Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery
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Approximately 5% to 15% of patients undergoing coronary stent implantation are estimated to undergo a surgical procedure within 2 years.1–7 In the largest (N=126 773) cohort study to date describing the incidence and timing of noncardiac surgery after coronary stent placement, 12% of patients who received bare metal stents (BMSs) and 47% of patients who received drug-eluting stents (DESs) had early surgery, defined as surgical procedures occurring within 6 weeks in patients treated with BMSs or within 12 months in those treated with DESs.8 Although the majority were minor procedures, major surgical procedures were more likely to occur within 12 months of stent placement in comparison with 12 to 24 months. Interestingly, a decline in surgical procedures was noted after publication of the American College of Cardiology/American Heart Association Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery in 2007 (preguidelines 25% versus postguidelines 13%, P=0.001).8 Stented patients undergoing surgery are likely to discontinue dual-antiplatelet therapy (DAPT), composed of aspirin and a P2Y12 receptor antagonist (mostly clopidogrel, but may also include prasugrel or ticagrelor), thereby being exposed to a withdrawal of protection with subsequent risk for stent thrombosis or other ischemic events. In a survey of 1358 consecutive patients treated with DESs and discharged on aspirin and clopidogrel, surgery was identified as the second cause of early discontinuation within 1 year (21%) and the first cause of late discontinuation thereafter (49%).9
Defining the fine balance between ischemic and bleeding risk remains a challenge in stented patients undergoing surgery treated with antiplatelet therapy. Understanding whether an antithrombotic drug should or should not be discontinued and tailoring treatment strategies based on the type of intervention are key to balancing the safety and efficacy profiles of antithrombotic medications in this particular scenario. Importantly, such …