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CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 230-233  

Dual antiplatelet therapy challenges in emergent noncardiac surgeries


Department of Anesthesiology and Critical Care, Maulana Azad Medical College, University of Delhi, New Delhi, India

Date of Submission12-May-2020
Date of Decision09-Oct-2020
Date of Acceptance13-Oct-2020
Date of Web Publication3-Mar-2021

Correspondence Address:
Anisha Singh
Department of Anesthesiology and Critical Care, Maulana Azad Medical College, University of Delhi, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_252_20

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  Abstract 


In today's era, patients with coronary stents are presenting for various surgeries while still being on dual antiplatelet therapy. This leads to balancing the risk between myocardial ischemia if therapy is discontinued and bleeding risk due to surgery. Hence, it arises the need to introduce guidelines for managing such patients coming for elective as well as emergency surgeries for easy implementation. Developments related to coronary stents and antiplatelet agents are continuously evolving. A comprehensive understanding of the pharmacology of newer antiplatelet agents, efficacies of newer coronary stents, risk of stent thrombosis, and role of platelet function tests must be determined. There is an urgent need for the development of guidelines to manage such patients.

Keywords: Cholecystectomy, clopidogrel, craniotomy, thrombosis


How to cite this article:
Singh R, Singh A, Kerai S. Dual antiplatelet therapy challenges in emergent noncardiac surgeries. Med J DY Patil Vidyapeeth 2021;14:230-3

How to cite this URL:
Singh R, Singh A, Kerai S. Dual antiplatelet therapy challenges in emergent noncardiac surgeries. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 13];14:230-3. Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/230/310707




  Introduction Top


The number of patients with coronary stenting presenting for noncardiac surgery is on the rise. While there are many guidelines for perioperative management of cardiac patients scheduled for elective surgeries, little information is available in literature regarding patients presenting for emergency surgery.[1] The risk of stent thrombosis and surgical bleeding needs to be carefully considered when decision for interruption of the dual antiplatelet therapy (DAPT) is to be made if patient comes for an elective surgery within 1 year of coronary stenting. Another scenario is when patients present for emergency surgery post stenting, being already on DAPT and there is no time available for interruption of DAPT.

We here describe, anesthetic management for two patients; one with coronary drug-eluting stenting (DES) done 3 months back presenting for urgent radical cholecystectomy and another patient with DES and on DAPT presenting for emergency evacuation of subdural hematoma.


  Case Reports Top


Case 1

A 61-year-old female presented for radical cholecystectomy in view of the carcinoma gall bladder. She was known hypertensive with coronary artery disease, underwent coronary stenting with DES 15 days back and was on tablets aspirin, prasugrel, and metoprolol. Her blood investigations were within acceptable range.

Surgeons expressed inability to wait for 6 months for endothelialization of stent. Hence, with cardiologist opinion, it was decided to perform surgery after 3 months in view of semi-emergent nature of illness. The risk of stent thrombosis, perioperative myocardial infarction (MI), excessive bleeding, and intensive care unit (ICU) stay were explained and consent was obtained. The echocardiography showed regional wall motion abnormalities with 40% ejection fraction.

On re-evaluation after 3 months, prasugrel was discontinued 7 days before surgery, aspirin, and metoprolol were continued. Blood and blood products availability were ensured. On the day of surgery, the patient was shifted to operation theater (OT) and baseline vitals recorded. Anesthesia was induced using morphine, etomidate, and vecuronium. For maintenance, oxygen and nitrous (50:50), sevoflurane ≤2% was employed. Post induction, blood pressure was persistently high so infusion of sodium nitroglycerine was started. Intraoperative blood loss was 850 ml and the surgery went uneventful. At the end, neuromuscular blockade was reversed with glycopyrrolate, neostigmine, and trachea were extubated. The patient was shifted to ICU where nitroglycerine was tapered off within 2 h. For analgesia patient was on fentanyl infusion and paracetamol injections 8 hourly. After 4 h, electrocardiogram (ECG) displayed T-wave inversion in lead II, V4–6 and patient complained of mild pain in the upper abdomen, immediately cardiac markers and cardiology consultation were obtained. MI was ruled out and additional bolus of fentanyl was given and the ECG changes reverted. From the next morning, prasugrel was restarted. However, on the next day, the patient developed oozing from surgical site which subsided within 12 h of stopping the drug. Then, ticagrelor was started but within 1 week patient developed bleeding from oral mucosa and melena, as a result, it was discontinued. Finally, clopidogrel with aspirin was well tolerated. There was no major adverse cardiac event (MACE) at 30 days postoperatively. Written and informed consent was obtained from the patient before writing this case report in his own language.

