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In reply: Perioperative interruption of dual antiplatelet therapy (November 2017)

Ryan Munyon, Steven L. Cohn, MD, FACP, SFHM, Barbara Slawski, MD, MS, SFHM, Gerald W. Smetana, MD, MACP and Kurt Pfeifer, MD, FACP, SFHM
Cleveland Clinic Journal of Medicine April 2018, 85 (4) 262; DOI: https://doi.org/10.3949/ccjm.85c.04002

We reported on publications from 2016–2017 and, unfortunately, at the time we were writing our paper, the European Society of Cardiology (ESC) update on dual anti-platelet therapy1 had not yet been published. We presented the recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA),2 which differ from the recently published ESC guidelines. The ESC suggests that the minimum waiting period after drug-eluting stent placement before noncardiac surgery should be 1 month rather than 3 months but acknowledges that in the setting of complex stenting or recent acute coronary syndrome, 6 months is preferred. The recommendation in this latter scenario is a class IIb C recommendation—essentially expert consensus opinion.

Further, in the study by Egholm et al,3 the event rates in patients undergoing noncardiac surgery in the 1- to 2-month period were numerically higher than in the control group, and no adjusted odds ratios were given.

The numbers of events were very low, and a change of only 1 or 2 events in the other direction in the groups would likely make it statistically significant.

All of these recommendations are based on observational studies and registry data, as there are no randomized controlled trials to address this issue. There are many complexities to be accounted for including the type of stent, timing, circumstances surrounding stenting, anatomy, number of stents, patient comorbidities (particularly age, diabetes mellitus, cardiac disease), type of surgery and anesthesia, and perioperative management of antiplatelet therapy. While we acknowledge the ESC recommendation, we would urge caution in the recommendation to wait only 1 month, and in the United States most would prefer to wait 3 months if possible.

REFERENCES

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    1. Valgimigli M,
    2. Bueno H,
    3. Byrne RA,
    4. et al
    . 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260. doi:10.1093/eurheartj/ehx419.
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    1. Levine GN,
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    3. Bittl JA,
    4. et al
    . 2016 ACC/AHA guideline focused update on duration of dual antiplate-let therapy in patients with coronary artery disease. Circulation 2016; 134(10):e123–e155. doi:10.1161/CIR.0000000000000404.
    OpenUrlFREE Full Text
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    1. Egholm G,
    2. Kristensen SD,
    3. Thim T,
    4. et al
    . Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol 2016; 68(24):2622–2632. doi:10.1016/j.jacc.2016.09.967.
    OpenUrlFREE Full Text
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