HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.
Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because “the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal.”
Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although “many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality.”
Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said.
“Keep the nontherapeutic window short, from about 3 days before the surgery to 1-2 days afterward, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel,” Dr. Dardik said at the meeting.
Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose, said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.
The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be stopped – or even a year, when aspirin can also cease. When that's not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.
He said he has no relevant disclosures.