Antiplatelet Therapy in Patients with Coronary Stent Undergoing Orthopedic Surgery: Is It Still No Man’s Land?

Low bleeding risk

Hand surgery

Shoulder and knee arthroscopy

Minor spine surgery

Intermediate bleeding risk

Prosthetic shoulder surgery

Major spine surgery

Knee surgery (anterior cruciate ligament, osteotomies)

Foot surgery

High bleeding risk

Major prosthetic surgery (hip or knee)

Major traumatology (pelvis, long bones)

Fractures of the proximal femur in the elderly

Reproduced with permission from the Publisher, Il Pensiero Scientifico Editore

The present document is the first consensus to provide practical recommendations on the management of antiplatelet therapy in patients with coronary stents, undergoing diverse orthopedic interventions. Briefly, stent thrombosis risk is stratified in low, intermediate, and high (Table 3.2), and the most appropriate antiplatelet therapy and management is defined for each intervention, on the basis of the ischemic and hemorrhagic risk (Table 3.3).

Table 3.2

Definition of thrombotic risk in patients with coronary stents

Low risk	Intermediate risk	High risk
>6 months after PCI with BMS	>1 month <6 months after PCI with BMS	<1 month after PCI with BMS
>12 months after PCI with DES	>6 months <12 months after PCI with DES	<6 months after PCI with DES
>12 months after PCI with DES	>12 months after complex PCI with DES (long stents, multiple stents, overlapping, small vessels, bifurcations, left main, last remaining vessel).	<12 months after complex PCI with DES (long stents, multiple stents, overlapping, small vessels, bifurcations, left main, last remaining vessel)

Reproduced with permission from the Publisher, Il Pensiero Scientifico Editore

PCI in ACS, previous stent thrombosis, LVEF <35 %, chronic renal failure, and diabetes mellitus increase the thrombotic risk. The use of second-generation DES might reduce the thrombotic risk. Patients submitted to CABG or with ACS medically treated are considered at high risk in the first month, at intermediate risk between the 1st and 6th month, and at low risk after 6 months. Patients treated with POBA are considered at high risk within the first 2 weeks, at intermediate risk between 2 and 4 weeks, and at low risk after 4 weeks

ACS acute coronary syndrome, BMS bare metal stent, CABG coronary artery by-pass graft, DES drug-eluting stent, LVEF left ventricular ejection fraction, PCI percutaneous coronary intervention, POBA plain old balloon angioplasty

Table 3.3

Perioperative antiplatelet therapy in patients with coronary stents undergoing orthopedic surgery

	Orthopedic surgery		Thrombotic risk
		Low risk	Intermediate risk	High risk
Hemorrhagic risk	Low risk	ASA: continue	Elective surgery: postpone	Elective surgery: postpone
	Hand surgery	P2Y₁₂ receptor inhibitors	Non-deferrable surgery	Non-deferrable surgery
	Shoulder and knee arthroscopy	Discontinue 5 days before^a	ASA: continue	ASA: continue
	Minor spine surgery l	Resume within 24–72 h, with a loading dose	P2Y₁₂ receptor inhibitors	P2Y₁₂ receptor inhibitors:
			Discontinue 5 days before^a	Continue
			Resume within 24–72 h, with a loading dose^b	Continue
	Intermediate risk	ASA: continue	Elective surgery: postpone	Elective surgery: postpone
	Prosthetic shoulder surgery	P2Y₁₂ receptor inhibitors	Non-deferrable surgery	Non-deferrable surgery
	Major spine surgery	Discontinue 5 days before^a	ASA: continue	ASA: continue
	Knee surgery (anterior cruciate ligament, osteotomies)	Resume within 24–72 h, with a loading dose	P2Y₁₂ receptor inhibitors:	P2Y₁₂ receptor inhibitors
	Foot surgery		Discontinue 5 days before^a	Discontinue 5 days before^a
			Resume within 24–72 h, with a loading dose^b	Resume within 24–72 h, with a loading dose
			Resume within 24–72 h, with a loading dose^b	Bridge therapy with GPIIb/IIIa inhibitors^b
	High risk	ASA: continue	Elective surgery: postpone	Elective surgery: postpone
	Major prosthetic surgery (hip or knee)	P2Y₁₂ receptor inhibitors	Non-deferrable surgery	Non-deferrable surgery
	Major traumatology (pelvis, long bones)	Discontinue 5 days before^a	ASA: continue	ASA: continue
	Fractures of the proximal femur in the elderly	Resume within 24–72 h, with a loading dose	P2Y₁₂ receptor inhibitors	P2Y₁₂ receptor inhibitors
			Discontinue 5 days before^a	Discontinue 5 days before^a,c
			Resume within 24–72 h, with a loading dose^b	Resume within 24–72 h, with a loading dose
			Resume within 24–72 h, with a loading dose^b	Bridge therapy with GPIIb/IIIa inhibitors^b

