noncardiac surgery after pci
DESCRIPTION
In these slides I discuss what to do with the patient post stent who needs noncardiac surgery and I discuss what to do with anti-platelet therapy in the perioperative period. Watch my YouTube description of these slides at http://youtu.be/z8Okm3_GFbU.TRANSCRIPT
Noncardiac Surgery After PCIWhat to do?
Terry Shaneyfelt, MD, MPHAssoc. Professor, UAB Department of Medicine
You must balance…
Stent Thrombosis Bleeding
Adverse Cardiac Events Following Noncardiac Surgery in Patients With Stents
Hawn, et al. JAMA 2013;310:1462
• Class I• Elective noncardiac surgery should be delayed
• 14 D after balloon angioplasty• 30 D after BMS implantation• 365 D after DES implantation
• Class IIb• Elective noncardiac surgery after DES implantation may
be considered after 180 D if risk of further delay > risk of stent thrombosis
2014 ACC/AHA Perioperative Guidelines
• Class III (Harm)• Elective noncardiac surgery in which DAPT will need to
be discontinued should not be performed within• 30 D after BMS• 365 D after DES
• If elective noncardiac surgery is needed within 1-12 months then place BMS with 4-6 wks of DAPT with continuation of ASA perioperatively
2014 ACC/AHA Perioperative Guidelines
Approach to patients who need surgery after PCI
Wait 4-6 weeks Wait 12 months
Continue dual antiplatelet therapy if surgery needed before completion of
recommended therapy
No matter what continue at least aspirin*
* Except for neurosurgery, post eye, middle ear, and prostate
• Aspirin (and aspirin/dipyridamole)• POISE-2 trial (N Engl J Med 2014; 370:1494-1503)
suggests that aspirin is of no benefit in patients at moderate to high risk for cardiovascular events who are undergoing noncardiac surgery
• Stop 7-10 days prior to surgery• Bleeding time is a poor predictor of perioperative
hemorrhage
Managing antiplatelet agents in the perioperative period
• Platelet P2Y12 receptor blockers • Clopidogrel and ticagrelor: stop at least 5 days before
surgery• Prasugrel: stop at least 7 days before surgery
• Cilostazol • Selective phosphodiesterase-3 enzyme inhibitor with
weak, reversible antiplatelet activity• Stop 5 days before surgery
Managing antiplatelet agents in the perioperative period