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Anguita-Gámez M, Vivas D, Ferrandis R, González-Manzanares R, Anguita M, Esteve-Pastor MA, Echeverri M, Igualada J, Egocheaga I, Nozal-Mateo B, Abad-Motos A, Figuero E, Bouzó-Molina N, Lozano T, Álvarez-Ortega C, Torres J, Descalzo MJ, Catalá JC, Martín-Rioboo E, Molines A, Rodríguez-Contreras R, Carnero-Alcázar M, Marín F. Incidence and clinical impact of inappropriate periprocedural and perioperative management of antiplatelet therapy. Med Clin (Barc) 2024:S0025-7753(24)00355-5. [PMID: 38955604 DOI: 10.1016/j.medcli.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND AIMS There is little evidence on the impact of current recommendations on the use of antiplatelet therapy during the perioperative and periprocedural period in our setting. The aim of this study was to analyze the incidence and clinical impact of inappropriate use of antiplatelet therapy in a population of patients undergoing surgery or a diagnostic or therapeutic procedure in "real life" in Spain. METHODS A prospective multicenter observational study of patients treated with antiplatelet agents requiring intervention was conducted. The incidence of thrombotic and hemorrhagic events at 30 days was analyzed according to peri-intervention management of antiplatelet therapy. RESULTS We included 643 patients (31.9% women, 39.0% over 75 years of age), most of them (87.7%) receiving aspirin as antiplatelet therapy at a dose of 100mg/day. Indications for antiplatelet therapy were ischemic heart disease (44.9%), cerebrovascular disease (21.7%), and peripheral vascular disease (23.0%). Ischemic risk was low in 74.3%, while 51.6% had a low bleeding risk of the intervention. Periprocedural management was considered appropriate in 61.7% of cases. 30-day incidence of the combined primary endpoint of thrombotic events and major bleeding (12.1% versus 5.0%; p=0.002) and 30-day mortality (5.2% versus 1.5%; p=0.008) were significantly higher in patients with inappropriate periprocedural management of antiplatelet agents. CONCLUSIONS Despite current recommendations for the use of antiplatelet drugs in the perioperative/periprocedural period, their implementation in the "real world" remains low. Inappropriate use is associated with an increased incidence of adverse events, both thrombotic and hemorrhagic.
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Affiliation(s)
| | - David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael González-Manzanares
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - María Asunción Esteve-Pastor
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Marysol Echeverri
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jesús Igualada
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Beatriz Nozal-Mateo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ane Abad-Motos
- Servicio de Anestesiología y Reanimación, Hospital Universitario Donostia, San Sebastián, Gipuzkoa, Spain
| | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas, Facultad de Odontología, Universidad Complutense, Madrid, Spain
| | - Nuria Bouzó-Molina
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Lozano
- Servicio de Cardiología, Hospital General Universitario Doctor Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Carlos Álvarez-Ortega
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Javier Torres
- Servicio de Cardiología, Hospital Universitario de Jaén, Jaén, Spain
| | | | - Juan Carlos Catalá
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, Spain
| | - Enrique Martín-Rioboo
- Medicina de Familia, Unidad de Gestión Clínica Poniente, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Alejandra Molines
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Rocío Rodríguez-Contreras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Francisco Marín
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain
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2
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Vivas D, Anguita-Gámez M, Ferrandis R, Esteve-Pastor MA, Echeverri M, Igualada J, Anguita M, Egocheaga I, Nozal-Mateo B, Abad-Motos A, Figuero E, Bouzó-Molina N, Lozano T, Álvarez-Ortega C, Torres J, Descalzo MJ, Catalá JC, Martín-Rioboo E, Molines A, Rodríguez-Contreras R, Carnero-Alcázar M, Marín F. Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in "real world": the REQXAA study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:729-738. [PMID: 36914025 DOI: 10.1016/j.rec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/23/2023] [Indexed: 03/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. METHODS This prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. RESULTS We included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. CONCLUSIONS The implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.
