Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians

Cangrelor in patients undergoing cardiac surgery: the BRIDGE study

The benefit of long-term dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes, drug-eluting stents and those at high risk for thromboembolic events has been well established in a number of well-designed randomized controlled studies. Current research in this area has focused on the development of novel antiplatelet agents for clinical use. The BRIDGE trial evaluated the use of cangrelor as a bridge to coronary artery bypass graft surgery in patients receiving extended DAPT. The BRIDGE trial results confirm the efficacy and safety of cangrelor in this population. This study is novel as it attempts to address the lapse in thienopyridine therapy required for many surgical and invasive procedures. The future of antiplatelet agents, particularly cangrelor, must also focus on bridging for high-risk patients undergoing noncoronary artery bypass graft surgical procedures. Overall, the BRIDGE trial represents a significant advance for patients appropriate for long-term DAPT.

Benefits and harms of extending the duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stents: a meta-analysis

BACKGROUND

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is unclear.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials evaluating risk of adverse events in participants receiving different durations of DAPT following insertion of drug-eluting stents.

RESULTS

Five trials were included, but only four had data suitable for meta-analysis (n = 8,231 participants). No significant increase in the composite endpoint of death and nonfatal myocardial infarction was observed with earlier cessation of DAPT in any instance when compared to longer durations of DAPT (RR 0.64 95% CI 0.25-1.63 for 3 versus 12 months, RR 1.09 95% CI 0.84-1.41 for 6 versus 12 months and, RR 0.64 95% CI 0.35-1.16 for 12 versus 24 months). Pooled results showed a significantly lower risk of major bleeding (RR 0.48 95% CI 0.25-0.93) and total bleeding (RR 0.30 95% CI 0.16-0.54) for shorter compared to longer duration of DAPT. Subgroup analysis based on age, prior diabetes, and prior ACS failed to show any group where longer durations were consistently better than shorter ones.

CONCLUSIONS

There are no cardiovascular or mortality benefits associated with extended duration of DAPT, but the risk of major bleeding was significantly lower with shorter lengths of therapy.

Prospective and systematic analysis of unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stent implantation

PURPOSE

Unexpected requests for non-cardiac surgery requiring discontinuation of dual antiplatelet therapy (DAPT) frequently occur in daily clinical practice. The objectives of this study were to evaluate prevalence, timing and clinical outcomes of such unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stents (DESs) implantation.

MATERIALS AND METHODS

We prospectively investigated the prevalence, timing and clinical outcomes of unexpected requests for non-cardiac surgery or other procedures during the first year after DESs implantation in 2117 patients.

RESULTS

The prevalence of requested non-cardiac surgery or invasive procedures was 14.6% in 310 requests and 12.3% in 261 patients. Among 310 requests, those were proposed in 11.3%<1 month, 30.0% between 1 and 3 months, 36.8% between 4 and 6 months and 21.9% between 7 and 12 months post-DES implantation. The rates of actual discontinuation of DAPT and non-cardiac surgery or procedure finally performed were 35.8% (111 of 310 requests) and 53.2% (165 of 310 requests), respectively. On multivariate regression analysis, the most significant determinants for actual discontinuation of DAPT were Endeavor zotarolimus-eluting stent implantation with 3-month DAPT (OR=5.54, 95% CI 2.95-10.44, p<0.001) and timing of request (OR=2.84, 95% CI 1.97-4.11, p<0.001). There were no patients with any death, myocardial infarction, or stent thrombosis related with actual discontinuation of DAPT.

CONCLUSION

Those unexpected requests with premature discontinuation of DAPT were relatively common and continuously proposed during the first year following DES implantation. No death, myocardial infarction or stent thrombosis occurred in patients with actual discontinuation of DAPT.

New anticoagulant and antiplatelet agents: a primer for the gastroenterologist

A large number of patients worldwide receive anticoagulant and antiplatelet agents, collectively known as antithrombotic agents. Several new anticoagulants and antiplatelet agents recently were approved for use. Gastroenterologists may be unfamiliar with the mechanism of action, indications for use, and pharmacokinetics of these newer drugs. In patients undergoing elective and urgent endoscopic procedures, clinicians must be familiar with these medications to optimize outcomes. When the decision is made to continue the newer antithrombotic agents for elective procedures, the clinician must understand the risk that these agents may impart on procedural-induced bleeding. Finally, it is important to understand how to manage these agents in the presence of acute gastrointestinal bleeding. In this article the use of newer antithrombotic agents is reviewed.

