Recommendations for management of antiplatelet therapy in patients undergoing elective noncardiac surgery after coronary stent implantation

Single-antiplatelet regimen in ruptured cerebral blood blister and dissecting aneurysms treated with flow-diverter stent reconstruction

BACKGROUND

Flow diversion treatment of ruptured cerebral aneurysms remains challenging due to the need for double-antiplatelet therapy. We report our experience with flow-diverter stent (FDS) reconstruction with single-antiplatelet therapy of ruptured cerebral blood blister and dissecting aneurysms.

METHODS

In this case series we performed a retrospective analysis of all patients with ruptured cerebral aneurysms who were treated with a phosphoryl-bonded FDS between 2019 and 2022 in a single center. Periprocedurally, all patients received weight-adapted eptifibatide IV and heparin IV. After 6-24 hours, eptifibatide was switched to oral prasugrel as monotherapy. We analyzed the rate of bleeding complications, thromboembolic events, occlusion rate and clinical outcome.

RESULTS

Nine patients with subarachnoid hemorrhage were treated, eight within 24 hours of symptom onset. Seven patients were treated with one FDS and two patients received two FDS in a telescopic fashion. Two aneurysms were additionally coil embolized. Fatal re-rupture occurred in one case; eight patients survived and had no adverse events associated with the FDS. Six patients showed complete occlusion of the aneurysm after 3 months (n=2) and 1 year (n=4), respectively. Two patients showed subtotal occlusion of the aneurysm at the last follow-up after 3 months and 6 months, respectively. Favorable clinical outcome was achieved in five patients.

CONCLUSIONS

Peri-interventional single-antiplatelet therapy with eptifibatide followed by prasugrel was sufficient to prevent thromboembolic events and reduce re-bleeding using an anti-thrombogenic FDS. FDS with single-antiplatelet therapy might be a viable option for ruptured blood blister and dissecting cerebral aneurysms.

Optimizing the Use of Cangrelor in the Real World

Thrombotic events such as myocardial infarction or stent thrombosis are the major cause of adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). While current antiplatelet agents, anticoagulants, and PCI techniques have reduced the risk of thrombotic events in PCI-treated patients, a considerable hazard still remains. Cangrelor is an intravenous P2Y12 receptor antagonist that provides a rapid onset and maximal platelet inhibition, which is quickly reversible. In the large-scale CHAMPION PHOENIX trial, cangrelor was shown to reduce ischemic events significantly, including myocardial infarction and stent thrombosis, without increasing the risk of severe bleeding across the full spectrum of patients undergoing PCI, with substantial benefits in all patient subgroups examined. The pharmacologic profile of cangrelor makes it a valuable addition to the armamentarium of physicians providing care to a broad range of patients with coronary artery disease. Cangrelor is currently approved for reducing thrombotic events in patients undergoing PCI who have not been pretreated with a P2Y12 receptor inhibitor and are not receiving a glycoprotein IIb/IIIa inhibitor. Future studies are needed to determine the role of cangrelor in other clinical settings, such as upstream therapy in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS), and as a bridge to coronary artery bypass graft (CABG) or other non-cardiac surgeries in patients who require ongoing adenosine diphosphate receptor blockade.

Bridging Experience With Eptifibatide After Stent Implantation

BACKGROUND

Patients who have undergone intracoronary stent implantation often require surgery within the first year after the procedure. Planned or emergent surgical intervention requires interruption of antiplatelet therapy and is associated with an increased risk of stent thrombosis. Eptifibatide, an intravenous glycoprotein IIb/IIIa inhibitor (GPIIb/IIIa), can be considered for antiplatelet bridging of high-risk patients in the periprocedural period.

OBJECTIVES

The aim of this report is to describe the management of antiplatelet therapy and outcomes of patients who were bridged with eptifibatide perioperatively within 1 year of intracoronary stent implantation.

METHODS

We performed a retrospective analysis of patients identified through the hospital's computer system consecutively from January 1, 2011 to December 31, 2014. We included 18 patients who were bridged from an oral P2Y12-receptor antagonist with eptifibatide before surgery. Outcome measures were the incidence of thromboembolic events or stent thrombosis within 30 days of surgery and death within 90 days of hospital discharge. Safety measures were the incidence of thrombolysis in myocardial infarction major, minor, or minimal bleeding.

RESULTS

Of the 18 patients assessed, no patients experienced thromboembolic events or stent thrombosis. There was one major bleeding event and one minimal bleeding event postoperatively. Antiplatelet therapy management was highly variable in the perioperative period with 72.2% receiving the recommended GPIIb/IIIa loading dose, 50% of patients not continuing aspirin throughout the surgery, 27.8% of patients stopping antiplatelet therapy less than 5 days before surgery, and 50% not receiving a loading dose of an oral P2Y12-receptor antagonist postoperatively.

CONCLUSIONS

Within a limited sample size, bridging with an intravenous GPIIb/IIIa inhibitor appeared feasible. Further study is needed on the optimal strategy to manage patients with recent stenting who need surgical procedures.

