• long-term antiplatelet therapy may be interrupted for various reasons
    • most often due to planned diagnostic or surgical procedures
    • in case of a significant bleeding
  • the decision regarding antiplatelet therapy during the perioperative/periprocedural period depends on the balance between thrombotic (corresponding indication) and bleeding risks (type of antiplatelet therapy)
  • these questions need to be addressed:
    • is there a high risk of thrombosis?
    • is it necessary to discontinue antiplatelet therapy?
    • is bridging therapy necessary?
    • when should the antiplatelet therapy be restarted after the procedure?

Assessment of thrombotic risk

  • very high risk of thrombosis is bound to conditions where temporal DAPT is required
    • drug-eluting coronary stent (DES) < 6-12 months
    • carotid artery stent < 3 months
    • recent stroke (< 3 months)
  • discontinuation of DAPT results in increased risk for thrombosis
    • the highest risk of thrombosis (as high as 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, as opposed to disruption due to noncompliance
  • it is recommended to postpone elective surgery for a minimum of 4-6 weeks and ideally for up to 3 months after stent implantation, with the perioperative continuation of aspirin (whenever possible)
    • the risk of stent thrombosis after this period declines and appears to reach a plateau 6 months after DES implantation
  • in stroke patients, the perioperative continuation of aspirin is advised (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
EMG
transbronchial biopsy
colonoscopic polypectomy
endoscopic gastric biopsy
ultrasound-guided biopsies
sphincterotomy
The risk of bleeding is possibly increased
The risk of bleeding is probably increased total endoprosthesis (TEP)

Aspirin monotherapy

  • should be continued, as it has been found to reduce ischemic risk without significantly increasing risk of severe bleeding
  • consider withdrawal for 3 days for procedures with a very high risk of bleeding (e.g., neurosurgical procedures)
  • unless contraindicated, a low dose (100mg/d) should be administered and maintained; higher doses (e.g., 300mg) do not justify deferral

P2Y12 inhibitor monotherapy

  • withdraw the drug 3-7 days before the procedure + switch to aspirin where 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 of 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 (and except for procedures with a low bleeding risk), discontinue the P2Y12 inhibitor as shown above)
  • the strategy in patients with a high thrombotic risk will depend on the bleeding risk associated with the procedure
    • if the bleeding risk is low, continue with DAPT
    • in moderate-to-severe bleeding risk evaluate individual patient within a multidisciplinary team (use of bridging?)

Timing of antiplatelet therapy discontinuation

ASA and P2Y12 inhibitor
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GP IIb/IIIa antagonists
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Others
  • discontinue cilostazol 42h before the procedure
  • dipyridamole has a half-life of 10-12h, no specific precautions are needed, it can be restarted after 6h

Urgent reversal of the antiplatelet drugs effect

  • urgent reversal of antiplatelet drugs effect is not a routine procedure (usually considered in case of acute bleeding) and rather should be avoided (risk of thrombosis)
    • literature does not consistently demonstrate that the use of antiplatelet agents before an, e.g., ICH leads to poor clinical outcomes, nor does it consistently demonstrate that reversal 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 benefit; there is no standard dose (more units for patients on DAPT)
    • no effect has been demonstrated in patients with spontaneous ICH ( PATCH trial)
  • desmopressin (ddAVP) OCTOSTIM – 0,3 ug/kg +100 mL of NS, infuse over 15-30 min
    • the effect was proven in general surgery (less bleeding and lower transfusion requirements)
    • no clear evidence in reducing the intracerebral hematoma expansion  [Schmidt, 2019]
  • recombinant factor VIIa (rFVIIa) – reverses the inhibitory effect 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 decrease bleeding complications arising from either antiplatelet monotherapy or DAPT   (Fischer, 2020)
    • multiple studies demonstrated the impact on platelet function resulting from administering TXA through lower volumes of blood loss, lower transfusion requirements, and lower incidence of surgical revisions
  • bentracimab – a recombinant IgG1 monoclonal antibody seems safe and effective in promptly reversing the antiplatelet effect of ticagrelor among patients undergoing urgent surgery/procedure or with major bleeding (REVERSE-IT trial)

Is bridging required?

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Restart of the antiplatelet therapy

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