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Patients on Antiplatelet Drugs Undergoing Surgery
Management of Patients on Antiplatelet Drugs Undergoing Surgery
This is a complex issue and management needs to be individualized. The surgeon responsible for the surgical procedure will make the final decision with regard to antiplatelet drug dosage perioperatively.
Some key factors to consider:
- Is the patient at high risk of bleeding complications, e.g., is there severely impaired renal function (CrCl <30 mL/min), or severe liver dysfunction?
- If the drug is stopped, what is the risk of re-thrombosis with the antiplatelet drug concerned, and the patient’s clinical condition?
- Does the antiplatelet drug itself carry a high risk of bleeding complications?
- Does the proposed surgical procedure carry a high risk of significant morbidity/mortality in the event of bleeding, e.g., cardiac or intra-cranial operations?
- Can the antiplatelet drug be safely withheld and the procedure be delayed (e.g., for 3-4 days), to allow for some recovery of platelet function?
Some management considerations:
- Aspirin may increase operative bleeding but this is usually not significant, especially at doses of 100 - 150 mg /day, so surgery rarely needs to be delayed.
- Clopidogrel. If this drug is being given as antiplatelet monotherapy, it is reasonable to continue it during surgery unless it is cardiac or intracranial surgery. If the patient is considered a high bleeding risk or cardiac or intracranial surgery is to be done, stopping clopidogrel for 3-4 days before surgery should be considered. However in patients who have had a stent placed in the past 12 months, stopping clopidogrel carries a significant risk of re-thrombosis and consultation with a Cardiologist is essential before altering the dose of this drug.
- Ticagrelor, compared to aspirin and clopidogrel, carries the highest risk of causing increased bleeding at surgery, probably because it causes a greater degree of inhibition of platelet function. Where possible it should be stopped 3-4 days before surgery. However in patients who have had a stent placed in the past 12 months, stopping ticagrelor also carries a significant risk of re-thrombosis and consultation with a Cardiologist is essential before altering the dose of this drug.
- Consider restarting an antiplatelet drug 6 to 24 hours post-op, unless the result of any bleeding (e.g., intracranial) would be critical. In the latter situation, consultation with a Cardiologist and relevant Surgeon is recommended.
Reference: Guideline on the use of antiplatelet drugs in patients having cardiac and noncardiac operations. (American Society of Thoracic Surgeons). Ferraris et al. 2012;94:1761-1781.
Topic Code: 75873