How should prasugrel be managed perioperatively in a 58-year-old patient with hypertension, diabetes, and coronary artery disease with stents undergoing open left inguinal hernia repair with mesh?

Perioperative Management of Prasugrel for Inguinal Hernia Repair

Discontinue prasugrel at least 7 days before the scheduled open inguinal hernia repair and resume it as soon as possible postoperatively once hemostasis is secure. 1, 2, 3

Preoperative Discontinuation Timeline

• Stop prasugrel 7 days before surgery to allow dissipation of antiplatelet effects, as prasugrel irreversibly inhibits platelets for their entire lifespan (7-10 days). 1, 2, 3

• This 7-day window is explicitly recommended by the ACC/AHA guidelines and FDA labeling for all surgical procedures. 1, 3

• Open inguinal hernia repair with mesh is considered an intermediate bleeding risk procedure, making the standard 7-day discontinuation appropriate. 1

Assessing Stent Thrombosis Risk

Critical consideration: Determine when the patient's stents were placed and what type they are. 1

• If drug-eluting stents (DES) were placed <12 months ago, this patient is at very high risk for stent thrombosis if prasugrel is discontinued. 1

• If bare-metal stents (BMS) were placed <6 weeks ago, similarly high thrombosis risk exists. 1

• Additional high-risk features in this patient include diabetes (explicitly mentioned) and likely multiple stents given his CAD burden. 1

If Within High-Risk Window:

• Postpone the elective hernia repair until 12 months after DES placement or 6 weeks after BMS placement whenever feasible. 1

• If surgery cannot be delayed, convene a multidisciplinary meeting with cardiology, surgery, anesthesia, and hematology to weigh thrombosis risk versus bleeding risk. 1

• Consider continuing aspirin monotherapy while stopping prasugrel for the 7-day window, though this strategy lacks robust evidence for prasugrel specifically. 1

If Beyond High-Risk Window:

• Proceed with the standard 7-day discontinuation as the thrombosis risk is substantially lower. 1, 2

Aspirin Management

• Continue aspirin (75-162 mg daily) throughout the perioperative period if at all possible, as open hernia repair can typically be performed safely on aspirin alone. 1

• Aspirin continuation provides some protection against stent thrombosis during the prasugrel interruption window. 1

Postoperative Resumption

• Resume prasugrel as soon as hemostasis is achieved postoperatively, ideally within 24-48 hours after surgery. 1, 2

• Some experts recommend giving a 300 mg loading dose of prasugrel upon resumption to rapidly restore platelet inhibition, though this is based on expert opinion rather than trial data. 1

• The patient should continue prasugrel for at least 12 months total from the time of DES placement. 1

Special Considerations for This Patient

• Check the patient's weight: If <60 kg, he should be on prasugrel 5 mg daily (not 10 mg) due to increased bleeding risk from higher drug exposure. 1, 2, 4, 5, 3

• Verify age: If ≥75 years, prasugrel carries increased risk of fatal and intracranial bleeding, though his diabetes and CAD may justify continued use. 1, 2, 4, 5, 3

• Confirm no history of stroke/TIA: Prasugrel is absolutely contraindicated in patients with prior stroke or TIA. 1, 3

Critical Pitfalls to Avoid

• Never stop prasugrel abruptly without a plan: Premature discontinuation dramatically increases risk of stent thrombosis, MI, and death. 1, 3, 6, 7

• Do not perform elective surgery within 12 months of DES placement unless absolutely necessary, as one case report documented very late stent thrombosis 1,659 days after stent placement when antiplatelet therapy was interrupted. 6

• Ensure the patient understands the importance of resuming prasugrel postoperatively: Patient adherence is critical, with studies showing 98.5% adherence correlates with excellent outcomes. 8

• Coordinate closely with the patient's cardiologist before making any changes to antiplatelet therapy, particularly if stents were placed recently. 1, 4