How to proceed with tracheostomy in a patient on dual antiplatelet therapy (DAPT) with recent acute coronary syndrome (ACS)?

Management of Tracheostomy in Patients on Dual Antiplatelet Therapy with Recent ACS

For patients on dual antiplatelet therapy (DAPT) with recent acute coronary syndrome (ACS) requiring tracheostomy, it is recommended to continue aspirin perioperatively if bleeding risk allows, and resume the recommended antiplatelet therapy as soon as possible post-operatively. 1

Risk Assessment and Timing Considerations

• DAPT discontinuation within the first month after ACS/PCI is not recommended due to high risk of stent thrombosis and recurrent cardiac events 1
• The timing of tracheostomy relative to ACS onset is critical:
  • If <1 month since ACS: Postpone elective tracheostomy if possible 1
  • If 1-6 months since ACS: Proceed with caution, maintaining at least partial antiplatelet coverage 1
  • If >6 months since ACS: Lower thrombotic risk allows more flexibility 1

Perioperative Management Algorithm

For Urgent/Emergent Tracheostomy:

1. Continue aspirin (75-100 mg daily) throughout the perioperative period 1
2. Consider temporary interruption of P2Y12 inhibitor based on specific agent:
   • Ticagrelor: Interrupt 3 days before procedure 1
   • Clopidogrel: Interrupt 5 days before procedure 2
   • Prasugrel: Interrupt 7 days before procedure 2
3. Resume P2Y12 inhibitor as soon as hemostasis is achieved, ideally within 24-48 hours 1

For Elective Tracheostomy:

• Delay procedure until completion of minimum required DAPT duration when possible 1
• For patients at high bleeding risk (PRECISE-DAPT ≥25), consider shortening DAPT to 6 months before elective procedures 1

Special Considerations

• Platelet transfusion may be considered in cases of significant perioperative bleeding, particularly if P2Y12 inhibitor was recently administered 2
• Proton pump inhibitor should be used in combination with DAPT to reduce bleeding risk 1
• Surgical technique modifications to minimize bleeding risk:
  • Consider percutaneous rather than open surgical approach when appropriate
  • Meticulous hemostasis during the procedure
  • Consider prophylactic electrocautery for potential bleeding points 3

Balancing Thrombotic and Bleeding Risks

• Patients with recent ACS (especially with stent placement) have high thrombotic risk that decreases over time 1, 2
• The first month after ACS/PCI carries the highest risk for stent thrombosis if DAPT is interrupted 1
• For patients requiring long-term anticoagulation in addition to DAPT (triple therapy), individualized decisions should consider bleeding risk regarding continuation of DAPT alongside anticoagulation 1

Post-Tracheostomy Management

• Monitor closely for bleeding complications in the first 48-72 hours 3
• Resume full DAPT as soon as hemostasis is secure 1
• Consider de-escalation strategies (switching from more potent P2Y12 inhibitors to clopidogrel) after the acute phase if bleeding risk remains high 4

Common Pitfalls to Avoid

• Complete discontinuation of both antiplatelet agents simultaneously, especially within first month after ACS 1
• Delaying resumption of antiplatelet therapy for prolonged periods after procedure 1
• Failing to coordinate care between cardiology and surgical teams to develop a cohesive perioperative plan 3