Abstract
Preoperative withdrawal of antiplatelet (AP) therapy in secondary prevention multiplies the risk of myocardial infarction, stent thrombosis, stroke, or death, by five to ten times. Aspirin is a lifelong therapy and should never be interrupted. Dual AP therapy with aspirin plus clopidogrel, prasugrel, or ticagrelor is essential for at least 6 weeks after coronary revascularization using bare-metal stents, 12 months after treatment for acute coronary syndrome, and 6–12 months after implanting drug-eluting stents. These time spans might even be prolonged in high-risk cases. Elective surgery should be postponed until after these periods. Vital or urgent operations undertaken earlier must be performed under continued dual AP therapy.
Preoperatively, patients might be on prophylactic or therapeutic doses of anticoagulants. The indication for the anticoagulation therapy must be reevaluated in order to balance the thrombotic risk of interrupting against the risk of bleeding when continuing the treatment. A detailed protocol, comprising the pre-, peri-, and postoperative phases needs then to be established. It should include indications regarding anticoagulation reversal, bridging (when necessary), and postoperative reintroduction of the anticoagulant therapy.
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References
Ageno W, Gallus AS et al (2012) Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e44S–e88S
Albaladejo P, Marret E et al (2011) Non-cardiac surgery in patients with coronary stents: the RECO study. Heart 97(19):1566–1572
American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT et al (2009) Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 110(2):218–230
Anand SS, Brimble S et al (1997) Management of iliofemoral thrombosis in a pregnant patient with heparin resistance. Arch Intern Med 157(7):815–816
Angiolillo DJ, Firstenberg MS et al (2012) Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 307(3):265–274
Aradi D, Komocsi A et al (2010) Prognostic significance of high on-clopidogrel platelet reactivity after percutaneous coronary intervention: systematic review and meta-analysis. Am Heart J 160(3):543–551
Artang R, Dieter RS (2007) Analysis of 36 reported cases of late thrombosis in drug-eluting stents placed in coronary arteries. Am J Cardiol 99(8):1039–1043
Asmis LM, Alberio L et al (2012) Rivaroxaban: Quantification by anti-FXa assay and influence on coagulation tests: a study in 9 Swiss laboratories. Thromb Res 129(4):492–498
Barash P, Akhtar S (2010) Coronary stents: factors contributing to perioperative major adverse cardiovascular events. Br J Anaesth 105(Suppl 1):i3–i15
Barrett YC, Wang Z et al (2010) Clinical laboratory measurement of direct factor Xa inhibitors: anti-Xa assay is preferable to prothrombin time assay. Thromb Haemost 104(6):1263–1271
Basu D, Gallus A et al (1972) A prospective study of the value of monitoring heparin treatment with the activated partial thromboplastin time. N Engl J Med 287(7):324–327
Bates ER, Lau WC et al (2011) Clopidogrel-drug interactions. J Am Coll Cardiol 57(11):1251–1263
Berger PB, Bellot V et al (2001) An immediate invasive strategy for the treatment of acute myocardial infarction early after noncardiac surgery. Am J Cardiol 87(9):1100–1102, A1106, A1109
Bhatt DL, Fox KA et al (2006) Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 354(16):1706–1717
Bijsterveld NR, Moons AH et al (2002) Ability of recombinant factor VIIa to reverse the anticoagulant effect of the pentasaccharide fondaparinux in healthy volunteers. Circulation 106(20):2550–2554
Biondi-Zoccai GG, Lotrionte M et al (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 27(22):2667–2674
Brey RL (1992) Antiphospholipid antibodies and ischemic stroke. Heart Dis Stroke 1(6):379–382
Burger W, Chemnitius JM et al (2005) Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med 257(5):399–414
Chassot PG, Delabays A et al (2007) Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 99(3):316–328
Chassot PG, Marcucci C et al (2010) Perioperative antiplatelet therapy. Am Fam Physician 82(12):1484–1489
Chernoguz A, Telem DA et al (2011) Cessation of clopidogrel before major abdominal procedures. Arch Surg 146(3):334–339
