Key result
Perioperative antiplatelet therapy management in patients with cardiac stents undergoing non-cardiac surgery lacks sufficient evidence to guide practice, with MACE and bleeding rates varying widely (0-21% and 0-22%) regardless of the strategy used.
Why the study?
Does perioperative antiplatelet therapy management affect major adverse cardiac events and bleeding in patients with coronary stents undergoing elective non-cardiac surgery?
Systematic Review
Does perioperative antiplatelet therapy management affect major adverse cardiac events and bleeding in patients with coronary stents undergoing elective non-cardiac surgery?
Current evidence is insufficient to guide perioperative antiplatelet management in patients with coronary stents undergoing non-cardiac surgery, as MACE and bleeding rates do not clearly correlate with specific antiplatelet strategies.
Insufficient evidence precludes firm perioperative antiplatelet recommendations in stented patients; leaves open optimal strategy pending targeted trials.
BACKGROUND: 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. METHODS: 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. RESULTS: Of 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small (< 50: n = 5, 51-150: n = 5, >150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (< 6 months: n = 3, 6-12 months: n = 1, > 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. CONCLUSIONS: 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. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036607.
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Childers et al. (2018) conducted a systematic review in Coronary stents undergoing non-cardiac surgery. Perioperative antiplatelet therapy management vs. Alternative antiplatelet strategies was evaluated on Major adverse cardiac events (MACE) and bleeding events. Perioperative antiplatelet therapy management in patients with cardiac stents undergoing non-cardiac surgery lacks sufficient evidence to guide practice, with MACE and bleeding rates varying widely (0-21% and 0-22%) regardless of the strategy used.
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