How to manage a patient on dual antiplatelet therapy (aspirin and P2Y12 inhibitors, such as clopidogrel, prasugrel, or ticagrelor) perioperatively?

Perioperative Management of Dual Antiplatelet Therapy

Continue aspirin throughout the perioperative period in most cases, but discontinue the P2Y12 inhibitor 3-7 days before surgery depending on the specific agent, then resume both medications within 24 hours postoperatively when hemostasis is adequate. 1

Pre-operative Assessment and Timing

Risk Stratification Framework

• Assess thrombotic risk: Determine time since stent placement, stent type, and indication for DAPT (acute coronary syndrome vs. stable disease) 1
• Assess bleeding risk: Identify if surgery is high-risk (intracranial, spinal, posterior chamber eye surgery) versus standard risk 1
• Convene multidisciplinary team: Include cardiology, surgery, and anesthesia to determine optimal timing and management strategy 1

Optimal Surgical Timing After Stent Placement

• Minimum delay of 1 month after any stent type if aspirin can be maintained perioperatively 1
• Consider delaying 6 months after stent placement in patients with recent MI or high ischemic risk features 1
• For bare metal stents: Minimum 1 month delay is acceptable 1
• For drug-eluting stents: Ideally postpone 6 months, though 3 months may be acceptable if surgical delay poses greater risk than stent thrombosis 1

Pre-operative Discontinuation Strategy

Aspirin Management

• Continue aspirin perioperatively in the vast majority of cases, including all patients with coronary stents 1
• Stop aspirin only for highest bleeding-risk procedures (intracranial, spinal surgery) where even minor bleeding is catastrophic 1
• If aspirin must be stopped: Discontinue ≤7 days (not 7-10 days) before surgery 1, 2

P2Y12 Inhibitor Discontinuation Timing

Stop the P2Y12 inhibitor based on specific agent: 1

• Ticagrelor: 3-5 days before surgery (emerging evidence supports 3 days as sufficient) 1
• Clopidogrel: 5 days before surgery 1
• Prasugrel: 7 days before surgery 1

Special Circumstances: Surgery Within 1 Month of Stenting

• If surgery cannot be delayed beyond 1 month: Consider continuing both antiplatelet agents perioperatively, accepting increased bleeding risk to prevent stent thrombosis 1, 3
• Alternative bridging strategy: May consider IV antiplatelet agents (cangrelor or GP IIb/IIIa inhibitors) if both oral agents must be stopped, particularly within 1 month of stent placement 1
• Cangrelor bridging protocol: Stop clopidogrel 5 days pre-op, bridge with cangrelor infusion until surgery, then resume oral therapy postoperatively 4, 3, 5

Neuraxial Anesthesia Considerations

Central Neuraxial Blocks (Spinal/Epidural)

• Aspirin alone: Not a contraindication to neuraxial anesthesia if no other hemostatic abnormalities exist 1
• Any P2Y12 inhibitor: Absolute contraindication to central neuraxial blocks unless discontinued for full duration (clopidogrel 5 days, prasugrel 7 days, ticagrelor 5 days) 1

Peripheral Nerve Blocks

• Superficial blocks (femoral, axillary, popliteal sciatic): May perform on aspirin or DAPT if benefit outweighs risk 1
• Deep blocks (infraclavicular, parasacral sciatic, lumbar plexus): Contraindicated with P2Y12 inhibitors unless discontinued for appropriate duration 1
• All blocks: Use ultrasound guidance by experienced operators 1

Post-operative Resumption

Timing of Restart

• Resume antiplatelet therapy within 24 hours after surgery when adequate hemostasis is achieved 1
• Do not delay beyond 24 hours as this increases thrombotic risk, particularly in patients with recent stents or ACS 1, 6
• For CABG specifically: Resume P2Y12 inhibitor within 24 hours postoperatively 1

Resumption Strategy

• Aspirin: Resume at maintenance dose (75-100 mg daily) 1
• Clopidogrel: May use 300-600 mg loading dose if rapid platelet inhibition needed (e.g., recent stent), otherwise resume 75 mg daily 6, 2
• Ticagrelor: Resume at standard dosing (90 mg twice daily) 1
• Prasugrel: Resume at standard dosing (10 mg daily) 1

Cardiac Surgery-Specific Recommendations

Pre-operative Management for CABG

• Continue aspirin throughout perioperative period 1
• Discontinue P2Y12 inhibitor: Clopidogrel 5 days, ticagrelor 3 days minimum, prasugrel 7 days before surgery 1
• Platelet function testing: May be considered to guide timing in semi-urgent CABG, particularly for negative predictive value regarding bleeding 1

Post-CABG Management

• Resume P2Y12 inhibitor within 24 hours after surgery to complete recommended 12-month DAPT duration 1, 6
• May delay resumption if severe thrombocytopenia develops (platelet count <50,000/μL), typically with on-pump surgery 1

Critical Pitfalls to Avoid

• Do not routinely use platelet function testing to guide perioperative management in non-cardiac surgery; it is not recommended 1, 6
• Do not use outdated 7-10 day discontinuation windows for aspirin or ticagrelor; shorter durations are now supported 1, 2
• Do not use bridging with low molecular weight heparin for antiplatelet therapy; it increases bleeding without providing adequate antiplatelet effect 1
• Do not forget to assess for over-the-counter NSAIDs which have antiplatelet effects and increase bleeding risk when combined with DAPT 7, 2
• Do not discontinue DAPT within first month after stenting for elective surgery; delay surgery if at all possible 1