Tuesday, July 31, 2018

Should aspirin be discontinued preoperatively in patients undergoing non-cardiac surgery?

·         If the patient is on aspirin for primary prophylaxis, then discontinue aspirin for 5 to 7 days before the surgery. Restart as soon as the perioperative risk of major bleeding has passed.

·         If the patient is on long-term aspirin for secondary prophylaxis, continue aspirin in patients with prior PCI with stenting and those undergoing carotid endarterectomy, unless the risk of major bleeding is thought to be high (POISE-2 trial) or the surgery involved is not likely to have bleeding controlled by homeostasis (prostate surgery, intra ocular surgery, intra cranial surgery).

·         Aspirin can be safely continued in most patients undergoing minor dental surgery or dermatologic procedures.

·         Guidelines from the American Society of Regional Anesthesia (ASRA) suggest that NSAIDs, including aspirin do not create a level of risk that will interfere with the performance of neuraxial blocks, and should not impact catheter techniques, timing of neuraxial catheter removal, or postoperative monitoring.

·         Discontinue cilostazol for at least 2 to 3 days prior to an elective surgery.

·         There is no data on the safety of dipyridamole if continued in the perioperative period. If discontinued, the drug should be stopped at least 2 days before surgery.

Dual antiplatelet therapy (DAPT) after PCI with stenting

·         Defer non-emergent noncardiac surgery for at least 6 months irrespective of stent type. In patients who must undergo non-emergent (time sensitive) noncardiac surgery prior to six months, attempt to defer surgery for at least three months after bare metal or drug-eluting stent placement. In patients for whom surgery before three months is in their best interest after weighing risks and benefits, refer patients as early as one month after stent placement.

·         For most patients undergoing noncardiac surgery who are taking DAPT after PCI with stenting because they have not reached the recommended minimum duration of such therapy, continue DAPT, as opposed to stopping it prior to surgery

·         In patients for whom the risk of bleeding is likely to exceed the risk of a perioperative event due to the premature cessation of DAPT, continue aspirin alone.

·         Stop both antiplatelet agents, in patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate, or posterior eye procedures.

·         For patients taking DAPT after PCI with balloon angioplasty who are scheduled to undergo elective noncardiac surgery, wait at least 14 days after PCI

·         Clopidogrel, prasugrel, and ticagrelor when stopped should be stopped 5, 7 and 3-5 days, respectively, before surgery.

·         Clopidogrel, if stopped, should be restarted with a loading dose of 300-600 mg as soon as possible after surgery, perhaps even later in the day if postoperative bleeding has stopped.

·         Surgery be performed in centers with 24-hour interventional cardiology coverage

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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