Strong Recommendations Lacking in Perioperative Antiplatelet Management

Few high-quality studies have directly assessed whether to continue or interrupt antiplatelet therapy, the timing of interruption, and the role of bridging therapy in the perioperative management of patients receiving antiplatelet therapy, according to a study in Mayo Clinic Proceedings: Innovations, Quality & Outcomes.

The systematic review and meta-analysis sought to summarize and assess the evidence for prespecified clinical questions associated with the perioperative management of patients who are receiving antiplatelet therapy with acetylsalicylic acid (ASA) alone, P2Y₁₂ inhibitors, or combined antiplatelet therapy to support the development of the 2022 American College of Chest Physicians (ACCP)/CHEST guidelines.

Investigators conducted a literature search in multiple databases from inception to July 16, 2020, for studies that included adult patients (aged ≥18 years) with or without coronary stents who were receiving antiplatelet therapy and required an elective procedure, a noncardiac procedure or coronary artery bypass graft (CABG), or minor procedures and who reported an outcome of interest (major and minor bleeding, arterial or venous thromboembolic events).

A total of 38 studies were included that addressed 6 patients–interventions–comparators–outcomes (PICO) questions.

In 1 randomized controlled trial (RCT) and 1 cohort study with a total of 699 patients, stopping ASA 7 days or less before the procedure, compared with stopping ASA 7 days or more, was not associated with a statistically significant difference in the risk for major bleeding, major thromboembolism, and MI, with very low certainty of evidence (COE).

Analysis of 3 RCTs and 2 cohort studies of 485 patients compared stopping ASA within 7 days before surgery to continuing ASA throughout the elective surgery. No statistically significant difference was found in the risk for major bleeding, major thromboembolism, and MI, with very low COE.

In analysis of 5 RCTs with 28,062 patients, compared with participants who received placebo perioperatively, ASA continuation was associated with an increased risk for major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and a reduced risk for major thromboembolism (RR, 0.75; 95% CI, 0.59-0.95; high COE).

A total of 1 RCT and 2 cohort studies included 638 patients with coronary stents at high or low-moderate risk for CV events who continued antiplatelet therapy perioperatively or stopped antiplatelet agents 7 to 10 days before the procedure. Continuing antiplatelet therapy perioperatively vs stopping antiplatelet therapy was not associated with a statistically significant difference in the risk for major bleeding and major thromboembolism, with low to very low COE.

Compared with no bridging during interruption in 1 cohort study with 215 patients with coronary stents who were receiving antiplatelet agents, bridging with low-molecular-weight heparin was associated with a statistically significant increased risk for major bleeding (RR, 1.86; 95% CI, 1.24-2.79) and thromboembolism (RR, 26.2; 95% CI, 1.56-441.6; very low COE).

Continuation of antiplatelet therapy compared with stopping of antiplatelet therapy was associated with a statistically significant increased risk for major bleeding in patients receiving CABG in 3 RCTs (RR, 1.68; 95% CI, 1.29-2.18), with moderate COE.

Continuing antiplatelet therapy in minor dental procedures was not associated with a statistically significant difference in major bleeding risk, compared with stopping antiplatelet therapy 7 to 10 days before the procedure, with very low COE. In addition, continuing antiplatelet therapy was not associated with a statistically significant difference in the risk for major bleeding, stroke, MI, and other major thromboembolism events in patients receiving minor ophthalmologic procedures, with low to very low COE

The researchers noted that firm conclusions were precluded by limited evidence, as a small number of high-quality studies directly evaluated the perioperative management of antiplatelet therapy. Also, certainty in the estimates of effect was low for many PICO questions and associated outcomes.

“This review highlights the urgent need for further research to address these gaps in knowledge, especially as the prevalence of patients taking 1 or more antiplatelet agents is increasing with an aging population and such patients are most likely to require a surgery/procedure,” the investigators wrote.

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.