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
Roberta Rossini, Giuseppe Musumeci, Luigi Oltrona Visconti, Ezio Bramucci, Battistina Castiglioni, Stefano De Servi, Corrado Lettieri, Maddalena Lettino, Emanuela Piccaluga, Stefano Savonitto, Daniela Trabattoni, Davide Capodanno, Francesca Buffoli, Alessandro Parolari, Gianlorenzo Dionigi, Luigi Boni, Federico Biglioli, Luigi Valdatta, Andrea Droghetti, Antonio Bozzani, Carlo Setacci, Paolo Ravelli, Claudio Crescini, Giovanni Staurenghi, Pietro Scarone, Luca Francetti, Fabio D'Angelo, Franco Gadda, Andrea Comel, Luca Salvi, Luca Lorini, Massimo Antonelli, Francesco Bovenzi, Alberto Cremonesi, Dominick J Angiolillo, Giulio Guagliumi, Italian Society of Invasive Cardiology (SICI-GISE), Italian Association of Hospital Cardiologists (ANMCO), Italian Society for Cardiac Surgery (SICCH), Italian Society of Vascular and Endovascular Surgery (SICVE), Italian Association of Hospital Surgeons (ACOI), Italian Society of Surgery (SIC), Italian Society of Anaesthesia and Intensive Care Medicine (SIAARTI), Lombard Society of Surgery (SLC), Italian Society of Maxillofacial Surgery (SICMF), Italian Society of Reconstructive Plastic Surgery and Aesthetics (SICPRE), Italian Society of Thoracic Surgeons (SICT), Italian Society of Urology (SIU), Italian Society of Orthopaedics and Traumatology (SIOT), Italian Society of Periodontology (SIdP), Italian Federation of Scientific Societies of Digestive System Diseases Lombardia (FISMAD), Association of Obstetricians Gynaecologists Italian Hospital Lombardia (AOGOI), Society of Ophthalmology Lombardia (SOL), Roberta Rossini, Giuseppe Musumeci, Luigi Oltrona Visconti, Ezio Bramucci, Battistina Castiglioni, Stefano De Servi, Corrado Lettieri, Maddalena Lettino, Emanuela Piccaluga, Stefano Savonitto, Daniela Trabattoni, Davide Capodanno, Francesca Buffoli, Alessandro Parolari, Gianlorenzo Dionigi, Luigi Boni, Federico Biglioli, Luigi Valdatta, Andrea Droghetti, Antonio Bozzani, Carlo Setacci, Paolo Ravelli, Claudio Crescini, Giovanni Staurenghi, Pietro Scarone, Luca Francetti, Fabio D'Angelo, Franco Gadda, Andrea Comel, Luca Salvi, Luca Lorini, Massimo Antonelli, Francesco Bovenzi, Alberto Cremonesi, Dominick J Angiolillo, Giulio Guagliumi, Italian Society of Invasive Cardiology (SICI-GISE), Italian Association of Hospital Cardiologists (ANMCO), Italian Society for Cardiac Surgery (SICCH), Italian Society of Vascular and Endovascular Surgery (SICVE), Italian Association of Hospital Surgeons (ACOI), Italian Society of Surgery (SIC), Italian Society of Anaesthesia and Intensive Care Medicine (SIAARTI), Lombard Society of Surgery (SLC), Italian Society of Maxillofacial Surgery (SICMF), Italian Society of Reconstructive Plastic Surgery and Aesthetics (SICPRE), Italian Society of Thoracic Surgeons (SICT), Italian Society of Urology (SIU), Italian Society of Orthopaedics and Traumatology (SIOT), Italian Society of Periodontology (SIdP), Italian Federation of Scientific Societies of Digestive System Diseases Lombardia (FISMAD), Association of Obstetricians Gynaecologists Italian Hospital Lombardia (AOGOI), Society of Ophthalmology Lombardia (SOL)
Abstract
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.
Source: PubMed