To Bleed or Not to Bleed: Is That the Question?

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Perioperative management of antiplatelet agents for noncardiac operations remains a challenging problem in contemporary surgical practice, compounded by the myriad of medications and the indications for them. Dr Colombo et al1 have performed a well-designed systematic review and meta-analysis examining the risk of postoperative bleeding associated with patients on single or dual antiplatelet therapy (DAPT). They conclude that antiplatelet therapy is associated with minimal bleeding risk and may therefore be safe to continue in the perioperative period, based on their primary finding for this heterogeneous collection of studies with endpoints including an increased risk of transfusion, no increased risk of bleeding-related interventions, and no difference in major adverse cardiovascular events (MACE).
These conclusions should be tempered, as the analysis is bound by the limitations of the individual studies. Significant bleeding was defined as the need for transfusion or reinterventions; other sequelae of bleeding such as the need for drains, nonoperatively managed wound hematomas, or excess hospital days were not captured. The drivers of transfusion or reintervention were not standardized and may reflect individual or institutional practices. Additionally, studies were inconsistent in their dosing of antiplatelet agents with some studies straying from current dosing recommendations,2,3. Other factors that may have affected the conclusions include the absence of large randomized controlled trials for agents other than aspirin and the heterogeneity of clopidogrel data.
Perhaps the most common reason for DAPT facing the operative surgery is a recent coronary intervention. However, studies focusing solely on DAPT after percutaneous coronary interventions were specifically excluded, thereby precluding an analysis and recommendation for this especially common and challenging patient population. A large portion of included studies centered on vascular procedures, thus limiting the generalizability to other noncardiac procedures. Many vascular procedures are performed on patients receiving aspirin, clopidogrel, or DAPT specifically in the setting of high thrombotic risk, a scenario that may not be applicable to other elective surgical populations. Clopidogrel continuation, for example, has been shown to be safe with regard to bleeding for carotid and peripheral arterial surgery.4
When deciding whether or not to continue antiplatelet therapy at the time of noncardiac nonvascular surgery, the surgeon must weigh the risks of bleeding with the benefits of protection from MACE. Importantly, these dichotomous events of bleeding and thrombosis are not mutually exclusive. Bleeding can lead to coronary ischemia, and likewise treatment for thrombosis can lead to bleeding. Such an analysis will likely yield different outcomes when considering the type of surgery, the stability of cardiovascular disease, and the presence of recent coronary interventions or other cardiovascular interventions. In the absence of a cardioprotective effect, it is reasonable to discontinue perioperative antiplatelet therapy, even with a relatively safe risk profile for continuation. Most patients with stable cardiovascular disease are on aspirin monotherapy and for this cohort discontinuation of aspirin 5 to 7 days prior to surgery results in fewer bleeding events with no increase in cardiovascular events.5 Platelet P2Y12 receptor blockers such as clopidogrel are typically prescribed after coronary stent placement. For these patients premature discontinuation of clopidogrel increases the risk of stent thrombosis or MACE, and current recommendations include postponing elective surgery whenever possible until it is safe to discontinue clopidogrel.3 Several cohort and registry studies have found that temporary discontinuation of APT in the perioperative period was not associated with increased risk for MACE, particularly if surgery was more than 6 months following coronary stenting.6–8 Procedures that cannot be postponed and for which the risk of bleeding requires cessation or modification of DAPT should be performed in a center with ready access to emergent interventional cardiology services in the event of an acute coronary thrombosis.
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