What are the concerns with using dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, such as clopidogrel, in a diabetic and hypertensive patient who underwent cataract surgery recently and is now scheduled for coronary angiography (CAG) and revascularization with a positive treadmill test (TMT)?

Dual Antiplatelet Therapy After Recent Cataract Surgery in a Patient Requiring Coronary Revascularization

You can safely proceed with dual antiplatelet therapy (DAPT) and coronary angiography/revascularization in this patient who underwent cataract surgery, as the benefits of preventing stent thrombosis and cardiovascular death far outweigh the minimal risk of ocular bleeding complications. 1

Primary Recommendation for DAPT Regimen

For this diabetic patient with a positive TMT requiring revascularization, initiate ticagrelor (180 mg loading dose, then 90 mg twice daily) plus aspirin (75-100 mg daily) immediately, as this is the first-line regimen for acute coronary syndrome regardless of recent non-cardiac surgery. 1, 2

• Ticagrelor is specifically recommended over clopidogrel in diabetic patients with complex coronary disease, as diabetes is associated with higher ischemic risk 1
• If ticagrelor is contraindicated or unavailable, prasugrel (60 mg loading dose, 10 mg daily) is the second choice for PCI patients, unless the patient has prior stroke/TIA, age ≥75 years, or weight <60 kg 1, 2
• Clopidogrel (600 mg loading dose, 75 mg daily) should only be used if both ticagrelor and prasugrel are contraindicated 1

Timing Considerations After Cataract Surgery

The recent cataract surgery does not contraindicate DAPT initiation, as ophthalmic procedures carry minimal bleeding risk compared to the catastrophic consequences of delaying necessary coronary revascularization. 3

• Premature discontinuation or delay of DAPT after stent placement dramatically increases the risk of stent thrombosis, which frequently leads to myocardial infarction and death 3, 2
• The ESC guidelines emphasize that DAPT should not be discontinued within the first month after stent placement under any circumstances except life-threatening bleeding 1
• For elective non-cardiac surgery, guidelines recommend continuing aspirin perioperatively if bleeding risk allows, and resuming P2Y12 inhibitor therapy as soon as deemed safe post-operatively 1

Bleeding Risk Mitigation Strategies

Implement these mandatory measures to minimize bleeding complications while on DAPT: 1, 2

• Prescribe a proton pump inhibitor (PPI) to all patients on DAPT to reduce gastrointestinal bleeding risk 1, 2
• Maintain aspirin dose at 75-100 mg daily (not higher doses) to minimize bleeding while preserving efficacy 1, 2
• Use radial artery access (rather than femoral) for coronary angiography if performed by an expert radial operator 1
• Ensure optimal blood pressure control, as hypertension increases bleeding risk 1

Standard DAPT Duration

Continue DAPT for 12 months after coronary stent implantation, regardless of stent type, unless excessive bleeding complications occur. 1, 2

• In patients with high bleeding risk (PRECISE-DAPT score ≥25), consider shortening DAPT duration to 6 months 1
• In diabetic patients who tolerate DAPT without bleeding complications and have high ischemic risk, prolonged DAPT beyond 12 months may be considered 1

Critical Pitfalls to Avoid

Do not delay coronary revascularization due to recent cataract surgery, as the cardiovascular risk far exceeds any ophthalmic bleeding concern. 3, 2

• Do not use clopidogrel as first-line therapy when ticagrelor is available and not contraindicated, as this represents suboptimal care for high-risk patients 1, 2
• Do not omit PPI prescription, as this simple intervention significantly reduces gastrointestinal bleeding without compromising antiplatelet efficacy 1, 2
• Do not discontinue DAPT prematurely if any bleeding occurs unless it is life-threatening and the source cannot be treated 1
• Do not use aspirin doses higher than 100 mg daily, as this increases bleeding risk without improving efficacy 1, 2

Special Considerations for Diabetic Patients

Diabetic patients require particularly aggressive antiplatelet therapy due to higher platelet reactivity and increased thrombotic risk. 1, 4

• Diabetes is associated with dual non-responsiveness to antiplatelet agents, which is a stronger predictor of cardiac adverse events than isolated non-responsiveness 4
• The ESC guidelines specifically emphasize that diabetic patients with complex coronary anatomy should receive Heart Team discussion for optimal revascularization strategy (PCI vs. CABG) 1
• Similar type and duration of DAPT are recommended in patients with and without diabetes, but diabetic patients may benefit more from potent P2Y12 inhibitors like ticagrelor 1

Coordination with Ophthalmology

Inform the ophthalmologist that DAPT will be continued, but reassure them that serious ocular bleeding complications are extremely rare with modern antiplatelet therapy. 3

• The risk of vision-threatening hemorrhage from DAPT after cataract surgery is negligible compared to the risk of stent thrombosis from discontinuing antiplatelet therapy 3
• If any ocular bleeding occurs, local hemostatic measures should be attempted first before considering DAPT modification 1