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

Perioperative management of antiplatelet therapy

Background

Preoperative bridging with a glycoprotein IIb/IIIa inhibitor is often performed in patients with prior coronary stents undergoing surgery who require antiplatelet therapy discontinuation, but its safety and efficacy have received limited study. We performed a weighted meta-analysis of the outcomes in patients with coronary stents undergoing bridging with glycoprotein IIb/IIIa inhibitors prior to surgery.



Methods

We conducted a weighted meta-analysis of preoperative bridging studies published between 2002 and 2013 in patients with coronary stents undergoing surgery. Data on in-hospital mortality, stent thrombosis, bleeding, hemoglobin decrease, blood transfusion, time to hospital discharge and myocardial infarction were collected.



Results

A total of eight studies with 280 patients were included. Pooled estimates of outcomes were as follows: in-hospital mortality 3.5% (95% confidence interval [CI] 1.7–5.9%); stent thrombosis 1.3% (95% CI 0.3–3.0%); major bleeding 7.4% (95% CI 2.8–14.1%); any bleeding 20.6% (95% CI 4.8–43.2%); mean decrease in hemoglobin 2.8 g/dL (95% CI 2.5–3.0 g/dL); mean blood loss 271 mL (95% CI 211–311 mL); blood transfusion 13.9% (95% CI 1.0–38.2%); time to hospital discharge 5.9 days (95% CI 4.4–7.3 days); and myocardial infarction 1.6% (95% CI 0.3–3.6%).



Conclusions

Preoperative bridging with a glycoprotein IIb/IIIa inhibitor in patients undergoing surgery after coronary stenting does not abolish the risk of perioperative stent thrombosis and may carry increased risk for bleeding. © 2014 Wiley Periodicals, Inc.

Outcomes of preoperative bridging therapy for patients undergoing surgery after coronary stent implantation: A weighted meta-analysis of 280 patients from eight studies

The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention.

The correct perioperative management of antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) is often debated by clinicians. American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend postponing elective NCS at least 3 months after stent implantation. Regardless of the timing of surgery, ACC/AHA guidelines recommend continuing at least ASA throughout the perioperative period and ideally continuing dual APT (DAPT) therapy “unless surgery demands discontinuation.” The objective of this review was to ascertain the risks and benefits of APT in the perioperative period, to assess how these risks and benefits vary by APT management, and the significance of length of time since stent implantation before operative intervention. PubMed, Web of Science, and Scopus were searched from inception through October 2017. Articles were included if patients were post PCI with stent placement (bare metal [BMS] or drug eluting [DES]), underwent elective NCS, and had rates of major adverse cardiac events (MACE) or bleeding events associated with pre and perioperative APT therapy. Of 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small ( 150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (  12 months: n = 6). At least six different APT strategies were described. Six studies further utilized bridging protocols using three different pharmacologic agents. Studies typically included multiple surgical fields with varying degrees of invasiveness. Across all APT strategies, rates of MACE/bleeding ranged from 0 to 21% and 0 to 22%. There was no visible trend in MACE/bleeding rates within a given APT strategy. Stratifying the articles by type of surgery, timing of discontinuation of APT therapy, bridging vs. no bridging, and time since stent placement did not help explain the heterogeneity. Evidence regarding perioperative APT management in patients with cardiac stents undergoing NCS is insufficient to guide practice. Other clinical factors may have a greater impact than perioperative APT management on MACE and bleeding events. PROSPERO CRD42016036607

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Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review

Recognition of myocardial injury after non-cardiac surgery is difficult, since strong analgesics (e.g. opioids) can mask anginal symptoms, and ECG abnormalities are subtle or transient. Thorough knowledge of the pathophysiological mechanisms is therefore essential. These mechanisms can be subdivided into four groups: type I myocardial infraction (MI), type II MI, non-ischaemic cardiac pathology, and non-cardiac pathology. The incidence of type I MI in patients with a clinical suspicion of perioperative acute coronary syndrome (ACS) is 45–57 %. This percentage is higher in patients with a high likelihood of MI such as patients with ST-elevation ACS. Of note, the generalisability of this statement is limited due to significant study limitations. Non-ischaemic cardiac pathology and non-cardiac pathology should not be overlooked as a cause of perioperative myocardial injury (PMI). Especially pulmonary embolism and dysrhythmias are a common phenomenon, and may convey important prognostic value. Implementation of routine postoperative troponin assessment and accessible use of minimally invasive imaging should be considered to provide adequate individualised therapy. Also, addition of preoperative imaging may improve the stratification of high-risk patients who may benefit from preoperative or perioperative interventions.

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The aetiology of myocardial injury after non-cardiac surgery

Objectives
To evaluate stent-related adverse cardiac events and bleeding complications within 30 days after surgical procedures in patients with recent drug-eluting stent (DES) implantation, in whom a bridging protocol was used.

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A. C. Da Fonseca

Papers

Bridging therapy for early surgery in patients on dual antiplatelet therapy after drug-eluting stent implantation