title: Significant differences between vascular and nonvascular surgeons in the perioperative management of antiplatelet therapies in patients with coronary stents.
abstract: BACKGROUND
  An increasing number of patients undergoing noncardiac surgery have coronary stents. Although guidelines regarding perioperative management of antiplatelet therapies in this patient population exist, practice patterns remain incompletely understood. This study evaluated these practice patterns, with particular attention to differences in management between vascular and nonvascular surgeons.
  
  
  METHODS
  A link to a 16-question survey was displayed in the American College of Surgeons (ACS) electronic newsletter NewsScope, which is posted on the ACS Web site. Questions were focused on perioperative management of antiplatelets (aspirin, clopidogrel) for bare-metal (BMS; placed within 2 months) and drug-eluting stents (DES; placed within the past year) during low- and high-risk bleeding procedures, assuming a patient with no other confounding medical issues. Primary stratification was by surgeon specialty.
  
  
  RESULTS
  A total of 244 surgical providers responded to the survey, of which 40 (17%) were vascular surgeons. The majority of respondents were attending surgeons in practice for at least 10 years (79%, n = 190). A significantly higher percentage of vascular versus nonvascular surgeons would not stop aspirin preoperatively in low bleeding risk procedures (BMS: 90% vs. 54%, P = 0.001; DES: 88% vs. 58%, P = 0.009). A higher percentage of vascular surgeons would not stop aspirin preoperatively in high bleeding risk procedures as well (BMS: 70% vs. 28%, P < 0.001; DES: 78% vs. 32%, P < 0.001). Most vascular surgeons would not stop clopidogrel in a low-risk BMS patient (53% vs. 21% of nonvascular surgeons, P = 0.001). Similar findings with clopidogrel were observed in low- (would not stop: 65% vascular versus 30% nonvascular, P < 0.001) and high-risk DES patients (would not stop: 30% vascular versus 8% nonvascular, P = 0.001). The same trends were observed in resuming antiplatelets in the postoperative period. The majority of respondents were not familiar with professional guidelines regarding perioperative antiplatelet management (52%, n = 128), with no differences between vascular and nonvascular surgeons (45% vs. 54%, P = 0.30).
  
  
  CONCLUSIONS
  This national survey demonstrates significant variation in perioperative antiplatelet management in patients with coronary stents, with marked differences between vascular and nonvascular surgeons. More effective communication of existing guidelines or the development of new specialty-specific professional guidelines appears prudent in reducing this variability in practice.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Arman
authors.initials: A
authors.lastname: Kilic
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Ibrahim S
authors.initials: IS
authors.lastname: Sultan
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD. Electronic address: treifsn1@jhmi.edu.
authors.forename: Thomas
authors.initials: T
authors.lastname: Reifsnyder
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control; D003324:Coronary Artery Disease / Q000628:therapy*; D004334:Drug Administration Schedule; D054855:Drug-Eluting Stents; D019538:Health Care Surveys; D006801:Humans; D008670:Metals; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation*; D019990:Perioperative Care; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011474:Prosthesis Design; D012307:Risk Factors; D013038:Specialization; D015607:Stents; D066231:Surgeons / Q000639:trends*; D013514:Surgical Procedures, Operative / Q000009:adverse effects; D011795:Surveys and Questionnaires
chemical_list: D008670:Metals; D010975:Platelet Aggregation Inhibitors