Use Of Antiplatelet Drugs In Patients Having Cardiac And Noncardiac Operations

Publication Date: November 1, 2012
Last Updated: March 14, 2022

Recommendations

Risk factor screening

Risk factor screening for bleeding in patients requiring cardiovascular procedures is indicated as soon as possible before operation to intervene and modify risk factors, if possible. Special attention should be given to patients with combinations of the major risk factors listed below. (B, Class I)
One of the few modifiable preoperative risk factors is use of antiplatelet drugs, and special attention should be given to this risk factor.
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Monitoring platelet function

Because of their high negative predictive value, preoperative point-of-care testing to assess bleeding risk may be useful in identifying patients with high residual platelet reactivity after usual doses of antiplatelet drugs, and who can undergo operation without elevated bleeding risk. (B, Class IIb)
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Point-of-care testing to assess perioperative platelet function may be useful in limiting blood transfusion. (B, Class IIb)
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Perioperative management of patients taking antiplatelet drugs

Discontinuation of P2Y12 inhibitors for a few days before cardiovascular operations is recommended to reduce bleeding and blood transfusion, especially in high-risk patients. (B, Class I)
Stopping antiplatelet drugs before operation is associated with reduced bleeding, blood transfusion, and reoperation but not with increased postoperative death, myocardial infarction, or stroke. The interval between discontinuation of antiplatelet drugs and operation is uncertain and depends on multiple factors mostly related to patient drug responsiveness and thrombotic risk.
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Preoperative discontinuation of aspirin in certain high-risk patients such as those who refuse blood transfusion for religious reasons (Jehovah's Witness) is reasonable. (B, Class IIa)
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Aspirin discontinuation before purely elective operations in patients without acute coronary syndromes is reasonable to decrease the risk of bleeding. Aspirin increases perioperative bleeding and blood transfusion, but to a lesser extent than other antiplatelet drugs. This effect may depend on the dose of preoperative aspirin, with doses less than 100 mg daily having less bleeding risk but having important efficacy in patients with acute coronary syndromes. (A, Class IIa)
Numerous studies show no increased risk of myocardial events with discontinuation of aspirin for a few days before operation in these patients.
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Management of antiplatelet drugs in patients with intrinsic (hereditary) or acquired platelet defects

Patients with known preoperative intrinsic (hereditary) platelet defects or with thrombocytopenia and who require cardiac operations should not receive antiplatelet drugs before operation. (C, Class III)
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Patients with acquired preoperative platelet defects associated with thrombocytopenia or bleeding should not receive antiplatelet therapy before cardiac operations. (C, Class III)
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Management of antiplatelet drugs during noncardiac operations

Continuing antiplatelet monotherapy (with either aspirin or clopidogrel) is reasonable in patients undergoing most noncardiac operations, regardless of procedure urgency. Patients with very high risk from even modest bleeding (eg, intracranial procedures) or expected major bleeding complications represent the only significant exceptions to this recommendation and should have antiplatelet therapy discontinued before operation if possible. (B, Class IIa)
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In patients with coronary stents who require noncardiac operations, perioperative continuation of dual antiplatelet therapy can be reasonable unless the bleeding risk is prohibitive. (C, Class IIb)
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Antiplatelet drugs after cardiac operations

For stable nonbleeding patients, aspirin should be given within 6 to 24 hours of coronary artery bypass graft surgery (CABG) to optimize vein graft patency. (A, Class I)
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In patients undergoing CABG after acute coronary syndromes, Guideline-indicated dual antiplatelet drugs should be restarted when bleeding risk is diminished to decrease intermediate-term adverse cardiovascular outcomes (MACE). That may have secondary benefit of increasing early vein graft patency. (A, Class I)
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Once postoperative bleeding risk is decreased, testing of response to antiplatelet drugs, either with genetic testing or with point-of-care platelet function testing, early after cardiac procedures might be considered to optimize antiplatelet drug effect and minimize thrombotic risk to vein grafts. (B, Class IIb)
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For patients with high platelet reactivity after usual doses of clopidogrel, it may be helpful to switch to another P2Y12 inhibitor (eg, prasugrel or ticagrelor). (C, Class IIb)
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Treatment options for patients on antiplatelet drugs who require urgent operations

For patients who require urgent operation while on dual antiplatelet therapy, delay of even a day or two before operation is reasonable to decrease bleeding risk and minimize thrombotic risk in patients with acute coronary syndromes. (B, Class IIa)
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For patients on dual antiplatelet therapy, it is reasonable to make decisions about surgical delay based on tests of platelet inhibition rather than arbitrary use of a specified period of surgical delay. (B, Class IIa)
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For patients with high thrombotic risks who require urgent operation while on dual antiplatelet therapy, bridging strategies using short-acting antiplatelet agents might be helpful in limiting bleeding while avoiding thrombotic risks. (B, Class IIb)
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For patients taking dual antiplatelet drugs for acute coronary syndrome or with drug-eluting stents less than 1 year old, operation should likely proceed at intervals less than 5 days to minimize prothrombotic risks of antiplatelet withdrawal, or with use of a short-acting antiplatelet agent “bridge” to minimize these risks. (C, Class IIb)
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Platelet transfusions may be helpful in patients receiving dual antiplatelet drugs who require urgent operation and have excessive perioperative bleeding. Platelet transfusion amounts may be excessive in this setting. (C, Class IIb)
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For intractable operative bleeding in patients on dual antiplatelet drugs, recombinant factor VIIa may be helpful, but carries the risk of thrombosis. Risk-benefit analysis is essential in this situation. (C, Class IIb)
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Multidisciplinary management of patients taking antiplatelet drugs

Efforts at team coordination among multiple providers involved in the management of patients taking antiplatelet drugs who need cardiac procedures are reasonable and likely to result in reduced bleeding with safe operative outcomes. (B, Class IIa)
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Recommendation Grading

Overview

Title

Use Of Antiplatelet Drugs In Patients Having Cardiac And Noncardiac Operations

Authoring Organization

Society of Thoracic Surgeons

Publication Month/Year

November 1, 2012

Last Updated Month/Year

January 8, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This document represents synthesis of new information regarding the use of antiplatelet agents in the perioperative period. Additional features of this publication include broader discussion of point-of-care testing to monitor platelet function and wider exploration of treatment options of patients exposed to antiplatelet drugs who need urgent operation.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse practitioner, nurse, physician, physician assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D062645 - Percutaneous Coronary Intervention, D003324 - Coronary Artery Disease, D003327 - Coronary Disease

Keywords

antiplatelet agents, Ambulatory surgical procedures, urgent surgery

Source Citation

2012 Update to The Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and Noncardiac Operations

Ferraris, Victor A. et al.
The Annals of Thoracic Surgery, Volume 94, Issue 5, 1761 - 1781