· 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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