Optimal Duration of Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation

Background—

The risks and benefits of long-term dual antiplatelet therapy remain unclear.

Methods and Results—

This prospective, multicenter, open-label, randomized comparison trial was conducted in 24 clinical centers in Korea. In total, 5045 patients who received drug-eluting stents and were free of major adverse cardiovascular events and major bleeding for at least 12 months after stent placement were enrolled between July 2007 and July 2011. Patients were randomized to receive aspirin alone (n=2514) or clopidogrel plus aspirin (n=2531). The primary end point was a composite of death resulting from cardiac causes, myocardial infarction, or stroke 24 months after randomization. At 24 months, the primary end point occurred in 57 aspirin-alone group patients (2.4%) and 61 dual-therapy group patients (2.6%; hazard ratio, 0.94; 95% confidence interval, 0.66–1.35; P =0.75). The 2 groups did not differ significantly in terms of the individual risks of death resulting from any cause, myocardial infarction, stent thrombosis, or stroke. Major bleeding occurred in 24 (1.1%) and 34 (1.4%) of the aspirin-alone group and dual-therapy group patients, respectively (hazard ratio, 0.71; 95% confidence interval, 0.42–1.20; P =0.20).

Conclusions—

Among patients who were on 12-month dual antiplatelet therapy without complications, an additional 24 months of dual antiplatelet therapy versus aspirin alone did not reduce the risk of the composite end point of death from cardiac causes, myocardial infarction, or stroke.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01186146.

Early experience with the multilayer aneurysm repair stent in the endovascular treatment of trans/infragenicular popliteal artery aneurysms: a mixed bag

PURPOSE

To present a preliminary experience using a multilayer flow-modulating stent for trans/infragenicular popliteal endovascular aneurysm repair.

METHODS

Five men (mean age 76 years, range 62-86) with 6 popliteal artery aneurysms (PAAs) measuring 22 to 39 mm in diameter (mean 30) underwent endovascular repair using the Cardiatis Multilayer Aneurysm Repair System (MARS) between June and August 2011. Radiological assessments post procedure using duplex ultrasonography and biplanar knee radiographs (additional contrast studies as necessary) sought evidence of aneurysm exclusion, graft patency, and preservation of branches and runoff vessels.

RESULTS

Technical success was achieved in each case. There was one symptomatic stent occlusion requiring thrombectomy at 4 days, with reocclusion, and one leak via the stent struts into the sac with no branch outflow identified. Two further symptomatic stent occlusions were identified within a 6-week follow-up period, totaling 3 occlusions among the 6 devices deployed.

CONCLUSION

No firm conclusion can be reached on the efficacy of the MARS in PAAs due to the inherent limitations of this small series, although a 50% thrombosis rate is a poor outcome. The risk of early thrombosis in flow-modulating stents deployed in the popliteal artery exists, as it does with earlier generation stent-grafts. Larger prospective trials and the influence of more aggressive antithrombotic/anticoagulant therapy should be considered to enable accurate evaluation of this device in popliteal artery aneurysms.

Office-based anesthesia for the urologist

This article describes office-based surgery and office-based anesthesia (OBA), including the safe setup of OBA and safety concerns regarding OBA. Also discussed are the preoperative selection and workup of a patient undergoing OBA, anesthetic options, the prevention and treatment of postoperative nausea, vomiting, and pain, and planning for safe discharge.

Patients with ischemic heart disease

Ischemic heart disease (IHD) occurs when myocardial oxygen supply is not adequate for myocardial oxygen demand. Patients with IHD who are undergoing surgery are at risk for development of perioperative cardiac events (PCEs), and this risk depends on the type of surgery, the presence of clinical risk factors, and functional status of the patients. Appropriate perioperative management of medications such as dual antiplatelet therapy and β-blockers has a significant impact on outcomes. Perioperative management decisions should be communicated clearly between the surgeon, cardiologist, and anesthesiologist in charge of the patient. Appropriate perioperative management reduces the incidence of PCEs.

Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: a prospective study

Controversy exists concerning the suspension or maintenance of anti-platelet drugs before elective surgical procedures. We assessed the association of the risk of prolonged postoperative bleeding with anti-platelet therapy by type of minor surgical procedure and the association between anti-platelet therapy and the level of hemostatic measures required. Five hundred and forty-six patients were included in the study group: those on aspirin (n = 310), clopidogrel (n = 97), and aspirin + clopidogrel dual therapy (n = 139); the control group comprised 575 healthy individuals. Cramer's V test was significant (P < 0.05) but showed a weak association between anti-platelet therapy and prolonged immediate postoperative bleeding. Compared to controls, the odds ratio revealed that the risk of prolonged bleeding in the immediate postoperative period was significantly higher with dual therapy, followed by clopidogrel and aspirin. Prolonged bleeding occurred in 22 patients in the study group and 20 in the control group, and was successfully controlled with local hemostatic measures. Fisher's exact test showed a significant association between dual therapy and higher levels of hemostatic measures (P = 0.004; P = 0.035). Prolonged bleeding in patients on anti-platelet therapy was independent of the type of minor surgical procedure. The greatest risk of prolonged bleeding was found in patients on dual therapy; this required higher levels of hemostatic measures.

Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital

BACKGROUND

The effect of antiplatelet therapy (APT) on surgical blood loss and perioperative complications in patients receiving abdominal laparoscopic surgery still remains unclear.

STUDY DESIGN

A total of 1,075 consecutive patients undergoing abdominal laparoscopic surgery between 2005 and 2011 were reviewed. Our perioperative management protocol consisted of interruption of APT 1 week before surgery and early postoperative reinstitution in low thromboembolic risk patients (n = 160, iAPT group). Preoperative APT was maintained in patients with high thromboembolic risk or emergent situation (n = 52, cAPT group). Perioperative and outcomes variables of cAPT and iAPT groups, including bleeding and thromboembolic complications, were compared with those of patients without APT (non-APT group, n = 863).

RESULTS

In this cohort, 715 basic and 360 advanced laparoscopic operations were included. No patient suffering excessive intraoperative bleeding due to continuation of APT was observed. There were 10 postoperative bleeding complications (0.9%) and 3 thromboembolic events (0.3%), but the surgery was free of both complications in the cAPT group. No significant differences were found between the groups in operative blood loss, blood transfusion rate, and the occurrence of bleeding and thromboembolic complications. Multivariable analyses showed that multiple antiplatelet agents (p = 0.015) and intraoperative blood transfusion (p = 0.046) were significant prognostic factors for postoperative bleeding complications. Increased thromboembolic complications were independently associated with high New York Heart Association class (p = 0.019) and history of cerebral infarction (p = 0.048), but not associated with APT use.

CONCLUSIONS

Abdominal laparoscopic operations were successfully performed without any increase in severe complications in patients with APT compared with the non-APT group under our rigorous perioperative assessment and management. Maintenance of single APT should be considered in patients with high thromboembolic risk, even when an abdominal laparoscopic approach is considered.

Antithrombotic drugs: pharmacology and implications for dental practice

Appropriate preoperative assessment of the dental patient should always include an analysis of the patient's medications. This article reviews the actions and indications for the various categories of antithrombotic medications and considers actual risks for postoperative bleeding and potential interactions with drugs the dental provider might administer or prescribe.

The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors

BACKGROUND

When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use.

METHOD

We selectively searched for relevant publications that appeared from 2003 to February 2013, with particular consideration of the guidelines of the European Society of Cardiology, the Association of Scientific Medical Societies in Germany (AWMF), the American College of Cardiology, and the American Heart Association.

