• long-term antiplatelet therapy may be interrupted for various reasons
    • most usually for planned diagnostic or surgical procedures
    • in the event of significant bleeding
  • the decision regarding perioperative/periprocedural  antiplatelet therapy depends on the balance between thrombotic risk  (indication) and bleeding risks (type of antiplatelet therapy)
  • these questions need to be answered:
    • is the risk of thrombosis high?
    • is it necessary to discontinue antiplatelet therapy?
    • is bridging therapy required?
    • when should antiplatelet therapy be resumed after the procedure?

Thrombotic risk assessment

  • very high risk of thrombosis is associated with conditions requiring temporary dual antiplatelet therapy (DAPT), such as:
    • drug-eluting coronary stent (DES) < 6-12 months
    • carotid artery stent < 3 months
    • recent stroke (< 3 months)
  • discontinuation of DAPT significantly increases the risk of thrombosis
    • the highest risk (up to 20%) is present within 6 weeks following coronary stenting when DAPT is discontinued
    • according to the PARIS registry, temporary DAPT interruption for up to 14 days was not associated with an increased rate of thrombotic events, unlike interruption due to non-compliance
  • it is recommended to postpone elective surgery for a minimum of 4-6 weeks and ideally up to 3 months after stent implantation, with the perioperative continuation of aspirin whenever possible
    • the risk of stent thrombosis decreases after this period, with a plateau at 6 months after DES implantation
  • in stroke patients, the perioperative continuation of aspirin is recommended whenever possible

Is it necessary to stop antiplatelet therapy?

The risk of bleeding is unlikely to be increased
simple dental procedures
The risk of bleeding is probably not increased
cataract surgery
dermatological procedures
TRUS (ultrasound-guided prostate biopsy)
spinal and epidural punctures
carpal tunnel surgery
The risk of bleeding is apparently not increased
transbronchial biopsy
colonoscopic polypectomy
endoscopic gastric biopsy
ultrasound-guided biopsies
The risk of bleeding is possibly increased
The risk of bleeding is probably increased total endoprosthesis (TEP)

Aspirin monotherapy

  • should be continued, as it reduces ischemic risk without significantly increasing the risk of major bleeding
  • consider withdrawal for 3 days before procedures with a very high risk of bleeding (e.g., neurosurgery)
  • unless contraindicated, a low dose (100mg/d) should be administered and maintained; even higher doses (e.g., 300mg) do not warrant deferral

P2Y12 inhibitor monotherapy

  • withdraw the drug 3-7 days before the procedure and switch to aspirin if possible
    • ticagrelor: 3-5 days (5 days for high-risk procedures)
    • clopidogrel: 5 days (at least 3 days in an emergency)
    • prasugrel: 7 days (at least 5 days in an emergency)

DAPT (ASA + P2Y12 inhibitor)

  • consider postponing the procedure if the patient has a moderate-to-high risk for thrombosis until the risk is low (e.g., recent stent)
    • it is important not to stop DAPT in the first 30 days after the index event for which it was prescribed
  • otherwise, maintain aspirin for all procedures unless contraindicated (e.g., neurosurgery)
  • in patients with a moderate risk of thrombosis (except for procedures with a low bleeding risk), discontinue the P2Y12 inhibitor as described above
  • the strategy for patients at high risk of thrombosis depends on the bleeding risk associated with the procedure
    • if bleeding risk is low, continue with DAPT
    • for moderate to severe bleeding risk, evaluate patients within a multidisciplinary team (consider the use of bridging therapy)

Timing of antiplatelet therapy discontinuation

ASA and P2Y12 inhibitor
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GP IIb/IIIa antagonists
  • the exact risk of bleeding is unknown but is likely increased due to their mechanism of action (as they block the final common pathway)
  • no laboratory monitoring test is available
  • the drug must be discontinued before the procedure:
    • tirofiban or eptifibatide:  withhold ≥ 4-24 hours before the procedure (timing differs according to various recommendations)
    • abciximab: withhold ≥ 48h before the procedure
  • cilostazol should be discontinued 42 hours before the procedure
  • dipyridamole has a half-life of 10-12h; no specific precautions are needed, and it can be restarted after 6h

