Perioperative management of antiplatelet agents in patients with coronary stents: recommendations of a French Task Force
Editor—Following recent articles relating to perioperative antiplatelet drugs (APs) in the British Journal of Anaesthesia,1–3 we thought it would be of interest to share with you the recommendations of a recent working party in France which addressed the use of APs in patients with coronary stents.Currently, high-level evidence is lacking in the literature in support for strong recommendations on the perioperative use of APs. The lack of evidence is particularly striking when considering patients with coronary stents, especially drug-eluting stents. This is a problem because an increasing number of patients with stents and receiving a combination of APs (aspirin and clopidogrel) are candidates for an invasive procedure or surgery. The risk of bleeding and/or thrombosis while maintaining or withdrawing AP treatment in these patients has not been assessed.
A multidisciplinary group of experts (cardiologists, haematologists, surgeons and anaesthesiologists) met in December 2005 under the auspices of the French Society of Anaesthesiology and Intensive Care (SFAR) to review the state-of-the-art in the field and to produce recommendations on appropriate clinical practice. In view of the paucity of evidence-based data, the recommendations are based in large part on agreement among the members of the task force. A consensus was not reached on all points; at times, more than one management option was proposed. The recommendations are not meant to be evidence-based guidelines but a guide to practitioners in their routine practice.
Recommendations
- Combination AP treatment should be maintained for at least 4–6 weeks after placement of a bare metal stent and at least 6–12 months after placement of a drug-eluting stent.4
- If AP treatment is well managed, the risk of acute thrombosis is independent of stent type (drug-eluting or not). Withdrawing APs is a major risk factor for thrombosis for all types of stent and especially for late stent thrombosis in the case of drug-eluting stents,5 6 treatment should therefore be long term. However, one or both APs may need to be withdrawn in order to perform an invasive diagnostic or surgical procedure.7 8 The frequency of stent thrombosis in this situation has not been established for drug-eluting stents as only isolated clinical cases have been reported in the literature without any data on the number of cases with no perioperative thrombotic complications.9–11
- Whether a stent should be placed or not should always be discussed early on. If surgery is to be performed in 6–12 months time, a bare metal stent is the preferred option. Before placement of a drug-eluting stent, any surgery likely to take place in the future should always be considered.
- Patients with drug-eluting stents who have a very high risk of stent thrombosis should be identified. This includes patients who have discontinued AP in the 6–12 months after stent placement, patients with a history of stent thrombosis, patients with more than one stent, long stents, or stents placed at a bifurcation, incomplete revascularization, patients who have relapsed during treatment, diabetic patients or patients with a low ejection fraction.5
- A multidisciplinary team meeting must take place in order to decide on perioperative AP use in these patients. The meeting should be attended by the cardiologist, the haemostasis specialist, the surgeon or practitioner carrying out an invasive procedure (e.g. endoscopy) and the anaesthetist. They should discuss the risk of bleeding during surgery if APs are maintained and the risk of thrombosis on discontinuing one or more APs. They should decide jointly how the patient should be managed perioperatively, or whether the procedure should be postponed or cancelled. Their conclusions should be entered in the record of the multidisciplinary team meeting and should be easily accessible in the patient's file. The patient should be informed of the conclusions.
- The task force agreed that aspirin should be maintained and that clopidogrel could be withdrawn for a 5 day window in a patient with a drug-eluting stent and receiving AP combination treatment, who needs to undergo a diagnostic or surgical procedure at a time when AP treatment cannot be totally discontinued (high risk of thrombosis) (Table 1). This recommendation is not based on the results of a prospective study but on a compromise between platelet half-life (10 days), risk of bleeding associated with antiplatelet agents' maintenance, and risk of stent thrombosis associated with withdrawal. Treatment should be resumed as soon as possible after surgery. Some panel members recommended a loading dose of at least 300 mg of clopidogrel on treatment resumption.
