Coronary artery stents and non-cardiac surgery
Luton, UK
* E-mail: bhatiaanuj{at}hotmail.com
Editor—We read the review article by Howard-Alpe and colleagues1 on implications of coronary artery stents and antiplatelet therapy in patients undergoing non-cardiac surgery with great interest. We agree with the authors' statements that ‘the risk of an adverse cardiovascular event if clopidogrel is stopped in the perioperative period is unknown but is likely to be considerable’ and that ‘there are few data to guide the most appropriate management’. The decision about stopping clopidogrel in the perioperative period is often made by the surgical team, usually before the preoperative anaesthetic evaluation. Lack of adequate information on indications of clopidogrel therapy in a patient and the potential for thrombotic complications after coronary stenting (especially with drug-eluting stents) can confound the decision-making process and tilt the risk–benefit balance inappropriately. This has potential implications for patient safety as inappropriate decisions can result in avoidable morbidity and mortality. We recently surveyed 42 consultants from different surgical specialties at our hospital regarding awareness of perioperative implications of dual antiplatelet (clopidogrel and aspirin) therapy in patients with coronary artery stents. The survey included structured questions with categorical and non-categorical answers. The survey forms were sent out in a single internal mailing and the responses were compiled with comments being recorded separately. The majority of consultants (75%) indicated that although they frequently came across patients on low-dose aspirin therapy, they only occasionally (less than once a month) encountered patients on clopidogrel. There was a lack of consensus about the best strategy for continuing/stopping clopidogrel in the perioperative period and for how long to stop it for. Responses to the question regarding management of antiplatelet therapy in patients with stents who were on both aspirin and clopidogrel while awaiting elective surgery were varied suggesting that awareness about coronary stents (especially the drug-eluting variety) and the importance of preventing cardiovascular morbidity through the use of dual antiplatelet therapy could be improved. We were encouraged by comments from the majority of respondents, indicating that they would consult a cardiologist or anaesthetist for advice. Our survey confirmed that guidelines were required for optimal perioperative management of patients on clopidogrel therapy. As a result we have instituted the following measures:
- We have drawn up guidelines with the cardiologists regarding perioperative management of clopidogrel therapy.
- All patients listed for an operative procedure are screened at the time of listing for clopidogrel use and the notes of all patients on clopidogrel are viewed by a member of the anaesthetic department who regularly anaesthetizes for the surgical team due to perform the procedure. Using the local guidelines, the anaesthetist can advise on the perioperative management of clopidogrel for that patient.
- If the anaesthetist feels that an individual patient's case requires discussion between surgeon and cardiologist, they initiate and co-ordinate this process.
Oxford, UK
E-mail: georgina.howard-alpe{at}nda.ox.ac.uk
Editor—We would like to thank Drs Bhatia and Nicholls for their letter in response to our review article.1 I am delighted and encouraged to hear about the development of local guidelines and an education programme with regard to the perioperative management of patients prescribed clopidogrel in their institution. I hope this example will be repeated in all institutions so that general awareness of the issues and potential dangers involved in the management of these patients will be raised.
We would like to stress that, except in cases of ‘closed space surgery’, the evidence is now mounting that dual antiplatelet therapy in patients with coronary artery stents implanted recently should be continued throughout the perioperative period.3 In the case of elective closed space surgery, if possible, surgery should be delayed until dual antiplatelet therapy is no longer needed.
References
1 Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foex P, Sear JW. Coronary artery stents and non-cardiac surgery. Br J Anaesth (2007) 98:560–74.
2 Spahn DR, Howell SJ, Delabays A, Chassot PG. Coronary stents and perioperative anti-platelet regimen: dilemma of bleeding and stent thrombosis. Br J Anaesth (2006) 96:675–7.
3 Chassot P-G, Delebays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth (2007) 99:316–22.
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