Noncardiac Surgery After PCIWhat to do?

Terry Shaneyfelt, MD, MPHAssoc. Professor, UAB Department of Medicine

You must balance…

Stent Thrombosis Bleeding

Adverse Cardiac Events Following Noncardiac Surgery in Patients With Stents

Hawn, et al. JAMA 2013;310:1462

• Class I• Elective noncardiac surgery should be delayed

• 14 D after balloon angioplasty• 30 D after BMS implantation• 365 D after DES implantation

• Class IIb• Elective noncardiac surgery after DES implantation may

be considered after 180 D if risk of further delay > risk of stent thrombosis

2014 ACC/AHA Perioperative Guidelines

• Class III (Harm)• Elective noncardiac surgery in which DAPT will need to

be discontinued should not be performed within• 30 D after BMS• 365 D after DES

• If elective noncardiac surgery is needed within 1-12 months then place BMS with 4-6 wks of DAPT with continuation of ASA perioperatively

2014 ACC/AHA Perioperative Guidelines

Approach to patients who need surgery after PCI

Wait 4-6 weeks Wait 12 months

Continue dual antiplatelet therapy if surgery needed before completion of

recommended therapy

No matter what continue at least aspirin*

* Except for neurosurgery, post eye, middle ear, and prostate

• Aspirin (and aspirin/dipyridamole)• POISE-2 trial (N Engl J Med 2014; 370:1494-1503)

suggests that aspirin is of no benefit in patients at moderate to high risk for cardiovascular events who are undergoing noncardiac surgery

• Stop 7-10 days prior to surgery• Bleeding time is a poor predictor of perioperative

hemorrhage

Managing antiplatelet agents in the perioperative period

• Platelet P2Y12 receptor blockers • Clopidogrel and ticagrelor: stop at least 5 days before

surgery• Prasugrel: stop at least 7 days before surgery

• Cilostazol • Selective phosphodiesterase-3 enzyme inhibitor with

weak, reversible antiplatelet activity• Stop 5 days before surgery

Managing antiplatelet agents in the perioperative period