Case 2

A 60-year-old, presented to causality, intubated with a history of unconsciousness after slipping in bathroom. He was known hypertensive with DES done 1 year ago and was compliant with clopidogrel, aspirin, and metoprolol, which he had taken before the incident. Computed tomography (CT) scan revealed subdural hemorrhage with subarachnoid hemorrhage and emergency neurosurgery had to be done. His preoperative Glasgow coma scale (GCS) was E1VTM3 and blood investigations were unremarkable with hemoglobin of 14.0 gm/dl, platelet count of 1.2 lakhs, bleeding time of 3 min 20 s, and international normalized ratio (INR) of 1.2.

After discussing with neurosurgeons and taking high-risk consent in view of bleeding risk as the patient was already on DAPT, it was decided that 4 units of platelets were to be transfused before shifting to OT and additional blood products to be arranged. The patient was wheeled inside OT and vitals recorded. Invasive blood pressure monitoring was done using arterial cannula in the left radial artery. Anesthesia was induced with fentanyl, propofol, and vecuronium. For maintenance, oxygen and nitrous (50:50), isoflurane ≤1% was employed. Decompressive craniotomy was performed and intraoperative period of 2.5 h went uneventful with blood loss of 900 ml. The patient was shifted to ICU for elective postoperative ventilation in view of preoperative poor condition and measures were done to reduce ICP. Postoperative CT scan did not show any evidence of re-bleed. Surgical tracheostomy was performed on the 7th day of the patient being on ventilator due to persistent low GCS (E1VTM4). On the 10th day, the patient developed severe cerebral edema resulting in his death despite all medical measures.

Written and informed consent was obtained from the patient's relative before writing this case report in his own language.


  Discussion Top


Patients with recent coronary stenting undergoing noncardiac surgery are at increased risk for MACE. The risk of surgery is greatest when surgery occurs in the first 6 weeks following stent deployment and decreased to 1% after 6 months.[2] The perioperative cardiovascular risk stratification includes the assessment of intrinsic cardiac risk associated with surgery, thrombotic risk with stent and bleeding risk of surgery. In these patients, trade-off between the reduction of thrombotic risk with antiplatelet drugs and increased risk of surgical bleeding when their use is continued is difficult. In the absence of guidelines, clinical judgment considering the individual thrombotic profile of patient against bleeding risk intrinsic to each surgery should be made.

The thrombotic risk is inversely related with time from stenting to surgery and is influenced by the type of stent, duration of DAPT and factors related to patients medical condition[3] [Table 1]. The premature cessation of DAPT and hypercoagulable state of surgery contribute to increase risk of MACE, whereas continuation of drugs may increase bleeding risk.[4] The current guidelines for timing of noncardiac surgery following stent are dictated by type of stent.[1] In the interval between 6 and 12 months of implantation and beyond 1 year, the risk of cardiac death and MI is higher with older DES, whereas it is comparable between bare metal stents and newer DES. The better safety of newer DES even when surgery occurs early after stenting may be due to their thinner design with thromboresistant or bioabsorbable polymers. Therefore, for patients who develop high bleeding risk on DAPT, discontinuation after 3 months may be reasonable. However, this makes them vulnerable for MACE and risk of stent thrombosis. In such patients, the bridging strategy aimed at transient platelet inhibition to surgical procedure with minimum risk of ischemic or bleeding events have been proposed using unfractionated heparin, low-molecular-weight heparin, and short-acting antiplatelets drugs. Since the efficacy of bridging strategy remains inconclusive, it was not employed in our first patient. As our first patient, had undergone recent stenting and had surgical risk estimate of >5%, we decided to continue aspirin perioperatively. In the postoperative period, there was bleeding from mucosa on restarting prasugrel, which was managed by substituting with clopidogrel. At 3 months after surgery, the patient was found to be stable.
Table 1: Risk factors associated with higher rates of stent thrombosis

