Postoperative Anticoagulation Re-administration A Dilemma to be solved

1. Postoperative Anticoagulation Re-administrationA Dilemma to be solved Dr. Rania Hassan Dr. Dina ElEbiary

2. Case 73 year old male patient with history of episodes of chronic stable angina, he had right coronary drug eluting stent inserted 2 weeks ago. He is on aspirin and clopidogrel. He had fracture neck femur and needs Bipolar hemi-arthroplasty • Does he need to stop antiplatelet agents prior to surgery? • How soon prior to the procedure will he stop them? • How soon can it be restarted after surgery?

3. Management of anticoagulation in patients undergoing surgical procedures is challenging. A balance between reducing the risk of thromboembolism & preventing excessive bleeding must be reached for each patient.

4. Approach for decision making Estimate thromboembolic risk. Estimate bleeding risk Determine the timing of anticoagulant interruption Determine whether to use bridging anticoagulation

5. Estimate thromboembolic risk Major factors that increase thromboembolic risk are: Atrial fibrillation, Prosthetic heart valves Recent venous or arterial thromboembolism

6. Perioperative thrombotic risk

7. Estimate bleeding risk A higher bleeding risk confers a greater need for perioperative hemostasis, and hence a longer period of anticoagulant interruption. Bleeding risk is dominated by the type and urgency of surgery; some patient comorbidities also contribute. Procedures with a low bleeding risk (dental extractions, minor skin surgery) often can be performed without interruption of anticoagulation.

8. Procedural bleeding risk

10. Oral anticoagulants in the peri-procedural period

11. Determine whether to use bridging anticoagulation For most patients, do not use bridging anticoagulation because it increases bleeding risk without reducing the rate of thromboembolism. However, some patients on warfarin with an especially high thromboembolic risk (eg, mechanical heart valve, recent stroke) may benefit from bridging with heparin or low molecular weight (LMW) heparin.

12. Perioperative management of antiplatelet therapy Dual antiplatelet therapy (DAPT) following percutaneous coronary stenting and acute coronary syndrome (ACS) is common. Management of patients on DAPT who are referred for surgical procedures depends on the level of emergency and the thrombotic and bleeding risk of the individual patient

13. Perioperative management of antiplatelet therapy • Current recommendations for DAPT range from 4 weeks in patients undergoing elective stenting with bare metal stents (BMS) to up to 12 months in patients with drug-eluting stents (DES) or for patients undergoing coronary stenting for acute coronary syndrome • In some cases of complex stenting (eg bifurcation stenting), continuation of DAPT for longer than 1 year may be necessary. • Premature cessation of DAPT is thought to be one of the most important causes of stent thrombosis, which can have fatal consequences

14. Perioperative management of antiplatelet therapy The current guidelines recommend that elective non-cardiac surgeries be postponed for at least 6 weeks (ideally 3 months) following angioplasty with BMS and for 12 months after DES, as the risk of thrombosis is highest within 6 weeks after the placement of a bare-metal stent and within 3–6 months after the placement of a DES.

15. Perioperative management of antiplatelet therapy • Perioperative continuation of aspirin slightly increases bleeding risk but does not increase the risk for bleeding that requires medical or other interventions and therefore can usually be continued • On the other hand, perioperative interruption of aspirin confers a 3-fold increased risk for adverse cardiovascular events

16. Perioperative management of antiplatelet therapy • If a patient is to undergo surgery with a high risk of bleeding and an antiplatelet effect is not desired, clopidogrel should be discontinued 5–7 days prior to the procedure.

17. Case 73 years male with history of episodes of chronic stable angina, he had right coronary drug eluting stent inserted 2 weeks ago. He is on aspirin and clopidogrel. He had fracture neck femur and needs Bipolar hemi-arthroplasty • Does he need to stop antiplatelet agents prior to surgery? • How soon prior to the procedure will you stop them? • How soon can it be restarted after surgery?

18. So…….. Need to stop DAPT in this case If risk of bleeding is high, procedure is best postponed. If moderate risk of bleeding, or postponing is not an option, clopidogrel should be stopped 5-7 days before surgery Resuming DAPT after 24 hours of hemostasis Multi-disciplinary team is mandatory to make the right decision regarding such patients

19. Thank you 