Skip to main content

Advertisement

SpringerLink
Log in

How to manage patients with need for antiplatelet therapy in the setting of (un-)planned surgery

  • CRITICAL PERSPECTIVE
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

The growing incidence of cardiovascular diseases leads to an increase in patients who require treatment with antiplatelet drugs. About 5% of patients who underwent a percutaneous coronary intervention will have to undergo surgery within the first year. In these patients the problem evolves how to handle the antiplatelet therapy in the perioperative period. A continuation of these drugs in order to reduce cardiovascular events is associated with increased perioperative bleeding. Withdrawing antiplatelet agents in order to reduce surgical hemorrhage leads to a significant increase of cardiovascular morbidity and mortality, especially in patients who have been treated with implantation of drug eluting stents. This review balances the specific risks of either approach and offers an algorithm how to manage patients in need for antiplatelet therapy in the setting of (un-)planned surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Sacco RL, Schwamm LH, American Heart Association, American Stroke Association (2008) Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke J Cereb Circ 39(5):1647–1652

    Google Scholar 

  2. Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernandez-Aviles F, Fox KA, Hasdai D, Ohman EM, Wallentin L, Wijns W (2007) Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 28(13):1598–1660

    Article  PubMed  CAS  Google Scholar 

  3. Belisle S, Hardy JF (1996) Hemorrhage and the use of blood products after adult cardiac operations: myths and realities. Ann Thorac Surg 62(6):1908–1917

    Article  PubMed  CAS  Google Scholar 

  4. Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H, Vrolix M, Missault L, Chierchia S, Casaccia M, Niccoli L, Oto A, White C, Webb-Peploe M, Van Belle E, McFadden EP (1998) Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting The full anticoagulation versus aspirin and ticlopidine (fantastic) study. Circulation 98(16):1597–1603

    PubMed  CAS  Google Scholar 

  5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, Testa L, Sheiban I, Sangiorgi G (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50, 279 patients at risk for coronary artery disease. Eur Heart J 27(22):2667–2674

    Article  PubMed  Google Scholar 

  6. Brilakis ES, Banerjee S, Berger PB (2007) Perioperative management of patients with coronary stents. J Am Coll Cardiol 49(22):2145–2150

    Article  PubMed  Google Scholar 

  7. Burger W, Chemnitius JM, Kneissl GD, Rucker G (2005) Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med 257(5):399–414

    Article  PubMed  CAS  Google Scholar 

  8. Carlsson J, von Wagenheim B, Linder R, Anwari TM, Qvist J, Petersson I, Magounakis T, Lagerqvist B (2007) Is late stent thrombosis in drug-eluting stents a real clinical issue? A single-center experience and review of the literature. Clin Res Cardiol 96(2):86–93

    Article  PubMed  CAS  Google Scholar 

  9. Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF, Canos D, Castagna M, Weissman NJ, Waksman R (2003) Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 108(1):43–47

    Article  PubMed  Google Scholar 

  10. Chu MW, Wilson SR, Novick RJ, Stitt LW, Quantz MA (2004) Does clopidogrel increase blood loss following coronary artery bypass surgery? Ann Thorac Surg 78(5):1536–1541

    Article  PubMed  Google Scholar 

  11. Chu WW, Kuchulakanti PK, Torguson R, Wang B, Clavijo LC, Suddath WO, Pichard AD, Satler LF, Kent KM, Waksman R (2006) Impact of overlapping drug-eluting stents in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 67(4):595–599

    Article  PubMed  Google Scholar 

  12. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients (2002) BMJ 324(7329):71–86

  13. Collet JP, Montalescot G, Blanchet B, Tanguy ML, Golmard JL, Choussat R, Beygui F, Payot L, Vignolles N, Metzger JP, Thomas D (2004) Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 110(16):2361–2367

    Article  PubMed  CAS  Google Scholar 

  14. Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ, Carrozza JP Jr, Chauhan MS, Rodriguez O, Kuntz RE (2001) Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation 103(15):1967–1971

    PubMed  CAS  Google Scholar 

  15. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL, Jr., Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC Jr (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 105(10):1257–1267

    PubMed  Google Scholar 

  16. Fatah K, Beving H, Albage A, Ivert T, Blomback M (1996) Acetylsalicylic acid may protect the patient by increasing fibrin gel porosity Is withdrawing of treatment harmful to the patient? Eur Heart J 17(9):1362–1366

    PubMed  CAS  Google Scholar 

  17. Fox KA, Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ, Yusuf S (2004) Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation 110(10):1202–1208