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Affiliation(s)
- David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
| | - María Anguita-Gámez
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María Asunción Esteve-Pastor
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Marysol Echeverri
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jesús Igualada
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | | | - Beatriz Nozal-Mateo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ane Abad-Motos
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain; Servicio de Anestesiología y Reanimación, Hospital Universitario Donostia, San Sebastián, Gipuzkoa, Spain
| | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas, Facultad de Odontología, Universidad Complutense, Madrid, Spain
| | - Nuria Bouzó-Molina
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Lozano
- Servicio de Cardiología, Hospital General Universitario Doctor Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Carlos Álvarez-Ortega
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Javier Torres
- Servicio de Cardiología, Hospital Universitario de Jaén, Jaén, Spain
| | | | - Juan Carlos Catalá
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, Spain
| | - Enrique Martín-Rioboo
- Medicina de Familia, Unidad de Gestión Clínica Poniente, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Alejandra Molines
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Rocío Rodríguez-Contreras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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4
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Wu CT, Lien TH, Chen IL, Wang JW, Ko JY, Lee MS. The Risk of Bleeding and Adverse Events with Clopidogrel in Elective Hip and Knee Arthroplasty Patients. J Clin Med 2022; 11:jcm11071754. [PMID: 35407361 PMCID: PMC8999348 DOI: 10.3390/jcm11071754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/19/2022] [Indexed: 12/07/2022] Open
Abstract
Orthopedic surgeons often face a clinical dilemma on how to manage antiplatelet therapies during the time of surgery. This retrospective study is aimed to investigate the bleeding risk and adverse events in patients who hold or keep clopidogrel during elective major joints arthroplasty. Two hundred and ninety-six patients that were treated with clopidogrel while undergoing total hip or knee joint replacement between January 2009 and December 2018 were studied. Group 1 included 56 patients (18.9%) who kept using clopidogrel preoperatively. Group 2 included 240 patients who hold clopidogrel use ≥5 days preoperatively. Blood transfusion rates, estimated blood loss, complication rates, and adverse cardiocerebral events were collected and analyzed. The mean total blood loss was more in the group 1 patients as compared with that in the group 2 patients (1212.3 mL (685.8 to 2811.8) vs. 1068.9 mL (495.6 to 3294.3), p = 0.03). However, there was no significant difference between the two groups of patients regarding transfusion rates, bleeding-related complications, and infection rates. There was a trend toward a higher incidence of adverse cardiocerebral events in patients withholding clopidogrel for more than 5 days before surgery. The results of this study suggest that clopidogrel continuation could be safe and advisable for patients at thrombotic risk undergoing primary major joint replacement. Acute antiplatelet withdrawal for an extended period of time might be associated with an increased risk of postoperative thromboembolic events. More studies are required in the future to further prove this suggestion.
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Affiliation(s)
- Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Tzu-Hsien Lien
- Department of Family Medicine, E-Da Hospital, Kaohsiung 824, Taiwan;
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Jih-Yang Ko
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
- Correspondence: ; Tel.: +886-7-731-7123
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5
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Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Mojoli M, Guido P, Talanas G, Pierini S, Canova P, De Cesare N, Luceri S, Barzaghi N, Melloni G, Baralis G, Locatelli A, Musumeci G, Angiolillo DJ. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH OPEN 2020; 4:e437-e445. [PMID: 33376943 PMCID: PMC7758156 DOI: 10.1055/s-0040-1721504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/02/2020] [Indexed: 01/04/2023] Open
Abstract
Objective
The aim of the study is to describe the real-world use of the P2Y
12
inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).
Materials and Methods
We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.
Results
Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.
Conclusion
Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Affiliation(s)
| | | | | | - Enrico Passamonti
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | - Elba Calvaruso
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | | | | | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Pordenone, Pordenone, Italy
| | - Parodi Guido
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Giuseppe Talanas
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Simona Pierini
- P.O. BASSINI-ASST Nord Milano, U.O.C. Cardiologia, Milano, Italy
| | - Paolo Canova
- ASST Papa Giovanni XXIII, Unità di Cardiologia 2, Bergamo, Italy
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6
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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Cinnella G, Pavesi M, De Gasperi A, Ranucci M, Mirabella L. Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Minerva Anestesiol 2019; 85:635-664. [PMID: 30762323 DOI: 10.23736/s0375-9393.19.12151-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.