RESULTS

Vitamin K antagonists (VKA), low molecular weight heparins, and fondaparinux are the established anticoagulants. The past few years have seen the introduction of orally administered selective inhibitors of the clotting factors IIa (dabigatran) and Xa (rivaroxaban, apixaban). The timing of perioperative interruption of anticoagulation is based on pharmacokinetic considerations rather than on evidence from clinical trials. Recent studies have shown that substituting short-acting anticoagulants for VKA before a procedure increases the risk of bleeding without lowering the risk of periprocedural thromboembolic events. The therapeutic spectrum of acetylsalicylic acid and clopidogrel has been broadened by the newer platelet aggregation inhibitors prasugrel and ticagrelor. Patients with drug eluting stents should be treated with dual platelet inhibition for 12 months because of the risk of in-stent thrombosis.

CONCLUSION

Anticoagulants and platelet aggregation inhibitors are commonly used drugs, but the evidence for their perioperative management is limited. The risks of thrombosis and of hemorrhage must be balanced against each other in the individual case. Anticoagulation need not be stopped for minor procedures.

Patients who require non-cardiac surgery in acute coronary syndrome

The coexistence of an acute coronary syndrome (ACS) and non-cardiac surgery (NCS) in an individual patient can be summarized in two challenging clinical scenarios for the treating physician: 1) Post-operative patients who develop ACS and 2) Patients with ACS who subsequently require NCS. Both settings are characterized by a struggle on the part of treating physicians attempting to optimize antithrombotic therapies for ACS while minimizing post-surgical bleeding risk. In this review we address specific clinical issues related to patients with coexistent NCS and ACS, discussing possible management strategies balancing ischemic and bleeding risk in these complex patient scenarios.

Effect of routine clopidogrel use on bleeding complications after ultrasound-guided thoracentesis

BACKGROUND

Thoracentesis is one of the most commonly performed medical procedures with an excellent safety profile. Clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) is often prescribed for primary or secondary prevention of cardiovascular disease and has been associated with bleeding complications in patients undergoing surgical procedures. The purpose of this study was to assess the safety of ultrasound (US)-guided thoracentesis in patients receiving clopidogrel therapy.

METHODS

Data were collected on 30 consecutive patients taking clopidogrel without other known underlying coagulation problems. These patients underwent 45 US-guided thoracenteses over 26 months. Clopidogrel was not discontinued before the thoracentesis in patients presenting with symptomatic pleural effusion. Thoracenteses were performed in these patients and the incidence of bleeding and other complications among patients was reported.

RESULTS

Between June 2009 and August 2011, there were 30 consecutive patients on clopidogrel at the time of thoracenteses. These patients presented with respiratory distress because of pleural effusion and underwent a total of 45 thoracenteses. There was no significant bleeding or other complications in this patient population. No patient required transfusion after the procedure.

CONCLUSION

Patients who are receiving clopidogrel and present with symptomatic pleural effusion can safely undergo US-guided thoracentesis without interrupting clopidogrel before the procedure. Larger studies are required to confirm these results.

Pharmacotherapy for the reduction of stent thrombosis

The benefits of percutaneous coronary intervention (PCI) can be offset by periprocedural complications such as acute vessel closure and stent thrombosis in the absence of adequate antiplatelet and antithrombotic therapy. Additionally, conditions occurring after 30 days post-PCI, such as in-stent restenosis or late stent thrombosis can occur. Excess antithrombotic therapy, on the other hand, carries a risk of major gastrointestinal or intracranial bleeding as well as vascular access site bleeding complications. In this review, evidence related to the various pharmacological agents for reduction of stent thrombosis available to clinicians during and after PCI will be explored.

Continuous low-dose aspirin therapy in robotic-assisted laparoscopic radical prostatectomy does not increase risk of surgical hemorrhage

BACKGROUND

Withdrawal of oral antiplatelet therapy (OAT) is a major risk factor for stent thrombosis, myocardial infarction, and cerebral strokes. In order to minimize the risk for thrombotic complications, since 2007 robotic-assisted laparoscopic radical prostatectomy (RARP) has taken place under continuous OAT with aspirin at our institution. In this retrospective study we analyzed the risk for perioperative bleeding and surgical outcome after RARP with OAT.

PATIENTS AND METHODS

All patients who underwent RARP with aspirin OAT at our institution since 2007 were included in this analysis. The OAT group was compared with a group that underwent RARP without OAT, which contained twice the number of patients. Matching of the two groups was performed with regard to the tumor stage and whether a lymph node dissection or nerve-sparing was performed.

