Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies.
Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.
Address.
Roberta
R
Rossini
Giuseppe
G
Musumeci
Luigi Oltrona
LO
Visconti
Ezio
E
Bramucci
Battistina
B
Castiglioni
Stefano
S
De Servi
Corrado
C
Lettieri
Maddalena
M
Lettino
Emanuela
E
Piccaluga
Stefano
S
Savonitto
Daniela
D
Trabattoni
Davide
D
Capodanno
Francesca
F
Buffoli
Alessandro
A
Parolari
Gianlorenzo
G
Dionigi
Luigi
L
Boni
Federico
F
Biglioli
Luigi
L
Valdatta
Andrea
A
Droghetti
Antonio
A
Bozzani
Carlo
C
Setacci
Paolo
P
Ravelli
Claudio
C
Crescini
Giovanni
G
Staurenghi
Pietro
P
Scarone
Luca
L
Francetti
Fabio
F
D'Angelo
Franco
F
Gadda
Andrea
A
Comel
Luca
L
Salvi
Luca
L
Lorini
Massimo
M
Antonelli
Francesco
F
Bovenzi
Alberto
A
Cremonesi
Dominick J
DJ
Angiolillo
Giulio
G
Guagliumi
D000776:Anesthesiology; D001241:Aspirin / Q000627:therapeutic use; D006348:Cardiac Surgical Procedures / Q000379:methods; D002309:Cardiology; D000077144:Clopidogrel; D000077542:Eptifibatide; D006470:Hemorrhage / Q000517:prevention & control*; D006801:Humans; D007558:Italy; D017202:Myocardial Ischemia / Q000517:prevention & control*; D010455:Peptides / Q000627:therapeutic use; D019990:Perioperative Care / Q000592:standards*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D018570:Risk Assessment; D012955:Societies, Medical; D015607:Stents; D013514:Surgical Procedures, Operative / Q000379:methods*; D013903:Thoracic Surgery; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D000077466:Tirofiban; D014443:Tyrosine / Q000031:analogs & derivatives / Q000627:therapeutic use
D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077144:Clopidogrel; D000077466:Tirofiban; D000077542:Eptifibatide; D013988:Ticlopidine; D001241:Aspirin