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Affiliation(s)
- Gilda Cinnella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco Pavesi
- Division of Multispecialty Anesthesia Service of Polispecialistic Anesthesia, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Andrea De Gasperi
- Division of Anesthesia and Resuscitation, Niguarda Hospital, Milan, Italy
| | - Marco Ranucci
- Division of Anesthesia and Cardio-Thoraco-Vascular Therapy, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Lucia Mirabella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy -
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Dargham BB, Baskar A, Tejani I, Cui Z, Chauhan S, Sum-Ping J, Weideman RA, Banerjee S. Intravenous Antiplatelet Therapy Bridging in Patients Undergoing Cardiac or Non-Cardiac Surgery Following Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:805-811. [PMID: 30579773 DOI: 10.1016/j.carrev.2018.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/23/2018] [Accepted: 11/16/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effect of perioperative bridging therapy on risks of ischemic cardiac events and major bleeding complications in patients on dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains undefined. METHODS We report on 60 consecutive patients between 2010 and 2017 who required cardiac (CS; n = 15) or non-cardiac (NCS; n = 45) surgeries following PCI at our institution. Short-acting intravenous (IV) antiplatelet (APT) bridging with eptifibatide, tirofiban and cangrelor were instituted after DAPT interruption. RESULTS All patients were men with multiple atherosclerosis risk factors. An acute coronary syndrome indication (56.7%) was the most common PCI indication in the CS and NCS groups. Drug-eluting stents were used in 93.33% and 95.56% of the above groups, respectively. The median duration from PCI to CS and NCS were 11.17 and 18.25 months, respectively and 38.33% of all surgeries were performed within 6 months of the index PCI. Most patients were on background aspirin (83.33%) and clopidogrel (81.67%) and median duration of DAPT interruption was 7 days. Median duration of perioperative IV APT bridging was 3 days for CS and 5 days for NCS groups. In the CS group, two patients (13.33%) had non-fata myocardial infarction (MI), and four (26.67%) had clinically significant bleeding. No patients had perioperative stent thrombosis. In the NCS group, one patient (2.22%) had stent thrombosis; four (6.67%) had myocardial infarction, and five (11.11%) clinically significant bleeding. CONCLUSIONS Despite using IV APT as bridging therapy during perioperative DAPT interruption in post-PCI patients, postoperative cardiac events and bleeding complications can still occur.
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Affiliation(s)
- Bassel Bou Dargham
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Amutharani Baskar
- Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Ishita Tejani
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Zhonghao Cui
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Siddarth Chauhan
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - John Sum-Ping
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Rick A Weideman
- Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Subhash Banerjee
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America.
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9
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Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT y AEU. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.01.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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10
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Vivas D, Roldán I, Ferrandis R, Marín F, Roldán V, Tello-Montoliu A, Ruiz-Nodar JM, Gómez-Doblas JJ, Martín A, Llau JV, Ramos-Gallo MJ, Muñoz R, Arcelus JI, Leyva F, Alberca F, Oliva R, Gómez AM, Montero C, Arikan F, Ley L, Santos-Bueso E, Figuero E, Bujaldón A, Urbano J, Otero R, Hermida JF, Egocheaga I, Llisterri JL, Lobos JM, Serrano A, Madridano O, Ferreiro JL. Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU. ACTA ACUST UNITED AC 2018; 71:553-564. [PMID: 29887180 DOI: 10.1016/j.rec.2018.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/05/2018] [Indexed: 01/17/2023]
Abstract
During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.
