What is the recommended management of dual antiplatelet therapy (DAPT) in patients undergoing elective surgery after percutaneous coronary intervention (PCI)?

Management of Dual Antiplatelet Therapy (DAPT) for Patients Undergoing Elective Surgery After PCI

Elective surgery should be delayed for at least 6 months after drug-eluting stent (DES) placement for coronary artery disease, and ideally 12 months after DES placement for acute coronary syndrome to minimize perioperative major adverse cardiovascular events. 1

Timing of Elective Surgery After PCI

The timing of elective surgery after PCI depends on the indication for PCI and the type of stent:

For Drug-Eluting Stents (DES):

• ACS indication: Delay surgery for ≥12 months ideally 1
• Stable CAD indication: Delay surgery for ≥6 months 1
• Time-sensitive surgery: May consider surgery ≥3 months after PCI if benefits outweigh risks 1

For Bare-Metal Stents (BMS) or Balloon Angioplasty:

• Delay surgery for >30 days after BMS placement 1
• Delay surgery for >14 days after balloon angioplasty without stent placement 1

Contraindication:

• Elective surgery requiring interruption of antiplatelet therapy within 30 days of stent placement is potentially harmful due to high risk of stent thrombosis 1

Management of Antiplatelet Therapy During Surgery

General Recommendations:

1. Continue aspirin (75-100 mg) perioperatively if possible 1

   • Aspirin continuation reduces risk of cardiac events
   • This is particularly important for high thrombotic risk patients

2. P2Y12 Inhibitor Management:

   • Discontinue P2Y12 inhibitor before surgery if bleeding risk is high:
     • Clopidogrel: 5-7 days before surgery 2
     • Prasugrel: 7-10 days before surgery 2
     • Ticagrelor: 3-5 days before surgery 2
   • Restart P2Y12 inhibitor as soon as hemostasis is achieved (typically within 24-48 hours) 3

Special Situations:

High Thrombotic Risk (Surgery <3 months after DES or <30 days after BMS):

• Continue DAPT unless bleeding risk outweighs thrombotic risk 1
• If P2Y12 inhibitor must be discontinued:
  • Consider bridging with intravenous antiplatelet therapy (cangrelor, tirofiban, or eptifibatide) 1, 2
  • Cangrelor is a short-acting, reversible IV P2Y12 inhibitor that can be used as bridge therapy 4

Oral Anticoagulation:

• If oral anticoagulation must be discontinued before surgery, substitute with aspirin when feasible until oral anticoagulation can be safely restarted 1

Decision-Making Algorithm

1. Assess time since PCI:

   • <30 days after any stent: Delay elective surgery if possible
   • 1-3 months after DES: Consider delaying surgery unless urgent
   • 3-6 months after DES: Weigh risks/benefits of proceeding

   • 6 months after DES: Generally safe to proceed with appropriate antiplatelet management

2. Assess bleeding risk of procedure:

   • High bleeding risk (intracranial, spinal): Consider discontinuing P2Y12 inhibitor
   • Moderate bleeding risk: Consider continuing aspirin alone
   • Low bleeding risk: Consider continuing DAPT

3. Assess thrombotic risk:

   • High risk (recent ACS, complex PCI, multiple stents): Favor DAPT continuation
   • Low risk (>6 months after uncomplicated PCI): P2Y12 inhibitor can be safely discontinued

4. Implement management plan:

   • Continue aspirin if possible
   • If P2Y12 inhibitor must be discontinued, restart as soon as hemostasis is achieved
   • For very high thrombotic risk with necessary P2Y12 discontinuation, consider bridging therapy

Important Considerations and Pitfalls

• Multidisciplinary approach: Decisions should involve a consensus among the surgeon, anesthesiologist, and cardiologist 1

• Avoid complete DAPT discontinuation when possible, especially within 3 months of stent placement, as this significantly increases stent thrombosis risk 3

• Bleeding risk vs. thrombotic risk: The consequences of stent thrombosis are generally more serious than bleeding complications, except in cases of intracranial surgery 2

• Recent evidence on DAPT duration: Some patients may be eligible for shorter DAPT durations (28-31 days or 90 days) post-PCI based on recent data, but the safety of this approach in patients planned for surgery requires further study 1

• Newer-generation DES: The mandatory interval for elective surgery has been shortened from 1 year to 6 months (or 3 months if surgery cannot be further delayed) with newer-generation drug-eluting stents 2