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perioperative antiplatelet therapy

Management: aspirin: 1) aspirin 100 mg QD may be continued before & after surgery for patients with high risk of thrombosis, i.e. recent coronary stent or myocardial infarction [7] 2) continue for procedures of low bleeding risk, i.e.minor dental procedures, dermatologic procedures, cataract surgery, colonoscopy - aspirin not associated risk of bleeding in dermatologic procedures [2] 3) if aspirin is held, stop 7-10 days prior to surgery 4) perioperative low-dose aspirin associated with lower risk for death or nonfatal myocardial infarction vs placebo (6% vs 11%) in patients with prior PCI* P2Y12 inhibitors: 1) clopidogrel a) stop clopidogrel 5 days prior to surgery [3,6] b) clopidogrel should be continued perioperatively for - drug-eluting stent within 3 months - bare metal stent within 30 days - myocardial infarction or coronary revascularization within 4-6 weeks c) if possible, surgery should be delayed until clopidogrel may be stopped 2) stop ticagrelor 5-7 days prior to surgery [6] 3) stop prasugrel 7 days prior to surgery [6] 4) for minor procedures (i.e.minor dental procedures, dermatologic procedures, cataract surgery, colonoscopy), patients receiving single antiplatelet agents should continue them perioperatively [6] - patients receiving dual antiplatelet agent theraoy should continue aspirin & interrupt their P2Y12 inhibitor [6] * witholding low-dose aspirin & clopidogrel may be reasonable if bleeding risk is extreme or consequences catastrophic, as with neurosurgery NSAIDs: 1) generally NSAID stopped 7 days prior to surgery [3] 2) stop at least 5 half-lives before surgery a) 24 hours for ibuprofen b) days for naproxen Restart antiplatelet agent about 24 hours after surgery

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perioperative anticoagulation

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perioperative management anticoagulation

References

  1. Prescriber's Letter 15(8): 2008 COMMENTARY: Managing Warfarin & Antiplatelet Drugs Perioperatively GUIDELINES: ACCP Antithrombotic and Thrombolytic Guidelines, 8th edition. Executive Summary Detail-Document#: 240804 (subscription needed) http://www.prescribersletter.com
  2. Bordeaux JS et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011 Sep; 65:576. PMID: 21782278
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  4. Graham MM, Sessler DT, Parlow JL et al Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery. Ann Intern Med. 2017. Nov 14 PMID: 29132159 http://annals.org/aim/article-abstract/2663288/aspirin-patients-previous-percutaneous-coronary-intervention-undergoing-noncardiac-surgery - Piccolo R, Windecker S. Low-Dose Aspirin to Reduce the Risk for Myocardial Infarction Among Patients With Coronary Stents Undergoing Noncardiac Surgery. Ann Intern Med. 2017. Nov 14 PMID: 29132156 http://annals.org/aim/article-abstract/2663289/low-dose-aspirin-reduce-risk-myocardial-infarction-among-patients-coronary
  5. Banerjee S, Angiolillo DJ, Boden WE et al Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2017 Apr 11;69(14):1861-1870 PMID: 28385315. Free article
  6. Douketis JD et al. Executive summary. Perioperative management of antithrombotic therapy: An American College of Chest Physicians clinical practice guideline. Chest 2022 Nov; 162:1127. PMID: 35964703 https://journal.chestnet.org/article/S0012-3692(22)01364-2/fulltext - Douketis JD et al. Perioperative management of antithrombotic therapy: An American College of Chest Physicians clinical practice guideline. Chest 2022 Nov; 162:e207. PMID: 35964704 https://journal.chestnet.org/article/S0012-3692(22)01359-9/fulltext
  7. Kang DY, Lee SH, Lee SW et al. Aspirin monotherapy vs no antiplatelet therapy in stable patients with coronary stents undergoing low-to-intermediate risk noncardiac surgery. J Am Coll Cardiol 2024 Aug 31; PMID: 39217573 Free article https://www.sciencedirect.com/science/article/pii/S0735109724081968