Connolly SJ, Ezekowitz MD et al (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151
Dabbagh O, Nagam N et al (2010) Retrievable inferior vena cava filters are not getting retrieved: where is the gap? Thromb Res 126(6):493–497
Dangas GD, Caixeta A et al (2011) Frequency and predictors of stent thrombosis after percutaneous coronary intervention in acute myocardial infarction. Circulation 123(16):1745–1756
Douketis JD, Berger PB et al (2008) The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6 Suppl):299S–339S
Eberli D, Chassot PG et al (2010) Urological surgery and antiplatelet drugs after cardiac and cerebrovascular accidents. J Urol 183(6):2128–2136
Edson JR, Krivit W et al (1967) Kaolin partial thromboplastin time: high levels of procoagulants producing short clotting times or masking deficiencies of other procoagulants or low concentrations of anticoagulants. J Lab Clin Med 70(3):463–470
Eerenberg ES, Kamphuisen PW et al (2011) Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 124(14):1573–1579
Eisenberg MJ, Richard PR et al (2009) Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation 119(12):1634–1642
Fujimoto H, Ishimura R et al (2009) Two cases of acute coronary syndrome that occurred by preoperative discontinuation of antiplatelet therapy in the chronic phase after stent implantation. J Cardiol 54(3):470–474
Gaglia MA Jr, Waksman R (2011) Systematic review of thienopyridine discontinuation and its impact upon clinical outcomes. Eur Heart J 32(19):2358–2364
Garcia DA, Baglin TP et al (2012) Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e24S–e43S
Gavillet M, Angelillo-Scherrer A (2012) Quantification of the anticoagulatory effect of novel anticoagulants and management of emergencies. Cardiovasc Med 15(5):170–179
Gogarten W, Vandermeulen E et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27(12):999–1015
Green D, Hirsh J et al (1994) Low molecular weight heparin: a critical analysis of clinical trials. Pharmacol Rev 46(1):89–109
Gurbel PA, Bliden KP et al (2009) Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation 120(25):2577–2585
Hall R, Mazer CD (2011) Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. Anesth Analg 112(2):292–318
Hirsh J, van Aken WG et al (1976) Heparin kinetics in venous thrombosis and pulmonary embolism. Circulation 53(4):691–695
Jaff MR, McMurtry MS et al (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123(16):1788–1830
Jaffer AK, Brotman DJ et al (2010) Variations in perioperative warfarin management: outcomes and practice patterns at nine hospitals. Am J Med 123(2):141–150
Joner M, Finn AV et al (2006) Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol 48(1):193–202
Kearon C, Akl EA et al (2012) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e419S–e494S
Korte W, Cattaneo M et al (2011) Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (OGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost 105(5):743–749
Kubitza D, Becka M et al (2005) Safety, pharmacodynamics, and pharmacokinetics of single doses of BAY 59-7939, an oral, direct factor Xa inhibitor. Clin Pharmacol Ther 78(4):412–421
Levine MN, Hirsh J et al (1994) A randomized trial comparing activated thromboplastin time with heparin assay in patients with acute venous thromboembolism requiring large daily doses of heparin. Arch Intern Med 154(1):49–56
Mega JL, Simon T et al (2010) Reduced-function CYP2C19 genotype and risk of adverse clinical outcomes among patients treated with clopidogrel predominantly for PCI: a meta-analysis. JAMA 304(16):1821–1830
Mismetti P, Rivron-Guillot K et al (2007) A prospective long-term study of 220 patients with a retrievable vena cava filter for secondary prevention of venous thromboembolism. Chest 131(1):223–229
Moore M, Power M (2004) Perioperative hemorrhage and combined clopidogrel and aspirin therapy. Anesthesiology 101(3):792–794
Mourelo R, Kaidar-Person O et al (2008) Hemorrhagic and thromboembolic complications after bariatric surgery in patients receiving chronic anticoagulation therapy. Obes Surg 18(2):167–170
Nicholson W, Nicholson WJ et al (2010) Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade. Arch Intern Med 170(20):1827–1831
