🧑⚕️ Managing DAPT around 🏥 surgery post-stent placement is all about balancing 🩸 bleeding vs. 🧱 thrombosis risk. Let’s break down the essentials:
➡️ ACC guidelines: Recommend ⏱️ 6-12 mos of DAPT after most stents, but shorter durations are possible if 🩸 risk is high. 🕒 Chest guidelines note thrombosis risk is highest within 3 mos post-stent, though data are limited.
📝 Key points for peri-op DAPT decisions:
- Stents > 3 mos ago:
- 🛑 Hold P2Y12 inhibitors pre-op. Guidelines suggest:
- Brilique (ticagrelor) 🕒 3-5 days
- Plavix (clopidogrel) 🕔 5 days
- Effient (prasugrel) ⏳ 7 days
- ❌ Avoid IV antiplatelet bridging (e.g., Integrilin, Aggrastat, Kengreal) due to limited data and 🩸 risk.
- Exceptions may apply for recent MI, multiple stents, or critical artery stents where specialists may suggest bridging. ⚖️
- Stents ≤ 3 mos ago:
- If 🩸 risk is low, DAPT might continue pre-op. If high, hold the P2Y12 inhibitor.
- Consider IV antiplatelet bridging with high thrombotic risk and consult specialists.
- 💡 Bridging tips:
- No one IV antiplatelet is superior, but Kengreal (cangrelor) has a short half-life and no renal dosing. 💰 Costs can be high.
- Start IV antiplatelets within 72 hrs after stopping oral P2Y12 inhibitors, continue until ~1-6 hrs pre-op, then restart DAPT within 24 hrs post-op.
- 📋 Discharge: Document the intended DAPT duration.
References
- Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e243.
- Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med. 2022;17(1):25-35.
- Van Tuyl JS, Newsome AS, Hollis IB. Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety. Ann Pharmacother. 2019;53(7):726-737.