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Patients on DAPT, for emergency surgery, requires the assessment of procedure-related risks factors, choosing appropriate anesthesia technique and optimal perioperative management. Antiplatelet drugs have short plasma half-lives but may have a prolonged biological effect because of irreversible platelet inhibition. As there are no specific reversal agents, treatment of bleeding requires general hemostatic measures, cessation of antiplatelet treatment, or reversal of co-prescribed antithrombotics. If antiplatelet agents are withdrawn they should be re-started as soon as possible after hemostasis is secured.[5]

Platelet transfusion may be considered for emergency reversal of the antiplatelet effect but may cause risk of arterial thrombosis. Platelets should be transfused at least 2 h after the last dose of aspirin and 12–24 h after last dose of clopidogrel to avoid being inhibited by circulating drug or active metabolite.[6]

The assessment of platelet function is strongly recommended for patients on DAPT undergoing surgery as the need for platelet transfusion depends on the results.[7] A variety of devices are available for platelet function testing-thromboelastography platelet mapping or multiple electrode aggregometry.[6] Sophisticated laboratory assays are not accessible in emergency situations, but standard tests-activated partial thromboplastin time, INR are available. Multidisciplinary discussion to plan adequately in high-risk patients undergoing surgery is essential. As in our second case, early and prompt platelet transfusion was far more effective in averting the cascading consequences of diffuse intravascular coagulopathy with perioperative bleeding. Specific platelet function tests are time-consuming and difficult to obtain in useful clinical real-time. Hence, we decided on transfusion prior to surgery without platelet function tests.


  Conclusion Top


Developments related to coronary stents and antiplatelet agents are continuously evolving. A comprehensive understanding of pharmacology of newer antiplatelet agents, efficacies of newer coronary stents, risk of stent thrombosis, and the role of platelet function tests must be determined. There is an urgent need for the development of guidelines to manage such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient in the first case and the relative in the second case have given their consent for images and other clinical information to be reported in the journal. They understand that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016;68:1082-115.  Back to cited text no. 1
    
2.
Savonitto S, Caracciolo M, Cattaneo M, Servi DE. Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery. J Thromb Haemost 2011;9:2133-42.  Back to cited text no. 2
    
3.
Ferreira-González I, Marsal JR, Ribera A, Permanyer-Miralda G, García-Del Blanco B, Martí G, et al. Double antiplatelet therapy after drug-eluting stent implantation: Risk associated with discontinuation within the first year. J Am Coll Cardiol 2012;60:1333-9.  Back to cited text no. 3
    
4.
Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention Cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation. J Intern Med 2005;257:399-414.  Back to cited text no. 4
    
5.
Saia F, Belotti LM, Guastaroba P, Berardini A, Rossini R, Musumeci G, et al. Risk of adverse cardiac and bleeding events following cardiac and noncardiac surgery in patients with coronary stent: How important is the interplay between stent type and time from stenting to surgery? Circ Cardiovasc Qual Outcomes 2016;9:39-47.  Back to cited text no. 5
    
6.
Keeling D, Tait RC, Watson H, British Committee of Standards for Haematology. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016;175:602-13.  Back to cited text no. 6
    
7.
Campbell PG, Sen A, Yadla S, Jabbour P, Jallo J. Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: A clinical review. World Neurosurg 2010;74:279-85.  Back to cited text no. 7
    



 
 
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