RESULTS

Thirty-eight patients were assigned to the OAT group and 76 to the control group. A difference in the decrease of postoperative hemoglobin concentration was not detectable between the two groups (mean drop of 2.9±1.4 g/dL and 2.9±1.1 g/dL, respectively; P=.93). RARP was completed in all OAT patients without conversion to open surgery. Two of the 38 patients (5.3%) in the OAT group and none in the control group required blood transfusions (P=.11). Equivalent rates of positive surgical margins for pT2 tumors were detected (16% OAT versus 14% control group; P=1.0). No adverse cardiovascular events occurred in either group during the hospitalization.

CONCLUSIONS

Continued perioperative OAT with aspirin in RARP is safe, feasible, and not associated with increased blood loss.

Benefits and risks of long-term duration of dual antiplatelet therapy after drug-eluting stenting: a meta-analysis of randomized trials

BACKGROUND

The potential benefits and risks of at least 1-year dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) implantation remain uncertain.

METHODS AND RESULTS

PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched from database inception to December 2011 for randomized controlled trials that compared longer DAPT versus shorter DAPT duration after DES. Unpublished data were obtained from investigators. Trial-specific odds ratios (ORs) with 95% confidence interval (CI) were calculated and pooled using fixed-effects or random-effects model as appropriate. Data were independently extracted by 2 reviewers. Three randomized controlled trials comprising 5622 participants were included. Compared with patients receiving short-term therapy, participants receiving longer DAPT duration had a pooled OR of 1.26 (95% CI, 0.88 to 1.80; P=0.21, random-effects) for the primary outcome of cardiac death, myocardial infarction or stroke, OR of 1.29 (95% CI, 0.85 to 1.93; fixed-effects) for all-cause death, 1.23 (95% CI, 0.78 to 1.93; fixed-effects) for cardiac death, 0.91 (95% CI, 0.58 to 1.42; random-effects) for myocardial infarction, 1.93 (95% CI, 1.01 to 3.69; fixed-effects) for stroke and 2.51 (95% CI, 1.10 to 5.71, fixed-effects) for TIMI major bleeding. The number needed to treat for an additional harmful outcome was 217.6 for stroke and 243 for TIMI major bleeding.

CONCLUSIONS

This meta-analysis provides no evidence of benefits with longer DAPT duration as compared with a shorter course of therapy. It also reports significant harms with respect to major bleeding and stroke associated with prolonged DAPT use.

Pyrazole derivatives as inhibitors of arachidonic acid-induced platelet aggregation

Antiplatelet drugs are promising therapeutics to intervene with platelet aggregation in arterial thrombosis, most prominently in myocardial infarction and ischemic stroke. Here, we describe the synthesis and structure-activity relationships of potent inhibitors of platelet aggregation based on the 1,5-diarylpyrazol-3-carboxamide scaffold. Analogs from this series demonstrated potent anti-aggregatory activities against arachidonic acid-induced platelet aggregation, as measured by turbidimetric method of Born. 1,5-Diarylpyrazole-3-carboxamides obtained with small-basic amines (7, 8, 50, 51, 61, 62) displayed the strongest activity with IC50 values in low nanomolar range (5.7-83 nM). On the basis of their high potency in cellular environment, these straightforward pyrazole derivatives may possess potential in the design of more potent compounds for intervention with cardiovascular diseases.

Use of stent-assisted coil embolization for the treatment of wide-necked aneurysms: A systematic review

Background:

The use of stent-assisted coiling (SAC) has been shown to be a treatment option for complex aneurysms. We reviewed systematically the immediate and mid-term angiographic results following treatment of wide-necked aneurysms with self-expanding stents and coils, as well as the peri- and postprocedural rate of complications.

Methods:

A computerized database search was conducted from 01/2000 to 04/2011 using appropriate indexed terms on Pubmed. Inclusion criteria were: (1) homogeneous populations of ≥10 patients with wide-necked aneurysms; (2) use of a self-expandable neurovascular stent and coils for aneurysm treatment; (3) immediate and follow-up angiographic results; and (4) periprocedural and delayed thrombotic complications.