Current status of data on cangrelor

P2Y12 receptor inhibition in addition to aspirin is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention (PCI). Despite advances in contemporary antithrombotic therapy, periprocedural thrombotic complications such as myocardial infarction and stent thrombosis remain a major concern in patients treated with PCI. Current practice guidelines recommend treatment with a P2Y12 receptor inhibitor as early as possible in patients with ACS. Existing oral P2Y12 receptors inhibitors (clopidogrel, prasugrel, or ticagrelor) have several limitations such as delayed onset and offset of action, interindividual variation, and only oral availability. Cangrelor, an intravenous, fast-onset, direct-acting P2Y12 receptor inhibitor offers potent platelet inhibition that is rapidly reversible. In large randomized trials, cangrelor has shown substantial reduction in ischemic events with no increase in severe bleeding compared with clopidogrel among patients undergoing PCI. Cangrelor is approved as an adjunct to PCI to reduce the risk of periprocedural MI, repeat coronary revascularization, and stent thrombosis in patients who have not been pretreated with a P2Y12 receptor inhibitor and are not receiving a glycoprotein IIb/IIIa inhibitor. This review aims at providing a comprehensive analysis of the current evidence pertaining to the role of cangrelor in contemporary practice.

Coagulopathy and Anticoagulation During Thoracic Surgery

Coagulopathy and bleeding in thoracic surgery may be compounded by the chronic use of anticoagulants and antiplatelet agents. Timely preoperative cessation and postoperative resumption of these antithrombotic drugs are critical in reducing the risks of perioperative major bleeding and thromboembolism. This article describes the various strategies for the optimal perioperative management of antithrombotics based on individual assessment of each patient and the most recent multisociety guidelines.

Eight challenges faced by general practitioners caring for patients after an acute coronary syndrome

The general practitioner is essential in the management of the patient who has recently been discharged from hospital following an acute coronary syndrome (ACS), particularly as duration of hospital stay is shorter than in previous decades. GPs caring for patients after an ACS face numerous challenges. Often, the first of these is insufficient or delayed documentation from the discharging hospital, although electronic discharge summaries are alleviating this problem. Post-ACS patients often have comorbidities, and GPs play a key role in managing these. Patients taking dual antiplatelet therapy who need surgery, and post-ACS patients with atrial fibrillation, require particular care from GPs. Patients will often approach their GP for advice on the safety of other drugs, such as smoking cessation medication, and phosphodiesterase type 5 inhibitors for erectile dysfunction. For patients complaining of persistent lethargy after an ACS, GPs must consider several differential diagnoses, including depression, hypotension, hypovolaemia, and side effects of β-blockers. GPs play an important ongoing role in ensuring that target cholesterol levels are reached with statin therapy; this includes ensuring long-term adherence. They may also need to advise patients who want to stop statin therapy, usually due to perceived side effects. Many of these challenges can be met with improved and respectful communication between the hospital, the treating cardiologist and the GP. The patient needs to be closely involved in the decision-making process, particularly when balancing the risks of bleeding versus thrombosis.

Non-cardiac surgery after percutaneous coronary intervention

Perioperative management of patients after percutaneous coronary intervention presents physicians with unique challenges and dilemmas. Although newer generation drug-eluting stents, transcatheter-based therapies, and minimally invasive surgical techniques have changed the medical landscape, guidelines for managing perioperative patients after percutaneous intervention are based largely on expert opinion and inconsistent data from an earlier era. In conclusion, the aims of this review are to summarize the data pertinent to managing patients after percutaneous coronary intervention in the perioperative period and to explore future perspectives.

How to manage prasugrel and ticagrelor in daily practice

Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.

Perioperative management of antiplatelet therapy

Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.

Update in perioperative medicine 2013

Perioperative medicine is an important and rapidly expanding area of interest across multiple specialties, including internal medicine, anesthesiology, surgery, and hospital medicine. A multi-specialty team approach that ensures best possible patient outcomes has fostered collaborative strategies across the continuum of patient care. It is difficult to keep current in this multidisciplinary field, as physicians interested in perioperative medicine would need to review multiple specialty journals on a regular basis. To facilitate this process, we performed a focused review of this literature published in 2012. In this update, we review 9 key articles that potentially impact clinical practice in various areas of perioperative medicine including preoperative testing, cardiovascular medicine, pulmonary care, anticoagulation, and medication management.

Progress in platelet blockers: the target is the P2Y12 receptor

The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.

The Optimal Duration of Dual Combination Antiplatelet Therapy After Stent Implantation and Perioperative Management Issues

Impending risk of stent Thrombosis (ST) after percutaneous coronary intervention (PCI) has mandated post-PCI use of dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor. As the optimal duration of DAPT remains controversial, premature discontinuation of it potentiates the risk of ST, myocardial infarction or death; while use of DAPT itself increases the risk of bleed. Similarly, perioperative DAPT management is still ill defined, where there is higher operative risk of bleed on antiplatelet therapy and higher ST risk during this thrombogenic period if off antiplatelet therapy. Additional clinical investigation is warranted in these fields.