Reproduced with permission from the Publisher, Il Pensiero Scientifico Editore

ASA aspirin

^a7 days prior for prasugrel

^bCollegial discussion of risk, even with family/patient

^cIn case of femur fracture, it may be appropriate to proceed immediately to surgery, despite dual antiplatelet therapy, without waiting for the 5-day suspension

This stratification allows to define in detail the optimal antiplatelet regimen which should be maintained in the perioperative period, thus avoiding an arbitrary management. Of note, it is important to define the ideal timing of the orthopedic intervention as elective procedures should be delayed until a low cardiac ischemic risk is reached.

3.4 Antiplatelet Therapy: To Stop or to Maintain?

The antiplatelet therapy (especially aspirin) has to be maintained whenever possible, especially when the ischemic risk is intermediate or high due to the extremely enhanced risk of ST. In case of withdrawal of the antiplatelet therapy in the perioperative phase, cardiologists recommend restarting the drugs as soon as possible after the intervention (ideally 24–48 h later), with a loading dose. In selected cases, such as patients with high ischemic and hemorrhagic risk, in whom the discontinuation of the oral antiplatelet therapy is necessary, the “bridge therapy” is advocated (Rossini et al. 2012, 2014). This consists of the intravenous, prolonged infusion of glycoprotein (GP) IIb/IIIa inhibitor (tirofiban or eptifibatide), a potent antiplatelet drug which acts as the oral antiplatelet therapies, thus preventing ST. It is a short-acting drug given intravenously. Patients undergoing “bridge therapy” withdraw DAPT or only the second antiplatelet agent 5 days before surgery (7 days in case of therapy with prasugrel). The infusion of GP IIb/IIIa inhibitor starts 3 days before the intervention and is stopped 4 h before surgery (8 h in the case of creatinine clearance <30 ml min⁻¹). Oral antiplatelet therapy should be resumed within 24–48 h after the intervention. Of note, GP IIb/IIIa inhibitors are potent antiplatelet effects and are associated with an increased risk of bleeding during their infusion. Afterward, they might be contraindicated in patients with an active, clinically relevant bleeding. This therapy should be prescribed by cardiologists and administered in a cardiologic ward. “Bridge therapy” is currently off-label for perioperative period management of antiplatelet therapy (Douketis et al. 2008).

3.5 Conclusions

The risk of ST is significantly increased after premature discontinuation of DAPT. The management of the antiplatelet therapy in patients with coronary stents undergoing orthopedic procedures is still challenging and surely requires both an orthopedic and a cardiologic thorough assessment. It appears evident that the right direction is toward the application in clinical practice of the consensus documents available. The document endorsed by cardiologists, orthopedics, and anesthesiologists recommends to perioperatively discontinue the antiplatelet drugs if the known or assumed perioperative bleeding risks and their sequels are expected to be similar or more severe than the observed cardiovascular thrombotic risks after antiplatelet therapy withdrawal. A prospective case registry is now ongoing in Italy (the Surgery After Stenting (SAS) registry; ClinicalTrials.gov Identifier: NCT01997242), and its results might be a helpful tool to improve the DAPT patients’ management. To potentially improve the quality of evidence derived from the consensus document, randomized studies could be considered merely from a methodological point of view. However, a comparison between surgery performed with versus without DAPT is not ethical for benign disease, due to the extremely increased risk of ST. Probably, the only possible comparison could be between traditional versus minimally invasive surgery during DAPT in high-risk cardiovascular patients.

References

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography (2009) J Am Coll Cardiol 53(6):530–553

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