Results:

Seventeen studies were included, containing retrospectively collected data on 656 patients/702 aneurysms. The target aneurysm was located on the anterior circulation in 78.4% of patients. The immediate rate of complete occlusion was 46.3%, (19.3-98.1%). The intra- and postprocedural rate of intrastent thrombosis or thromboembolic event was 4.6% and 4.3%, respectively. Complete occlusion was documented in 71.9% at last angiographic follow-up. The rate of recanalization was 13.2% of aneurysms (0-28.8%). Delayed in-stent stenosis occurred in 5.3% cases (0-20.6%).

Conclusion:

SAC has been considered a treatment option for selected wide-necked aneurysms in some institutions. The use of intracranial stents should take into consideration the risk of ischemic complications, recanalization, delayed in-stent stenosis; and the currently unknown lifetime risks for stenosis, vascular injury, device failure, and aneurysm recurrence related to intracranial stenting. There is an evident need for a prospective multicenter registry for all treated patients with SAC.

Percutaneous coronary intervention in nonagenarians: pros and cons

Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.

Benefit of long-term dual anti-platelet therapy in patients treated with drug-eluting stents: from the NHLBI dynamic registry

The optimal duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an important, unanswered question. This study was designed to evaluate the association of varying durations of DAPT on clinical outcomes after DES implantation for the treatment of coronary artery disease. Using the National Heart, Lung, and Blood Institute Dynamic Registry, patients enrolled in the last 2 waves after index percutaneous coronary intervention with DES and who were event free at the time of landmark analysis were included. Landmark analysis was performed 12 and 24 months after percutaneous coronary intervention, and patients were stratified according to continued use of DAPT or not. Subjects were evaluated for rates of death, myocardial infarction, and stent thrombosis at 4 years from their index procedures. The numbers of evaluable patients were 2,157 and 1,918 for the 12- and 24-month landmarks, respectively. In both landmark analyses, there was a significantly lower 4-year rate of death or myocardial infarction in the group that continued DAPT compared to the group that did not (12 months: 10.5% vs 14.5%, p = 0.01; 24 months: 5.7% vs 8.6%, p = 0.02). Beneficial differences in the group that continued on DAPT were preserved after multivariate and propensity adjustment. There were no significant differences in definite stent thrombosis in either landmark analysis. In conclusion, at 12 and 24 months after DES implantation, continued use of DAPT was associated with lower 4-year risk for death and myocardial infarction.

Dual antiplatelet therapy with aspirin and clopidogrel: what is the risk in noncardiac surgery? A narrative review

Clopidogrel is one of the most commonly prescribed medications and is currently recommended along with aspirin as treatment to be used for 1 year in all patients without contraindications following an acute coronary syndrome. Patients who are committed to clopidogrel therapy due to recent coronary artery stent implantation may require noncardiac surgery during this recommended period of dual antiplatelet therapy (DAPT). Due to differing rates of endothelialization, patients who undergo bare-metal stent implantation generally require ≥ 1 month of uninterrupted DAPT, and those who undergo drug-eluting stent implantation require ≥ 12 months. Many surgeons ask their patients to stop taking clopidogrel in advance of their procedure to decrease perioperative bleeding. This practice is based largely on anecdotal experience and extrapolated from limited data in cardiac surgery. Premature cessation of aspirin and/or clopidogrel following coronary artery stenting, however, has been associated with acute stent thrombosis, myocardial infarction, and death. We searched PubMed for English language articles published from 1960 to 2012, using the keywords aspirin, clopidogrel, surgery, general, vascular, genitourinary, thoracic, orthopedic, ophthalmologic, dermatologic, endoscopy, colonoscopy, cardiac device implantation, pacemaker, defibrillator, bronchoscopy, bridging, bleeding complications, and transfusion, including various combinations. s were reviewed to confirm relevance, and then the full articles were extracted. References from extracted articles were also reviewed for relevant articles. Literature regarding perioperative clopidogrel continuation is predominantly composed of small, nonrandomized data, but suggests that most noncardiac surgeries or procedures can be performed safely while patients are taking clopidogrel. In this article, we review the current best evidence on the risk for bleeding with clopidogrel therapy in noncardiac surgery, summarize recent guidelines on appropriate duration of DAPT, and make recommendations on the management of perioperative DAPT.