Urgent reversal of the antiplatelet therapy

  • urgent reversal of antiplatelet therapy is not a routine procedure (usually considered for acute bleeding) and should be due to the risk of thrombosis
    • the literature does not consistently show that ICH on antiplatelet therapy is associated with worse clinical outcomes, nor does it consistently show that reversing the effect of antiplatelet therapy leads to improved outcomes
  • platelet transfusion (2-6 units) may be considered (provides functional, circulating platelets); consult a hematologist
    • studies have shown mixed results regarding the benefits; there is no standard dose (more units required for patients on DAPT)
    • no effect in patients with spontaneous ICH ( PATCH trial)
  • desmopressin (ddAVP) OCTOSTIM – 0,3 ug/kg +100 mL NS, IV infusion over 15-30 minutes
    • the effect was proven in general surgery (less bleeding and lower transfusion requirements)
    • no clear evidence that it f reduces the risk of ICH growth   [Schmidt, 2019]
  • recombinant factor VIIa (rFVIIa) – reverses the inhibitory effects of aspirin or aspirin plus clopidogrel and could be useful for bleeding complications or when acute surgery is needed during treatment with these antiplatelet drugs (Campbell, 2010)
  • tranexamic acid (EXACYL) 
    • TXA may reduce bleeding complications from either antiplatelet monotherapy or DAPT  (Fischer, 2020)
    • multiple studies demonstrated the impact of TXA  administration on platelet function through reduced blood loss, transfusion requirements, and the incidence of surgical revisions
  • bentracimab – a recombinant IgG1 monoclonal antibody, seems safe and effective in promptly reversing the antiplatelet effect of ticagrelor in patients undergoing urgent surgery/procedure or with major bleeding (REVERSE-IT trial

Is bridging required?

  • there is limited clinical experience with the use of bridging therapy in patients on antiplatelet therapy
  • do not use heparin (it may increase platelet reactivity and have the opposite effect than desired)
  • use of LMWHs is discouraged – lack of evidence of efficacy and safety
  • if bridging therapy is necessary (in high-risk conditions such as a recent coronary stent), consider antiplatelet rather than an anticoagulant agent
    •  the IV antiplatelet agents studied to date are the glycoprotein IIb/IIIa inhibitors (tirofiban and eptifibatide) and the P2Y12 adenosine diphosphate receptor inhibitor cangrelor
    • the results are controversial, and perioperative use of cangrelor has not been approved yet
    • large randomized trials are needed to confirm this strategy
  • a risk-benefit analysis should be performed by a multidisciplinary team on a case-by-case basis
  • if it is decided that bridging therapy is indicated, the patient should be started on a glycoprotein IIb/IIIa inhibitor 72 hours after withdrawal of the P2Y12 inhibitor
    • recommended doses are 0.1μg/kg/min for tirofiban and 2μg/kg/min for eptifibatide 
    • it should be maintained for up to 4-6 hours before the procedure (Vivas, 2018)
    • a loading dose is not required

Restart of the antiplatelet therapy

  • the timing of resumption should be determined in conjunction with the surgical/interventional team (adequate hemostasis during the procedure and absence of postprocedural bleeding are essential)
  • in general, antiplatelet therapy is resumed ≥ 24 hours after the procedure
  • if the patient is at high risk for thrombosis and was receiving DAPT, consider restarting the P2Y12 inhibitor with a loading dose
    • clopidogrel: 300-600 mg
    • prasugrel: 60 mg
    • ticagrelor: 180 mg

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Perioperative and Periprocedural Management of Antiplatelet Therapy
link: https://www.stroke-manual.com/perioperative-and-periprocedural-management-of-antiplatelet-therapy/