Published on January 3, 2014
Noncardiac Surgery After PCI What to do? Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine
You must balance… Stent Thrombosis Bleeding
Adverse Cardiac Events Following Noncardiac Surgery in Patients With Stents Hawn, et al. JAMA 2013;310:1462
Approach to patients who need surgery after PCI Wait 6 weeks Wait 6 months Continue dual antiplatelet therapy if surgery needed before completion of recommended therapy No matter what continue at least aspirin* * Except for neurosurgery, post eye, middle ear, and prostate
To continue or discontinue aspirin in the perioperative period? A randomized, controlled clinical trial Oscarsson, et al. Br J Anaesth. 2010;104(3):305 • Aspirin (75 mg) or placebo was given 7 days before noncardiac surgery and continued until the third postoperative day. Patients were followed up for 30 days after surgery • Twelve patients (5.4%) had an MACE • 2/109 (1.8%) in the aspirin group and 10/111 (9.0%) in the placebo group (P=0.02) • 7.2% absolute risk reduction [95% CI, 1.3-13%], NNT 14 • RRR= 80% (95% CI, 9.2-95%) • No significant differences in bleeding complications were seen between the two groups
Managing antiplatelet agents in the perioperative period • Aspirin (and aspirin/dipyridamole) • Safe to continue except in high bleeding risk surgeries • The 2012 guidelines from the American College of Chest Physicians suggest continuing aspirin in patients at moderate to high risk for cardiovascular events who are undergoing noncardiac surgery • Stop 7-10 days prior to surgery • Bleeding time is a poor predictor of perioperative hemorrhage
Managing antiplatelet agents in the perioperative period • Platelet P2Y12 receptor blockers • Clopidogrel and ticagrelor: stop at least 5 days before surgery • Prasugrel: stop at least 7 days before surgery • Cilostazol • Selective phosphodiesterase-3 enzyme inhibitor with weak, reversible antiplatelet activity • Stop 5 days before surgery
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Noncardiac Surgery and Bleeding After Percutaneous Coronary Intervention Andrew C.Y. To, MBChB; Guy Armstrong, MD; Irene Zeng, MSc; Mark W.I. Webster, MBChB
Although these results may add to our confidence for the safety of noncardiac surgery after coronary ... noncardiac surgery in advance of 1 year after PCI ...
Non-Cardiac Surgery After Percutaneous Coronary Intervention ... Review/Noncardiac Surgery After PCI 1615. 3.5% at >12 to 24 months; p <0.001) ...
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