From the Guidelines
It is generally safe to perform surgery after drug-eluting stent (DES) placement once the patient has completed at least 6 months of dual antiplatelet therapy (DAPT), as recommended by the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease 1.
Key Considerations
- The risk of stent thrombosis is highest in the weeks after stent implantation, and discontinuation of DAPT during this period is a strong risk factor for stent thrombosis.
- For most current-generation DES, a minimum of 6 months of DAPT (aspirin 81mg daily plus a P2Y12 inhibitor such as clopidogrel 75mg daily) is recommended before elective surgery.
- If surgery is semi-urgent, some procedures may be considered after 3 months of DAPT, though this carries increased risk, as stated in the guidelines with a Class IIb recommendation 1.
- For urgent or emergency surgeries that cannot be delayed, consultation with both the cardiologist and surgeon is essential to balance bleeding and thrombotic risks.
Perioperative Management
- When surgery must proceed before completing the full DAPT course, aspirin should be continued perioperatively if possible, and the P2Y12 inhibitor should be restarted as soon as hemostasis is achieved, ideally within 24-48 hours post-surgery 1.
- The decision to discontinue DAPT after coronary stent implantation should be individualized, taking into account the particular surgical procedure and the risks of delaying the desired surgical procedure.
Recommendations
- Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation 1.
- In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery 1.
From the Research
Surgery After Drug-Eluting Stent Implantation
- The optimal timing for surgery after drug-eluting stent (DES) implantation is a topic of ongoing debate, with various studies providing insights into the risks and benefits of different approaches 2, 3, 4, 5, 6.
- Dual antiplatelet therapy (DAPT) is typically recommended for 6-12 months after DES implantation to prevent ischemic events and late stent thrombosis 2.
- However, recent studies suggest that shorter durations of DAPT (≤6 months) may be associated with similar mortality and ischemic outcomes, but less bleeding events, compared to longer durations (12 months) 3, 5.
- The risk of stent thrombosis and major bleeding events should be carefully considered when determining the optimal timing for surgery after DES implantation 2, 3, 4.
- Some studies suggest that the safety window for surgery after DES implantation could be shortened to <6 months or even less with new-generation DES 6.
- Perioperative pharmacologic management is intricate due to the tradeoff between the increased thrombotic risk associated with premature DAPT discontinuation and the increased risk of bleeding in the presence of antithrombotics 6.
Key Findings
- A meta-analysis of prospective controlled studies found that short duration DAPT is safer and as effective as standard duration DAPT in patients with second-generation DES 2.
- Another meta-analysis showed that short DAPT ≤ 3 months followed by single antiplatelet therapy reduces bleeding and is not associated with an increase in stent thrombosis 3.
- A prospective multicenter randomized trial is ongoing to test the non-inferiority of P2Y12 inhibitor monotherapy compared with aspirin plus a P2Y12 inhibitor after mandatory 3-month DAPT in patients undergoing PCI with current-generation DES 4.
- A meta-regression analysis found a significant association between bleeding events and non-CV mortality with 12-month DAPT, as well as between stent thrombosis and mortality in addition to MI with ≤6-month DAPT 5.