Coronary Artery Stents

Perioperative Management of Dual Antiplatelet therapy after a recent coronary stent

Simple ‘rules’ are no substitute for thoughtful consideration of all issues involved in this complex clinical challenge.

For patients on dual antiplatelet therapy with a recent coronary artery stent, planning of periprocedural management must consider three questions:-

1. What is the risk of stopping Antiplatelet therapy with regard to adverse cardiac events?

2. What is the risk of continuing Antiplatelet therapy with regard to surgical bleeding?

3. What is the risk of postponing surgery?

Consideration of these questions will generally point to an appropriate management strategy (eg: Cease Clopidogrel five days preoperatively, and continuing aspirin.

Answering Question 1 (risk of adverse cardiac events) will need consideration of time since placement of stents, and the type of stent (bare metal or drug eluting). Other factors of particular concern include the anatomy of the stents (length, number, diameter and criticality of placement). The cardiologist’s advice will be useful in this regard. Types of stents are continuing to evolve. Simple ‘rules’ are no substitute for thoughtful consideration of all issues involved.

For very high risk patients a prolonged discussion involving the surgeon and cardiologist will be appropriate to plan an approach to the patient’s management.

 “Clexane Bridging” is inappropriate. Enoxaparin (Clexane) is an anticoagulant, not an antiplatelet agent, and such use may give an inappropriate sense of confidence that effective therapy is in place.

 Any patient at particularly high risk should be managed in hospital with 24/7 interventional cardiology capacity.

Management options for very high risk patients may be considered on a case by case basis. There is scant evidence to guide decision making in this regard. The literature is entirely anecdotal.

 One option reported by case reports is to cease Clopidogrel at an agreed time preoperatively, and wait one or two days, then start an infusion of Tirofiban, at standard “Cath Lab” rates. It is probably advisable not to give a loading dose, since the patient is already affected by residual effect of Clopidogrel. Cease the infusion 8 hours preoperatively and recommence as soon as the surgeon is agreeable, then restart clopidogrel.

 Another suggested ‘simpler’ option is to change Clopidogrel to Ticagrelor, (since this wears off quickly compared to clopidogrel.) Switchover may be done (say) 10-14 days preoperatively. Ticagrelor dose for an adult would be 90mg bd. The Ticagrelor could be ceased 48 hours preoperatively. The patient should be admitted 24 hours after Ticagrelor is ceased.

Simple ‘rules’ are no substitute for thoughtful consideration of all issues involved in this complex clinical challenge.

Guidelines

Coronary Artery Stents

Background/Reference Material

Discussion Notes

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