Management of patients with cardiac stents undergoing noncardiac surgery

Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention

BACKGROUND

The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown.

METHODS

We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation.

RESULTS

If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals.

CONCLUSION

Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.

Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.

METHODS

The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.

RESULTS

In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C).

CONCLUSIONS

Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.

Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach

The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007)

PURPOSE

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery.

METHODS

Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery.

RESULTS

A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints.

CONCLUSIONS

Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

The management of patients on dual antiplatelet therapy undergoing orthopedic surgery

Cardiovascular disease is prevalent in patients undergoing orthopedic surgery. Many patients who have undergone previous percutaneous coronary intervention (PCI) with stenting are on dual antiplatelet therapy in order to minimize the risk of stent thrombosis. The optimal management of these patients in the perioperative setting remains unclear. We aim to provide information about the management of patients who have undergone a PCI with stents who are subsequently indicated for an orthopedic procedure. We will review the concerns from a cardiologist's and orthopedic surgeon's perspective in regards to the management of these patients in the perioperative setting. In addition, the current American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and American College of Surgeons guidelines are reviewed. The decision to discontinue dual antiplatelet therapy in a patient who has undergone a PCI with stent should be made only after careful review of the risks for thrombosis and bleeding. Best practice suggests that these risks should be jointly assessed by the orthopedic surgeon and cardiologist. Those patients with stents at high risk of thrombosis should have surgery delayed if possible. There is little data supporting a significantly increased bleeding risk associated with mortality in orthopedic patients when antiplatelet therapy is continued perioperatively.

Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Noncardiac Surgery

Background—

Noncardiac surgery performed after coronary stent implantation is associated with an increased risk of stent thrombosis, myocardial infarction, and death. The influence of stent type and period of risk still have to be defined.

Methods and Results—

We linked the Scottish Coronary Revascularisation Register with hospital admission data to undertake a Scotland-wide retrospective cohort study examining cardiac outcomes in all patients who received drug-eluting or bare-metal stents between April 2003 and March 2007 and subsequently underwent noncardiac surgery. Of 1953 patients, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. There were no differences between drug-eluting and bare-metal stents in the primary end point of in-hospital mortality or ischemic cardiac events (14.6% versus 13.3%; P =0.3) or the secondary end points of in-hospital mortality (0.7% versus 0.6%; P =0.8) and acute myocardial infarction (1.2% versus 0.7%; P =0.3). Perioperative death and ischemic cardiac events occurred more frequently when surgery was performed within 42 days of stent implantation (42.4% versus 12.8% beyond 42 days; P <0.001), especially in patients revascularized after an acute coronary syndrome (65% versus 32%; P =0.037). There were no temporal differences in outcomes between the drug-eluting and bare-metal stent groups.

Conclusions—

Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents.

Cangrelor: a novel P2Y12 receptor antagonist

Antiplatelet therapy is critical in the prevention of thrombotic complications of acute coronary syndrome and percutaneous coronary interventions. Current antiplatelet agents (aspirin, clopidogrel and glycoprotein IIb/IIIa antagonists) have demonstrated the capacity to reduce major adverse cardiac events. However, these agents have limitations that compromise their clinical utility. The platelet P2Y12 receptor plays a central role in platelet function and is a focus in the development of antiplatelet therapies. Cangrelor is a potent, competitive inhibitor of the P2Y12 receptor that is administered by intravenous infusion and rapidly achieves near complete inhibition of ADP-induced platelet aggregation. This investigational drug has been studied for use during coronary procedures and the management of patients experiencing acute coronary syndrome and is undergoing evaluation for use in the prevention of perioperative stent thrombosis.

Perioperative management of antiplatelet agents in noncardiac surgery

It is common that patients who are scheduled for surgery are treated with antiplatelet agents (APAs) due to their wide indications. The management of these APAs in the perioperative period (acetylsalicylic acid alone, a thienopyridine alone or, in most cases, a combination of them) has a dual perspective: the risk of bleeding when the patient is operated under the effect of the APA against the risk of thrombosis if it has been withdrawn. The main challenges for the anaesthesiologist and the surgeon include patients with a coronary stent (mainly, new drug-eluting coronary stents), those undergoing urgent surgery and those undergoing high bleeding risk surgery. We review current protocols and discuss the most recent proposals for the management of APAs in patients undergoing noncardiac surgery. Current recommendations include the maintenance of aspirin if possible throughout the perioperative period, in order to limit the risks of cardiological, vascular or neurological postoperative events, although this makes it necessary to assume a small risk for haemorrhagic complications in some patients. Nevertheless, there are many circumstances that are not clear yet and, in this situation, it is crucial that patients are treated with a multidisciplinary approach (anaesthesiologists, surgeons, cardiologists and haematologists).