Should patients with a history of Coronary Artery Bypass Grafting (CABG) and subsequent Percutaneous Coronary Intervention (PCI) continue antiplatelet therapy during surgery?

From the Guidelines

Patients with a history of CABG and subsequent PCI should generally continue aspirin (75-100 mg daily) during most surgeries, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. The decision to continue or discontinue other antiplatelet medications like P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) before elective procedures should be made on a case-by-case basis, taking into account the individual patient's risk of stent thrombosis and perioperative bleeding. Some key considerations include:

• The timing of discontinuation of P2Y12 inhibitors depends on the specific medication, with clopidogrel and ticagrelor typically stopped 5 days before surgery, and prasugrel stopped 7 days before surgery, as suggested by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.
• For urgent surgeries within 6 months of PCI or within 12 months of drug-eluting stent placement, a multidisciplinary approach involving the surgeon, cardiologist, and anesthesiologist is recommended to weigh the risks and benefits of continuing or discontinuing antiplatelet therapy, as outlined in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1.
• Resumption of antiplatelet therapy should occur as soon as hemostasis is achieved, typically within 24-48 hours post-surgery, to minimize the risk of stent thrombosis, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. It is essential to note that the management of antiplatelet therapy in patients with a history of CABG and subsequent PCI undergoing surgery requires careful consideration of the individual patient's risk factors and clinical context, and should be guided by the most recent and highest-quality evidence, such as the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1 and the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

From the FDA Drug Label

Do not start ticagrelor in patients undergoing urgent coronary artery bypass graft surgery (CABG). If possible, manage bleeding without discontinuing ticagrelor. Stopping ticagrelor increases the risk of subsequent cardiovascular events.

Patients with a history of Coronary Artery Bypass Grafting (CABG) and subsequent Percutaneous Coronary Intervention (PCI) should not stop antiplatelet therapy with ticagrelor during surgery if possible, as stopping it increases the risk of subsequent cardiovascular events 2. However, the decision to continue antiplatelet therapy during surgery should be made on a case-by-case basis, considering the risk of bleeding versus the risk of thrombotic events.

• The FDA label recommends managing bleeding without discontinuing ticagrelor if possible.
• It also warns against starting ticagrelor in patients undergoing urgent CABG.
• The label suggests considering single antiplatelet therapy with ticagrelor in patients who have undergone PCI, based on the evolving risk for thrombotic versus bleeding events 2.

From the Research

Patients with History of CABG and Subsequent PCI

• Patients with a history of Coronary Artery Bypass Grafting (CABG) and subsequent Percutaneous Coronary Intervention (PCI) should continue antiplatelet therapy during surgery, except in low-risk settings or when bleeding may occur in closed spaces 3, 4.
• The risk of surgical bleeding if antiplatelet drugs are continued is lower than that of coronary thrombosis if they are withdrawn 3.
• Aspirin may be continued in most surgical procedures, while clopidogrel should not be discontinued before a noncardiac procedure, especially if prescribed for acute coronary syndrome or during stent re-endothelialization 3, 4.

Management of Antiplatelet Therapy

• For elective procedures, surgery should be postponed until the end of the indication for clopidogrel, and clopidogrel should be resumed within 12-24 hours after the operation 3.
• Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal 3.
• Dual antiplatelet therapy with ASA plus a P2Y12 antagonist may add a greater risk of bleeding, and the use of these agents should be balanced with the risk of thrombosis 5.
• Low-dose acetylsalicylic acid (ASA; ≤ 160 mg daily) reduces the incidence of perioperative myocardial infarction, acute renal injury, and mortality without increasing the risk of bleeding 5.

Perioperative Risk and Antiplatelet Management

• Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, especially in patients with recent PCI 6.
• The risk of thrombotic and bleeding events depends on the perioperative antiplatelet management, and high-risk and urgent/emergent surgeries tend to occur earlier post-PCI compared to low-risk and elective ones 6.
• Preoperative interruption of antiplatelet therapy was not associated with an increased risk of cardiac events in patients undergoing non-cardiac surgery within 1 year of PCI 6.
• Current guidelines recommend suspending P2Y12 inhibitors while aspirin continued before elective CABG, as well as 12 months of DAPT following CABG 7.