Post-Operative Antiplatelet and Anticoagulant Therapy After Coronary Endarterectomy
Dual antiplatelet therapy (DAPT) with aspirin 75-100 mg daily plus clopidogrel 75 mg daily for 12 months is recommended for patients after coronary endarterectomy, with aspirin continued indefinitely thereafter. 1
Recommended Antiplatelet Regimen
Initial Post-Operative Period
- Aspirin: 75-100 mg daily, started as soon as possible after surgery and continued indefinitely 1
- P2Y12 inhibitor: Clopidogrel 75 mg daily is the preferred agent after coronary endarterectomy 1
- Duration of DAPT: 12 months unless there are contraindications such as excessive bleeding risk 1
Special Considerations
- A proton pump inhibitor (PPI) should be administered in combination with DAPT to reduce gastrointestinal bleeding risk 1
- If using a PPI, consider pantoprazole or rabeprazole which have lower potential for drug interactions with clopidogrel compared to omeprazole or esomeprazole 1
- For patients with high bleeding risk (PRECISE-DAPT score ≥25), consider shortening DAPT duration to 6 months 1
Choice of P2Y12 Inhibitor
While clopidogrel is the standard P2Y12 inhibitor after coronary endarterectomy, other options may be considered in specific situations:
- Clopidogrel (75 mg daily): First-line therapy for most patients after coronary endarterectomy 1, 2
- Ticagrelor (90 mg twice daily): May be considered in high-risk patients, but has increased bleeding risk compared to clopidogrel 1
- Prasugrel (10 mg daily): Not recommended in patients:
- ≥75 years of age
- <60 kg body weight
- With history of stroke or TIA 3
Anticoagulation Considerations
If a patient requires oral anticoagulation in addition to antiplatelet therapy (triple therapy):
- Keep triple therapy duration as short as possible 1
- Consider dual therapy only (oral anticoagulant plus clopidogrel) after initial period 1
- When using warfarin, target INR 2.0-2.5 1
- Use low-dose aspirin (≤100 mg daily) 1
Monitoring and Follow-up
- The decision for DAPT duration should be reassessed during the course of treatment 1
- Occurrence of bleeding while on DAPT should prompt reconsideration of the regimen 1
- Routine platelet function testing to adjust antiplatelet therapy is not recommended 1
Special Scenarios
Urgent Non-Cardiac Surgery During DAPT
- Not recommended to discontinue DAPT within the first month of treatment 1
- For surgery after the first month, continue aspirin perioperatively if bleeding risk allows 1
- Resume recommended antiplatelet therapy as soon as possible post-operatively 1
Elective Cardiac Surgery
- Continue aspirin throughout the perioperative period 1
- For patients requiring P2Y12 inhibitor discontinuation:
- Ticagrelor: Discontinue at least 3 days before surgery
- Clopidogrel: Discontinue at least 5 days before surgery
- Prasugrel: Discontinue at least 7 days before surgery 1
Evidence from Coronary Endarterectomy Studies
A study specifically examining dual antiplatelet therapy prior to carotid endarterectomy showed that adding 75 mg of clopidogrel to daily aspirin therapy significantly reduced post-operative embolization and thromboembolic events 2. This supports the use of DAPT in patients undergoing endarterectomy procedures.
Common Pitfalls to Avoid
- Inadequate DAPT duration: Premature discontinuation of DAPT increases risk of thrombotic events
- Inappropriate P2Y12 inhibitor selection: Using prasugrel in patients with history of stroke/TIA or elderly patients
- Failure to use PPI: Increases risk of gastrointestinal bleeding complications
- Drug interactions: Certain PPIs (omeprazole, esomeprazole) may reduce clopidogrel effectiveness
- Discontinuing both antiplatelet agents before surgery: When possible, maintain aspirin therapy perioperatively
By following these evidence-based recommendations, the risk of post-operative thrombotic complications after coronary endarterectomy can be minimized while managing bleeding risk appropriately.