    Article  PubMed  CAS  Google Scholar 

  18. Garg R, Uretsky BF, Lev EI (2007) Anti-platelet and anti-thrombotic approaches in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 70(3):388–406

    Article  PubMed  Google Scholar 

  19. Hamm CW (2004) Guidelines: acute coronary syndrome (ACS) 1 ACS without persistent ST segment elevations. Zeitschrift fur Kardiologie 93(1):72–90

    Article  PubMed  CAS  Google Scholar 

  20. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, Jr., White CJ, White J, White RA, Antman EM, Smith SC, Jr., Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006) ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 47(6):1239–1312

    Article  PubMed  Google Scholar 

  21. Ho PM, Peterson ED, Wang L, Magid DJ, Fihn SD, Larsen GC, Jesse RA, Rumsfeld JS (2008) Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 299(5):532–539

    Article  PubMed  CAS  Google Scholar 

  22. Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M, Michev I, Corvaja N, Briguori C, Gerckens U, Grube E, Colombo A (2005) Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 293(17):2126–2130

    Article  PubMed  CAS  Google Scholar 

  23. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35(5):1288–1294

    Article  PubMed  CAS  Google Scholar 

  24. Kapetanakis EI, Medlam DA, Boyce SW, Haile E, Hill PC, Dullum MK, Bafi AS, Petro KR, Corso PJ (2005) Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist’s panacea or the surgeon’s headache?. Eur Heart J 26(6):576–583

    Article  PubMed  CAS  Google Scholar 

  25. Karabulut H, Toraman F, Evrenkaya S, Goksel O, Tarcan S, Alhan C (2004) Clopidogrel does not increase bleeding and allogenic blood transfusion in coronary artery surgery. Eur J Cardiothorac Surg 25(3):419–423

    Article  PubMed  Google Scholar 

  26. Khattab AA, Hamm CW, Senges J, Toelg R, Geist V, Bonzel T, Kelm M, Levenson B, Nienaber CA, Sabin G, Tebbe U, Schneider S, Richardt G (2007) Incidence and predictors of target vessel revascularization after sirolimus-eluting stent treatment for proximal left anterior descending artery stenoses among 2274 patients from the prospective multicenter German Cypher Stent Registry. Clin Res Cardiol 96(5):279–284

    Article  PubMed  CAS  Google Scholar 

  27. Lindblad B, Persson NH, Takolander R, Bergqvist D (1993) Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial. Stroke J Cereb Circ 24(8):1125–1128

    CAS  Google Scholar 

  28. Manning BJ, O’Brien N, Aravindan S, Cahill RA, McGreal G, Redmond HP (2004) The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures. Injury 35(2):121–124

    Article  PubMed  Google Scholar 

  29. McDonald SB, Renna M, Spitznagel EL, Avidan M, Hogue CW Jr, Moon MR, Barzilai B, Saleem R, McDonald JM, Despotis GJ (2005) Preoperative use of enoxaparin increases the risk of postoperative bleeding and re-exploration in cardiac surgery patients. J Cardiothorac Vasc Anesth 19(1):4–10

    Article  PubMed  CAS  Google Scholar 

  30. McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R, Serruys PW (2004) Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 364(9444):1519–1521

    Article  PubMed  CAS  Google Scholar 

  31. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG (2004) Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 351(27):2795–2804

    Article  PubMed  CAS  Google Scholar 

  32. Mehilli J, Dibra A, Kastrati A, Pache J, Dirschinger J, Schomig A (2006) Randomized trial of paclitaxel- and sirolimus-eluting stents in small coronary vessels. Eur Heart J 27(3):260–266

    Article  PubMed  CAS  Google Scholar 

  33. Michlig C, Vu DH, Wasserfallen JB, Spahn DR, Schneider P, Tissot JD (2003) Three years of haemovigilance in a general university hospital. Transfus Med (Oxford, England) 13(2):63–72

    CAS  Google Scholar 

  34. Neilipovitz DT, Bryson GL, Nichol G (2001) The effect of perioperative aspirin therapy in peripheral vascular surgery: a decision analysis. Anesth Analg 93(3):573–580

    Article  PubMed  CAS  Google Scholar 

  35. Nuttall GA, Santrach PJ, Oliver WC Jr, Horlocker TT, Shaughnessy WJ, Cabanela ME, Bryant S (1996) The predictors of red cell transfusions in total hip arthroplasties. Transfusion 36(2):144–149

    Article  PubMed  CAS  Google Scholar 

  36. Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW (2005) Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol 45(12):2088–2092

