Antiplatelet therapy and anticoagulation

Abstract

Preoperative withdrawal of antiplatelet (AP) therapy in secondary prevention multiplies the risk of myocardial infarction, stent thrombosis, stroke, or death, by five to ten times. Aspirin is a lifelong therapy and should never be interrupted. Dual AP therapy with aspirin plus clopidogrel, prasugrel, or ticagrelor is essential for at least 6 weeks after coronary revascularization using bare-metal stents, 12 months after treatment for acute coronary syndrome, and 6–12 months after implanting drug-eluting stents. These time spans might even be prolonged in high-risk cases. Elective surgery should be postponed until after these periods. Vital or urgent operations undertaken earlier must be performed under continued dual AP therapy. Preoperatively, patients might be on prophylactic or therapeutic doses of anticoagulants. The indication for the anticoagulation therapy must be reevaluated in order to balance the thrombotic risk of interrupting against the risk of bleeding when continuing the treatment. A detailed protocol, comprising the pre-, peri-, and postoperative phases needs then to be established. It should include indications regarding anticoagulation reversal, bridging (when necessary), and postoperative reintroduction of the anticoagulant therapy.