- In patients with drug-eluting stents, irrespective of when the stent was placed, maintaining aspirin during surgery was the preferred option (Table 1). This recommendation is based on expert opinion as high-level evidence studies are lacking. However, caution should be exercised and a group discussion is highly recommended when considering surgery associated with high blood loss (e.g. major tissue detachment, aorta, prostate, neurosurgery, ENT, posterior segment of the eye). Currently, there are no published data on the perioperative risk of bleeding with clopidogrel, except for cardiac surgery, and there are only few data for ticlopidine (a thienopyridine with a risk of bleeding equivalent to that of clopidogrel). Compared with aspirin, ticlopidine has been reported to show an increased risk of bleeding.12 13
- If AP treatment cannot be maintained (major risk of bleeding during surgery, or surgery that cannot be postponed), total withdrawal of combined treatment should be considered on a case by case basis, as the patient is exposed to a severe risk of thrombosis.6 If total withdrawal is decided, the task force considered drug substitution as a possibility but had no reasons for preferring either a non-steroid anti-inflammatory (flurbiprofen: 50 mg x 2, withdrawn 24 h before surgery) or low-weight heparin (s.c. dose of 85–100 iu aXa per kg for 12 h with effective anticoagulant activity and not just a preventive dose). Heparin exposes the patient to a substantial perioperative risk of bleeding.
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Task Force: members
Didier Blanchard, Yvonnick Blanloeil, Jean-Philippe Collet, Nicolas Danchin, Christophe Decoene, Jean-Jacques Domerego, Hélène Eltchaninoff, Ismaël Elalamy, Emile Ferrari, Gérard Helft, Brigitte Jude, Thomas Lecompte, Jean Mantz, Claude Girard, Jean-Jacques Lehot, Rémy Nizard, Gabriel Steg, Annick Steib and Claude Tayar.
Acknowledgements to Prof. Jean François Hardy (University of Montreal) for the translation of the table.
1 Paris, France
2 Lyon, France
*E-mail: marc.samama{at}htd.aphp.fr
References
1 Tam NLK, Pac-Soo C, Pretorius PM. Epidural haematoma after a combined spinal–epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br J Anaesth 2006; 96:262–5
2 Spahn DR, Howell SJ, Delabays A, Chassot P-G. Coronary stents and perioperative anti-platelet regimen: dilemma of bleeding and stent thrombosis. Br J Anaesth 2006; 96:675–7
3 Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery—a prospective outcome study. Br J Anaesth 2006; 96:686–93
4 Lehot JJ, Piriou V, Durand de Gevigney G, Coriat P. Le patient à risque de thrombose de stent coronaire en période périopératoire: une situation de plus en plus fréquente. Ann Fr Anesth Réanim 2005; 24:1247–9[CrossRef][Web of Science][Medline]
5 Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293:2126–30
6 Rodriguez-Alemparte AE, Mieres J, Fernandez-Pereira C, et al. Coronary stent thrombosis in the current drug eluting stent era: insights from the ERACI III trial. JACC 2006; 47:205–7
7 Collet JP, Montalescot G, Blanchet B, et al. Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 2004; 110:2361–7
8 Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005; 45:456–9
9 Fléron MH, Dupuis M, Mottet P, Le Feuvre C, Godet G. Chirurgie générale et endoprothèse coronaire: pensez au sirolimus!. Ann Fr Anesth Réanim 2003; 22:733–5[CrossRef][Web of Science][Medline]
10 McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 2004; 364:1519–21[CrossRef][Web of Science][Medline]
11 Decoene C, Vincentelli A, Fabre O, Crepin F, Pol A. Thrombose tardive d'une endoprothèse coronaire pharmacoactive après arrêt des agents antiplaquettaires. Ann Fr Anesth Réanim 2005; 24:1275–7[CrossRef][Web of Science][Medline]
12 Samama CM, Bastien O, Forestier F, et al. Antiplatelet agents in the perioperative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (Sfar) 2001—summary statement. Can J Anaesth 2002; 49:S26–35
13 Ernst A, Eberhardt R, Wahidi M, Becker HD, Herth FJ. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest 2006; 129:734–73
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