How to manage ANTIplatelets around surgery

As a clinical pharmacist, you will be asked how to manage dual antiplatelet therapy (DAPT) around surgery in patients with a recent coronary stent. It’s a balancing act between risk of thrombosis and bleeding. American College of Cardiology guidelines still prefer at least 6 to 12 months of DAPT after most stent placements, but suggest shorter durations as an option in patients at high bleeding risk. Now Chest peri-operative guidelines suggest the highest risk of thrombosis is often shorter, within 3 months of stent placement. But evidence is limited.

Continue to individualize peri-op DAPT management with your team, based on surgery type, number of stents, comorbidities, etc. Consider these starting points to guide discussions.

Stents placed MORE than 3 months ago. Generally, continue aspirin and hold the P2Y12 inhibitor, ticagrelor (Brilique) for 3 to 5 days before surgery, clopidogrel (Plavix) for 5 days, or prasugrel for 7 days. Don’t routinely bridge with IV antiplatelets, eptifibatide (Integrilin), tirofiban (Aggrastat), or cangrelor (Kengreal). Data with bridging are limited. Plus, bleeding concerns might outweigh benefit, especially if stent thrombosis risk is lower. But be ready for exceptions. Specialists may continue DAPT or use bridging in patients with very high thrombotic risk, such as a recent MI, multiple stents, or a stent in a critical artery.

Stents placed WITHIN the last 3 months. Don’t be surprised to see specialists continue DAPT if surgical bleeding risk is low. But if bleeding risk is high, anticipate holding the P2Y12 inhibitor. And work with specialists to evaluate the use of IV antiplatelet bridging if patients are also at high thrombotic risk.

Be aware, there’s no evidence that one IV antiplatelet works better than another. Cangrelor has the shortest half-life and doesn’t require renal adjustment, but costs the most. Usually start the IV antiplatelet within 72 hours after oral P2Y12 inhibitors are held, and continue until 1 to 6 hours pre-op, depending on the medication. Resume DAPT within 24 hours after surgery in most cases. At discharge, ensure the intended duration for DAPT is documented.

References

• Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022 Nov;162(5):e207-e243. Available at: https://journal.chestnet.org/article/S0012-3692(22)01359-9/fulltext

  Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med. 2022 Jan;17(1):25-35. Available at: https://pubmed.ncbi.nlm.nih.gov/34652572

  Van Tuyl JS, Newsome AS, Hollis IB. Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety. Ann Pharmacother. 2019 Jul;53(7):726-737. Available at: https://pubmed.ncbi.nlm.nih.gov/30646761