What is better for perioperative management of appendectomy in a patient with a recent myocardial infarction (MI) who stopped taking clopidogrel (Plavix) and aspirin 2 days prior, tranexamic acid (TXA) or platelet transfusion?

From the Guidelines

For a patient with a recent myocardial infarction who stopped taking clopidogrel and aspirin 2 days prior to appendectomy, platelet transfusion is the preferred choice over tranexamic acid (TXA) due to its ability to directly address the antiplatelet effect and provide functional platelets. The patient's high thrombotic risk following a myocardial infarction necessitates careful management of antiplatelet therapy in the perioperative period. According to the American College of Chest Physicians evidence-based clinical practice guidelines 1, the management of antithrombotic therapy in patients undergoing surgery involves balancing the risk of thrombosis against the risk of bleeding. Key considerations in this scenario include:

• The timing of antiplatelet discontinuation: The patient stopped clopidogrel and aspirin 2 days prior to surgery, which may not be sufficient for full recovery of platelet function.
• The risk of thrombotic complications: Patients with recent myocardial infarction are at high risk for thrombotic events, and withholding antiplatelet therapy must be carefully considered.
• The role of platelet transfusion: Administering 1-2 units of platelets immediately before surgery can provide functional platelets and help mitigate the risk of bleeding.
• The potential risks of TXA: While TXA can reduce surgical bleeding by inhibiting fibrinolysis, it may not be the best choice in this scenario due to the potential increased risk of thrombotic complications in a patient with recent MI. Given these considerations, platelet transfusion is the recommended approach for perioperative management of appendectomy in this patient, with cardiology consultation essential for determining optimal timing for restarting dual antiplatelet therapy postoperatively.

From the Research

Perioperative Management of Appendectomy

• The patient has a recent myocardial infarction (MI) and stopped taking clopidogrel and aspirin 2 days prior to surgery.
• The management of antiplatelet agents in patients undergoing surgery is complex and requires careful consideration of the risks and benefits 2, 3.

Tranexamic Acid (TXA) vs Platelet Transfusion

• TXA has been shown to reduce the risk of bleeding in patients undergoing cardiac surgery, including those with a recent MI 4, 5.
• However, TXA may also increase the risk of thrombotic complications, particularly in patients with complex stent anatomy 6.
• Platelet transfusion may be considered in patients with abnormal bleeding thought to be related to the persisting effect of antiplatelet therapy, but should not be transfused prophylactically 3.

Considerations for This Patient

• The patient stopped taking clopidogrel and aspirin 2 days prior to surgery, which may not be sufficient time for the antiplatelet effects to wear off completely 2, 3.
• The use of TXA in this patient may reduce the risk of bleeding, but also increases the risk of thrombotic complications, particularly given the recent MI and potential for complex stent anatomy 4, 6.
• Platelet transfusion may be considered if the patient experiences abnormal bleeding during or after surgery, but should be used judiciously and only when clinically indicated 3.