How should antiplatelet therapy be managed in patients undergoing major elective non-cardiac surgery?

Management of Antiplatelet Therapy in Major Elective Non-Cardiac Surgery

For patients on dual antiplatelet therapy (DAPT), elective non-cardiac surgery should be postponed until completion of the full DAPT course when it does not pose major life-threatening or functional risk, with aspirin continued perioperatively whenever possible. 1

Timing of Surgery Based on Cardiac Risk

Patients with Recent Stent Implantation

• Postpone elective surgery beyond 1 month following any stent implantation (regardless of stent type or indication) if DAPT discontinuation is required 1
• Postpone for up to 6 months in patients with:
  • Recent myocardial infarction 1
  • High thrombotic risk stents (≥3 lesions treated, ≥3 stents implanted, bifurcation with 2 stents, total stent length >60mm, chronic total occlusion treatment, or last remaining patent coronary artery) 1
• If surgery cannot be postponed beyond 1 month, perform only in hospitals with 24/7 catheterization laboratory availability 1

Patients Without Recent Stenting

• The ACC/AHA guidelines indicate elective surgery should not be performed within 14 days of balloon angioplasty if aspirin must be discontinued 1

Perioperative Antiplatelet Management

Aspirin Management

• Continue aspirin perioperatively in all patients when possible 1
• If aspirin must be discontinued, resume as early as possible after surgery, ideally the same day, according to bleeding risk 1
• Continuation of aspirin is reasonable when cardiac event risk outweighs bleeding risk 1

P2Y12 Inhibitor Management (Clopidogrel, Prasugrel, Ticagrelor)

• Discontinue 5-7 days before surgery if bleeding risk necessitates stopping:
  • Clopidogrel: 5 days 1
  • Prasugrel: 7 days 1
  • Ticagrelor: 5 days 1
• Resume within 24-72 hours postoperatively with the same P2Y12 inhibitor used preoperatively 1
• No clear recommendation exists regarding loading dose upon resumption 1

Dual Antiplatelet Therapy (DAPT)

• Continue DAPT during urgent surgery in the first 4-6 weeks after bare-metal or drug-eluting stent placement, unless bleeding risk outweighs stent thrombosis prevention benefit 1
• Discuss preoperative management with the patient's cardiologist for procedures with intermediate or high bleeding risk 1

Bridging Strategies for High-Risk Situations

• Consider IV antiplatelet bridging (tirofiban or cangrelor) only if both antiplatelets must be discontinued within 1 month of stent implantation, after multidisciplinary discussion 1
• This is off-label use and must be performed in intensive care units at centers with 24/7 catheterization laboratories 1
• Do not use concomitant parenteral anticoagulation due to increased bleeding risk 1

Regional Anesthesia Considerations

Neuraxial Anesthesia

• Epidural catheter insertion carries similar risks to manipulation and removal; apply same discontinuation criteria to all procedures 1
• Do not compromise postoperative resumption of P2Y12 inhibitors due to epidural catheter presence 1

Peripheral Nerve Blocks

Low bleeding risk blocks (femoral, axillary plexus, popliteal sciatic):

• May be performed on aspirin therapy if benefit/risk ratio is favorable 1

High bleeding risk blocks (infraclavicular brachial, para-sacral sciatic, posterior lumbar plexus):

• Contraindicated with P2Y12 inhibitors 1
• May be performed on aspirin alone 1

Additional Perioperative Medication Management

• Avoid NSAIDs in patients on DAPT 1
• Perioperative coxibs are acceptable 1

Evidence Quality Considerations

The French Working Group guidelines [1-1] represent the most comprehensive and recent (2018) guidance with strong consensus recommendations. A 2018 Cochrane review found low to moderate certainty evidence that continuation versus discontinuation of antiplatelet therapy may make little difference in mortality, bleeding requiring transfusion or surgery, or ischemic events 2. However, this evidence base is limited by few studies with few participants. The STRATAGEM trial similarly found no significant difference in thrombotic or bleeding events between aspirin continuation versus interruption 3, though this conflicts with observational data showing increased adverse events with arbitrary (non-consensus) antiplatelet decisions 4.

The critical pitfall is arbitrary discontinuation of antiplatelet therapy without multidisciplinary consensus, which independently increases net clinical adverse events, major adverse cardiac events, and major bleeding 4.