Continue or discontinue dual antiplatelet therapy in major surgical or endoscopic procedures.

See "Biliary-Pancreatic Endoscopic and Surgical Procedures in Patients under Dual Antiplatelet Therapy: A Single-Center Study" by Ahmed Abdel Samie, Michael Stumpf, Rui Sun, et al., on page 395-398

Dual antiplatelet therapy (i.e., aspirin and clopidogrel) is mandatory after acute coronary syndrome or stent implantation because coronary lesions and stents behave like unstable plaques as long as they are not fully covered by a cellular layer. Current guidelines recommend that elective, noncardiac surgery should be postponed for at least 6 weeks after the placement of bare-metal stents and for at least 12 months after the placement of drug-eluting stents.1 The question remains whether to continue or discontinue antiplatelet therapy and face the risk of either perioperative bleeding or adverse cardiac events, especially in urgent situations. With this question in mind, Abdel Samie et al.2 reported a small case series of 11 consecutive patients who underwent biliary-pancreatic surgery or endoscopic intervention while receiving dual antiplatelet therapy. In this retrospective study, neither immediate nor clinically significant delayed bleeding was reported in patients with endoscopic sphincterotomy (n=9) and major surgery (n=2). Although this study has only a limited number of patients, its results suggest that even major surgical and endoscopic procedures can be performed safely in patients who continue dual antiplatelet therapy.

Although there is a lack of randomized controlled trials comparing the effects of withdrawing versus continuing antiplatelet agents in the perioperative period, it appears that the average relative increase in bleeding during noncardiac surgery is 20% with aspirin or clopidogrel alone.3,4 Recently, Chernoguz et al.5 reported a significantly increased risk of postoperative bleeding in patients who received clopidogrel bisulfate before major abdominal surgery.

Stopping dual antiplatelet therapy, which allows major surgery during the first 6 weeks after angioplasty and stenting, leads to a cardiovascular mortality of up to 71%, whereas it is no more than 5% when the treatment is maintained perioperatively.6 Interruption of antiplatelet therapy is more hazardous in the perioperative period, which is characterized by increased platelet aggregability. In patients with stents who are on continuous dual antiplatelet therapy, the combined rate of perioperative myocardial infarction (MI) and mortality is the same as in stable coronary artery disease (1% to 6%), whereas withdrawing antiplatelet therapy is associated with a 5- to 10-fold increase in the risk of MI (20% to 40%) and mortality (20% to 85%), depending on the delay between revascularization and surgery.6,7 A meta-analysis including 474 studies comparing surgical bleeding of patients operated on with or without aspirin reported no change in the mortality and complication rates.4 Therefore, the risk of coronary thrombosis appears higher than the risk of surgical hemorrhage, and preoperative cessation of aspirin and/or clopidogrel should be avoided when possible.

In the absence of clinical trials, the current recommendations from specialty society guidelines are based on observational data and attempt to provide the safest possible management given the high risk of premature discontinuation of antiplatelet agents.1,8 Dual antiplatelet therapy is recommended during the 2 weeks after simple dilatation, 6 weeks after baremetal stents, and at least 12 months after drug-eluting stents.1,8 All elective operations should be postponed beyond these delays. Only vital surgery should be performed when the patients are still taking aspirin and clopidogrel; unless the hemorrhage risk is excessive, dual antiplatelet therapy should not be interrupted before surgery. Even if clopidogrel treatment must be interrupted in high-risk surgical situations, aspirin must be continued without interruption.1,9

The decision must be on a case by case basis among the cardiologist, anesthesiologist, surgeon, and endoscopist, after weighing all of the risk factors, including coronary status (e.g., high-risk or low-risk stent, amount of myocardium threatened), patient conditions (e.g., age, coagulopathy, comorbidities) and the type of surgery.