BOF: Clotting (Antiplatelet)

A 64 year old man on aspirin and clopidogrel for a bare metal stent inserted four weeks ago for severe LAD coronary artery disease is due to have biopsy of cervical lymph nodes for suspected malignancy.

Delay of the biopsy beyond two weeks is felt to be inappropriate. According to the latest guidelines of the American College of Chest Physicians, select the most appropriate antiplatelet agent management strategy for the perioperative period from the options below (a-e).

a) Discontinue aspirin and clopidogrel 5-10 days prior to the procedure.

b) Discontinue aspirin and clopidogrel 5-10 days prior to the procedure and add in GPIIbIIIa antagonist.

c) Discontinue ONLY clopidogrel 5-10 days prior to the procedure, continue aspirin throughout the procedure.

d) Discontinue ONLY clopidogrel 5-10 days prior to the procedure, continue aspirin throughout the procedure and add in GPIIbIIIa antagonist.

e) Remain on aspirin and clopidogrel throughout the procedure.

Answer:

e) Remain on aspirin and clopidogrel throughout the procedure.

Explanation:

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (2012) recommend discontinuation of aspirin and clopidogrel ten days prior to any elective non-cardiac invasive procedure except those at high risk of cardiac event (who should continue aspirin alone to minimise the significant additional bleeding risk of dual agent therapy) or those with coronary stents in situ (who may require continuation of both agents).

Surgery should ideally be delayed by six weeks following bare metal stent placement, and 12 months following drug-eluting stent placement where epithelialisation takes much longer, since the risk of a restenosis without dual antiplatelet therapy, with significant morbidity and mortality, is felt to be more significant than the bleeding risk.

If surgery is unavoidable it should be performed with continuation of both agents and accepting the bleeding risk. For cardiac surgery, aspirin should be continued and clopidogrel stopped for the procedure. No bridging therapy options with heparin or GPIIbIIIa antagonists are recommended.

Reference:

Eikelboom, J. W., Hirsh, J., Spencer, F. A., Baglin, T. P., & Weitz, J. I. (2012). Antiplatelet Drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e89S–e119S.SaveSaveSave