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Managing Dual Antiplatelet Therapy (DAPT) Around Surgery: Expert Advice

Effective management of dual antiplatelet therapy in coronary stent surgery. Aspirin, ticagrelor, clopidogrel, IV bridging.

As a clinical pharmacist, managing dual antiplatelet therapy (DAPT) around surgery in patients with recent coronary stents is crucial. According to American College of Cardiology guidelines, DAPT is typically recommended for 6 to 12 months post-stent placement, but shorter durations may be considered for patients at high bleeding risk.

Chest peri-operative guidelines highlight the highest thrombosis risk within 3 months of stent placement, despite limited evidence.

  • For stents placed > 3 months ago, continue aspirin and pause ticagrelor (Brilique) for 3-5 days, clopidogrel (Plavix) for 5 days, or prasugrel for 7 days pre-surgery. Avoid routine IV antiplatelet bridging (e.g., eptifibatide, tirofiban, cangrelor) due to limited data and bleeding risks, except for high thrombotic risk cases.
  • For stents placed ≤ 3 months ago, consider continuing DAPT if bleeding risk is low; otherwise, pause P2Y12 inhibitors. Evaluate IV antiplatelet bridging cautiously for high thrombotic risk. No IV antiplatelet has shown superiority; cangrelor, despite its cost, is an option with a short half-life and no need for renal adjustment.

Initiate IV antiplatelet therapy within 72 hours post-oral P2Y12 inhibitor cessation, continuing until 1-6 hours pre-op, depending on medication. Resume DAPT within 24 hours post-surgery, documenting planned duration at discharge.

Personalize peri-operative DAPT based on surgery type and comorbidities. Collaborate with your team for optimal outcomes. For more guidance, consult specialists.

RxPharm-adv

Take-home points
  1. Continue aspirin therapy post-stent to prevent thrombosis.
  2. Stop ticagrelor or clopidogrel 3-5 days before surgery to reduce bleeding risk.
  3. Avoid routine IV antiplatelet bridging; Minimize IV antiplatelet use (e.g., eptifibatide, cangrelor) due to unclear benefits and potential bleeding risks.
  4. Assess patient-specific factors like recent stent placement and surgical complexity to customize dual antiplatelet therapy (evaluate thrombotic and bleeding risks).
  5. Restart dual antiplatelet therapy within 24 hours after surgery to maintain effectiveness in preventing stent thrombosis.

References

  1. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline [published correction appears in Chest. 2023 Jul;164(1):267. doi: 10.1016/j.chest.2023.05.019]. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025
    2. Show more references

Keywords: Aspirin and P2Y12 inhibitors, Peri-operative antiplatelet therapy, Coronary stent management, Bleeding risk management, Tthrombosis prevention, Cardiovascular surgery guidelines, DAPT duration after stent, Clinical pharmacist advice, Stent thrombosis prevention

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.