From the Guidelines
It is generally recommended to continue aspirin, if possible, in patients with prior PCI undergoing noncardiac surgery, including those with intermittent claudication, to reduce the risk of cardiac events 1. When considering the management of antiplatelet therapy in patients with intermittent claudication undergoing surgery, several factors must be taken into account, including the type of surgery, the patient's cardiovascular risk profile, and the timing of any previous coronary interventions.
- The decision to hold antiplatelet therapy should be made on a case-by-case basis, weighing the risks of bleeding against the risks of thrombotic events.
- For patients with prior PCI, the guidelines suggest continuing aspirin, if possible, to reduce cardiac risk 1.
- In patients with coronary artery disease who require time-sensitive noncardiac surgery within 30 days of PCI with bare-metal stents or less than 3 months of PCI with drug-eluting stents, dual antiplatelet therapy (DAPT) should be continued unless the risk of bleeding outweighs the benefit of preventing stent thrombosis 1.
- The management of antiplatelet therapy in the perioperative period for patients with intermittent claudication should prioritize minimizing cardiovascular risk while also considering the risk of surgical bleeding.
- Recent guidelines, such as those from the American College of Cardiology/American Heart Association, provide a framework for decision-making but emphasize the importance of individualized patient assessment 1.
From the FDA Drug Label
5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.
It is not explicitly stated in the drug label whether it is okay to hold anti-platelet therapy for surgery in patients with intermittent claudication. The label does provide guidance on discontinuing clopidogrel for surgery with a major risk of bleeding, recommending interruption of therapy for five days prior to surgery and resuming as soon as hemostasis is achieved. However, this does not directly address the specific condition of intermittent claudication. Therefore, no conclusion can be drawn regarding the safety of holding anti-platelet therapy for surgery in patients with intermittent claudication based on the provided drug label 2.
From the Research
Perioperative Management of Anti-Platelet Therapy
The decision to hold anti-platelet therapy for surgery in patients with intermittent claudication depends on various factors, including the risk of myocardial infarction and the type of surgery.
- The risk of coronary thrombosis after anti-platelet drug withdrawal is higher than the risk of surgical bleeding if they are continued 3, 4.
- Aspirin is a lifelong therapy in secondary prevention and should never be stopped 3, 4.
- Clopidogrel is mandatory until coronary stents are fully endothelialized, which can take several months to a year 3, 4.
Recommendations for Patients with Intermittent Claudication
- Anti-platelet agents have a beneficial effect in reducing all-cause mortality and fatal cardiovascular events in patients with intermittent claudication 5.
- The use of anti-platelet drugs, such as aspirin and clopidogrel, is recommended for patients with intermittent claudication, unless there is a high risk of bleeding 6, 7.
- For patients undergoing surgery, the decision to continue or discontinue anti-platelet therapy should be based on the individual patient's risk of myocardial ischemia and bleeding 6, 3, 4.
Surgical Considerations
- Most surgical procedures can be performed while the patient is on low-dose aspirin treatment, except when bleeding may occur in closed spaces or where excessive blood loss is expected 6.
- Clopidogrel should not be discontinued before a non-cardiac procedure, and surgery should be postponed until the end of the indication for clopidogrel 6.
- Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal 6.