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Affiliation(s)
- David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Unidad de Cardiología, Clínica MD Anderson, Madrid, Spain.
| | - Inmaculada Roldán
- Servicio de Cardiología, Hospital Universitario La Paz, CIBER-CV, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Universitat de València, Valencia, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Servicio de Hematología, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Antonio Tello-Montoliu
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Juan Miguel Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante ISABIAL, CIBER-CV, Alicante, Spain
| | - Juan José Gómez-Doblas
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Victoria, CIBER-CV, Málaga, Spain
| | - Alfonso Martín
- Servicio de Urgencias, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Juan Vicente Llau
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic Universitari, València, Universitat de València, Valencia, Spain
| | | | - Rafael Muñoz
- Servicio de Cirugía Cardiaca, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Ignacio Arcelus
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Leyva
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Clínico San Carlos, Madrid, Spain
| | - Fernando Alberca
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Raquel Oliva
- Servicio de Ginecología y Obstetricia, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Ana María Gómez
- Servicio de Cirugía Torácica, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Montero
- Servicio de Neumología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Fuat Arikan
- Servicio de Neurocirugía, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Luis Ley
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas (DECO), Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - Antonio Bujaldón
- Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - José Urbano
- Servicio de Radiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rafael Otero
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - José Luis Llisterri
- Medicina de Familia, Centro de Salud Ingeniero Joaquín Benlloch, Valencia, Spain
| | | | - Ainhoa Serrano
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, Spain
| | - Olga Madridano
- Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - José Luis Ferreiro
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Gulizia MM, Colivicchi F, Abrignani MG, Ambrosetti M, Aspromonte N, Barile G, Caporale R, Casolo G, Chiuini E, Di Lenarda A, Faggiano P, Gabrielli D, Geraci G, La Manna AG, Maggioni AP, Marchese A, Massari FM, Mureddu GF, Musumeci G, Nardi F, Panno AV, Pedretti RFE, Piredda M, Pusineri E, Riccio C, Rossini R, di Uccio FS, Urbinati S, Varbella F, Zito GB, De Luca L. Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease. Eur Heart J Suppl 2018; 20:F1-F74. [PMID: 29867293 PMCID: PMC5978022 DOI: 10.1093/eurheartj/suy019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.
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Affiliation(s)
- Michele Massimo Gulizia
- U.O.C. di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia e UTIC, Ospedale San Filippo Neri, Roma, Italy
| | | | - Marco Ambrosetti
- Servizio di Cardiologia Riabilitativa, Clinica Le Terrazze Cunardo, Varese, Italy
| | - Nadia Aspromonte
- U.O. Scompenso e Riabilitazione Cardiologica, Polo Scienze Cardiovascolari, Toraciche, Policlinico Agostino Gemelli, Roma, Italy
| | | | - Roberto Caporale
- U.O.C. Cardiologia Interventistica, Ospedale Annunziata, Cosenza, Italy
| | - Giancarlo Casolo
- S.C. Cardiologia, Nuovo Ospedale Versilia, Lido di Camaiore (LU), Italy
| | - Emilia Chiuini
- Specialista Ambulatoriale Cardiologo, ASL Umbria 1, Perugia, Italy
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | | | - Domenico Gabrielli
- ASUR Marche - Area Vasta 4 Fermo, Ospedale Civile Augusto Murri, Fermo, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ferdinando Maria Massari
- U.O.C. Malattie Cardiovascolari "Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | - Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | | | | | - Massimo Piredda
- Centro Cardiotoracico, Divisione di Cardiologia, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Enrico Pusineri
- U.O.C. di Cardiologia, Ospedale Civile di Vigevano, A.S.S.T., Pavia, Italy
| | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, AZ. Ospedaliera S. Anna e S. Sebastiano, Caserta, Italy
| | | | | | - Stefano Urbinati
- U.O.C. Cardiologia, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | | | | | - Leonardo De Luca
- U.O.C. Cardiologia, Ospedale San Giovanni Evangelista, Tivoli, Roma, Italy
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12
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Kounis NG, Koniari I, Tsigkas G, Chourdakis E, Roumeliotis A, Patsouras N, Soufras G, Hahalis G. Perioperative Management of Dual Antiplatelet Therapy. J Cardiothorac Vasc Anesth 2017; 32:e64-e66. [PMID: 29273479 DOI: 10.1053/j.jvca.2017.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Achaia, Greece
| | - Ioanna Koniari
- Department of Cardiology, Royal Bromptom Hospital, London, England