    Article  PubMed  CAS  Google Scholar 

  37. Palmer JD, Sparrow OC, Iannotti F (1994) Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery 35(6):1061–1064 (discussion 1064–1065)

    Article  PubMed  CAS  Google Scholar 

  38. Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P, Mueller C, Jeger R, Bader F, Osswald S, Kaiser C (2006) Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents. J Am Coll Cardiol 48(12):2584–2591

    Article  PubMed  CAS  Google Scholar 

  39. Posner KL, Van Norman GA, Chan V (1999) Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analg 89(3):553–560

    Article  PubMed  CAS  Google Scholar 

  40. Qureshi AI, Saad M, Zaidat OO, Suarez JI, Alexander MJ, Fareed M, Suri K, Ali Z, Hopkins LN (2002) Intracerebral hemorrhages associated with neurointerventional procedures using a combination of antithrombotic agents including abciximab. Stroke J Cereb Circ 33(7):1916–1919

    CAS  Google Scholar 

  41. Sautter RD, Myers WO, Ray JF, 3rd, Wenzel FJ (1973) Relationship of fibrinolytic system to postoperative thrombotic phenomena. Arch Surg 107(2):292–296

    PubMed  CAS  Google Scholar 

  42. Schomig A, Neumann FJ, Kastrati A, Schuhlen H, Blasini R, Hadamitzky M, Walter H, Zitzmann-Roth EM, Richardt G, Alt E, Schmitt C, Ulm K (1996) A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med 334(17):1084–1089

    Article  PubMed  CAS  Google Scholar 

  43. Sharma AK, Ajani AE, Hamwi SM, Maniar P, Lakhani SV, Waksman R, Lindsay J (2004) Major noncardiac surgery following coronary stenting: when is it safe to operate? Catheter Cardiovasc Interv 63(2):141–145

    Article  PubMed  Google Scholar 

  44. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, Jorgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W (2005) Guidelines for percutaneous coronary interventions The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26(8):804–847

    Article  PubMed  Google Scholar 

  45. Steinhubl SR, Berger PB, Mann JT, 3rd, Fry ET, DeLago A, Wilmer C, Topol EJ (2002) Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 288(19):2411–2420

    Article  PubMed  CAS  Google Scholar 

  46. Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H (2006) Coronary artery stenting and non-cardiac surgery–a prospective outcome study. Br J Anaesth 96(6):686–693

    Article  PubMed  CAS  Google Scholar 

  47. Weber FD, Schneider H, Wiemer M, Pfannebecker T, Tebbe U, Hamm CW, Senges J, Schneider S, Nienaber CA (2008) Sirolimus eluting stent (Cyphertrade mark) in patients with diabetes mellitus: results from the German Cypher Stent Registry. Clin Res Cardiol 97(2):105–109

    Google Scholar 

  48. Wilson SH, Fasseas P, Orford JL, Lennon RJ, Horlocker T, Charnoff NE, Melby S, Berger PB (2003) Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 42(2):234–240

    Article  PubMed  Google Scholar 

  49. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK (2001) Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 345(7):494–502

    Article  PubMed  CAS  Google Scholar 

  50. Zahn R, Hamm CW, Schneider S, Zeymer U, Richardt G, Kelm M, Levenson B, Bonzel T, Tebbe U, Sabin G, Nienaber CA, Pfannebecker T, Senges J (2007) The Sirolimus-eluting coronary stent in daily routine practice in Germany Trends in indications over the years Results from the prospective multi-centre German Cypher Stent Registry. Clin Res Cardiol 96(8):548–556

    Article  PubMed  CAS  Google Scholar 

  51. Zellerhoff C, Schneider S, Senges J, Pfannebecker T, Hamm C, Tebbe U (2008) Sirolimus-eluting stents in the treatment of chronic total coronary occlusions: Results from the prospective multi-center German Cyphertrade mark Stent Registry. Clin Res Cardiol 97(4):253–259

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Dept. of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany

    Helge Möllmann, Holger M. Nef, Christian W. Hamm & Albrecht Elsässer

Authors
  1. Helge Möllmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Holger M. Nef
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christian W. Hamm
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Albrecht Elsässer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Helge Möllmann.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Möllmann, H., Nef, H.M., Hamm, C.W. et al. How to manage patients with need for antiplatelet therapy in the setting of (un-)planned surgery. Clin Res Cardiol 98, 8–15 (2009). https://doi.org/10.1007/s00392-008-0718-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-008-0718-x

Keywords

Search

Navigation