as the optimal duration of thienopyridine therapy is unknown and premature discontinuation conveys an increased risk of stent thrombosis, myocardial infarction, and death. However, prasugrel may be discontinued for elective surgery. The decision to discontinue antiplatelet medication should be made on a case-by-case basis, considering the individual patient's risk of bleeding and thrombotic events 2.
- Key considerations:
- Risk of stent thrombosis and myocardial infarction with premature discontinuation of antiplatelet medication
- Risk of bleeding with continued use of prasugrel and aspirin
- Individual patient's risk factors and medical history should be taken into account when making a decision about discontinuing antiplatelet medication.
From the Research
Discontinuation of Aspirin and Prasugrel 12 Weeks After PCI for Non-Cardiac Surgery
- The decision to discontinue aspirin and prasugrel 12 weeks after percutaneous coronary intervention (PCI) for non-cardiac surgery should be made on a case-by-case basis, considering the individual patient's risk of bleeding and ischemic events 3, 4.
- According to the study by 4, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding.
- However, the study by 3 suggests that the mandatory interval of 1 year for elective surgery after drug-eluting stent (DES) implantation can be shortened to 6 months, and that the P2Y12 inhibitor can be stopped for the amount of time necessary for platelet function recovery after this period.
- The study by 5 found that continuing aspirin monotherapy versus temporarily holding all antiplatelet therapy before noncardiac surgery in patients with previous DES implantation did not result in a significant difference in ischemic outcomes or major bleeding.
- Another study by 6 demonstrated the feasibility and safety of aspirin-free prasugrel monotherapy following successful everolimus-eluting stent implantation in patients with stable coronary artery disease.
- The STOPDAPT-3 randomized trial 7 found that an aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI.
- However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events, including unplanned coronary revascularization and subacute definite or probable stent thrombosis 7.
Key Considerations
- The risk of bleeding and ischemic events should be carefully weighed when deciding to discontinue aspirin and prasugrel 12 weeks after PCI for non-cardiac surgery 3, 4.
- The type of stent used, the patient's clinical presentation, and the timing of surgery after PCI should also be taken into account when making this decision 3, 4.
- Aspirin should be continued indefinitely in most cases, unless there is a high risk of bleeding 4.
- The P2Y12 inhibitor can be stopped for the amount of time necessary for platelet function recovery, which varies depending on the specific medication used (e.g., clopidogrel 5-7 days, prasugrel 7-10 days, ticagrelor 3-5 days) 3.