Nuttall GA, Brown MJ et al (2008) Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology 109(4):588–595
Olson JD, Arkin CF et al (1998) College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: laboratory monitoring of unfractionated heparin therapy. Arch Pathol Lab Med 122(9):782–798
Patel MR, Mahaffey KW et al (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365(10):883–891
Patrono C, Rocca B (2010) The future of antiplatelet therapy in cardiovascular disease. Annu Rev Med 61:49–61
Pengo V, Crippa L et al (2011) Questions and answers on the use of dabigatran and perspectives on the use of other new oral anticoagulants in patients with atrial fibrillation. A consensus document of the Italian Federation of Thrombosis Centers (FCSA). Thromb Haemost 106(5):868–876
Pharma BS (2009) Xarelto. Summary of product characteristics. www.xarelto.com/html/downloads/Xarelto_Summary_of_Product_Characteristics_May2009.pdf. Accessed Mar 2011
Price MJ (2009) Bedside evaluation of thienopyridine antiplatelet therapy. Circulation 119(19):2625–2632
Rabbitts JA, Nuttall GA et al (2008) Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology 109(4):596–604
Samama MM, Contant G et al (2012) Evaluation of the anti-factor Xa chromogenic assay for the measurement of rivaroxaban plasma concentrations using calibrators and controls. Thromb Haemost 107(2):379–387
Savonitto S, D’Urbano M et al (2010) Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth 104(3):285–291
Schouten O, van Domburg RT et al (2007) Noncardiac surgery after coronary stenting: early surgery and interruption of antiplatelet therapy are associated with an increase in major adverse cardiac events. J Am Coll Cardiol 49(1):122–124
Schulz S, Schuster T et al (2009) Stent thrombosis after drug-eluting stent implantation: incidence, timing, and relation to discontinuation of clopidogrel therapy over a 4-year period. Eur Heart J 30(22):2714–2721
Sharma AK, Ajani AE et al (2004) Major noncardiac surgery following coronary stenting: when is it safe to operate? Catheter Cardiovasc Interv 63(2):141–145
Stangier J, Rathgen K et al (2007) The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects. Br J Clin Pharmacol 64(3):292–303
Streiff MB (2000) Vena caval filters: a comprehensive review. Blood 95(12):3669–3677
Task Force on Myocardial Revascularization of the European Society of, Cardiology; The European Association for Cardio-Thoracic Surgery; et al (2010) Guidelines on myocardial revascularization. Eur Heart J 31(20):2501–2555
Taylor K, Filgate R et al (2011) A retrospective study to assess the morbidity associated with transurethral prostatectomy in patients on antiplatelet or anticoagulant drugs. BJU Int 108(Suppl 2):45–50
Valgimigli M, Campo G et al (2012) Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: a randomized multicenter trial. Circulation 125(16):2015–2026
van Ryn J, Stangier J et al (2010) Dabigatran etexilate–a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 103(6):1116–1127
Wallentin L, Becker RC et al (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 361(11):1045–1057
Warkentin TE, Margetts P et al (2012) Recombinant factor VIIa (rFVIIa) and hemodialysis to manage massive dabigatran-associated postcardiac surgery bleeding. Blood 119(9):2172–2174
Weitz JI (2010) New oral anticoagulants in development. Thromb Haemost 103(1):62–70
Whitfield LR, Lele AS et al (1983) Effect of pregnancy on the relationship between concentration and anticoagulant action of heparin. Clin Pharmacol Ther 34(1):23–28
Wilson SH, Fasseas P et al (2003) Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 42(2):234–240
Wiviott SD, Braunwald E et al (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357(20):2001–2015
Zhang D, He K et al (2009) Comparative metabolism of 14C-labeled apixaban in mice, rats, rabbits, dogs, and humans. Drug Metab Dispos 37(8):1738–1748
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Chassot, PG., Barelli, S., Blum, S., Angelillo-Scherrer, A., Marcucci, C.E. (2015). Antiplatelet Therapy and Anticoagulation. In: Marcucci, C., Schoettker, P. (eds) Perioperative Hemostasis. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-55004-1_8
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