| | - Grigorios Tsigkas
- Department of Cardiology, University of Patras Medical School, Achaia, Greece
| | | | | | - Nicholas Patsouras
- Department of Cardiology, University of Patras Medical School, Achaia, Greece
| | - George Soufras
- Department of Cardiology, "Saint Andrews" State General Hospital, Achaia, Greece
| | - George Hahalis
- Department of Cardiology, University of Patras Medical School, Achaia, Greece
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13
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Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M, Marquis-Gravel G, Robinson SD, Sibbald M, So DY, Wong GC, Abunassar JG, Ackman ML, Bell AD, Cartier R, Douketis JD, Lawler PR, McMurtry MS, Udell JA, van Diepen S, Verma S, Mancini GBJ, Cairns JA, Tanguay JF. 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2017; 34:214-233. [PMID: 29475527 DOI: 10.1016/j.cjca.2017.12.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.
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Affiliation(s)
- Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kevin R Bainey
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Warren J Cantor
- University of Toronto and Southlake Regional Health Centre, Toronto, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | | | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Matthew Sibbald
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graham C Wong
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Margaret L Ackman
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Alan D Bell
- University of Toronto, Toronto, Ontario, Canada
| | - Raymond Cartier
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | - James D Douketis
- McMaster University and St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Patrick R Lawler
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael S McMurtry
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jacob A Udell
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean van Diepen
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Subodh Verma
- University of Toronto and St Michael's Hospital, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John A Cairns
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jean-François Tanguay
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada.
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14
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Foëx P. Innovations in management of cardiac disease: drugs, treatment strategies and technology. Br J Anaesth 2017; 119:i23-i33. [DOI: 10.1093/bja/aex327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 01/15/2023] Open
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15
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Park SK, Jung DE, Jung SA, Kim WH, Bahk JH. Risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Sci Rep 2017; 7:16393. [PMID: 29180679 PMCID: PMC5704017 DOI: 10.1038/s41598-017-16672-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/16/2017] [Indexed: 02/02/2023] Open
Abstract
Elective non-cardiac surgery (NCS) should optimally be delayed one year after implantation of a drug-eluting stent (DES). Dual antiplatelet therapy or at least aspirin is recommended to be continued considering the relative risk of stent thrombosis especially during the 4 weeks after DES implantation. However, these recommendations were supported by insufficient evidence. We investigated predictors for postoperative major adverse cardiovascular and cerebral event (MACCE) in 1582 patients undergoing non-cardiac surgery after DES implantation. 96 patients (6.1%) developed postoperative MACCE. In the propensity score-matched analysis, aspirin maintenance was not associated with MACCE (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.48-1.27, P = 0.320) and was associated with increased risk of major bleeding (OR 1.84, 95% CI 1.02-3.32, P = 0.044). When patients who underwent NCS within one month after DES implantation were matched with those who underwent NCS thereafter, the risk of MACCE was higher when surgery was done within 30 days after PCI (OR 2.21, 95% CI 1.05-4.66, P = 0.036). Maintenance of aspirin did not decrease MACCE after NCS in patients with DES and only increased the risk of major bleeding. NCS within one month after DES implantation was associated with higher incidence of MACCE. However, prospective trials are required to validate our results.
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Affiliation(s)
- Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dhong Eun Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Ae Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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16
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Banerjee S, Angiolillo DJ, Boden WE, Murphy JG, Khalili H, Hasan AA, Harrington RA, Rao SV. Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2017; 69:1861-1870. [DOI: 10.1016/j.jacc.2017.02.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/21/2017] [Accepted: 02/03/2017] [Indexed: 01/19/2023]
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