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Perioperative Management of Patients

With Coronary Stents:
Considerations for the Anesthesiologist
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PRIYA A
A.. KUMAR, MD,
MD
D FA
FASA
SA
SA
s

RIYA
RIYA UMAR
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Professor, Anesthesiology
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Director, Clinical Research

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University of North Carolina School of Medicine

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Chapel Hill
19
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Dr. Kumar reported no relevant financial disclosures.

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n order to prevent major
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adverse cardiovascular events

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and safely manage these patients,

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it is imperative for perioperative

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physicians to be familiar with stent dynamics.

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Introduction implantation will require noncardiac surgery within two

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From its humble beginnings over four decades ago, years of their coronary intervention.2
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percutaneous coronary intervention (PCI) has evolved It’s no surprise that anesthesiologists must consis-
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into one of the most commonly performed standard tently stay current with rapidly evolving guidelines for
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medical procedures in the United States.1 Technologi- the perioperative management of these patients. Some
d.

cal advances combined with evidence from large clin-
ical trials have resulted in a modern era for PCI, which
continues to rapidly progress. About 480,000 PCI pro-
cedures are being performed annually, which includes
balloon angioplasties with or without the placement
of a coronary stent.1 Contemporary data suggest that
approximately one in five patients with coronary stent
of the clinical questions that arise include the following:
• How soon can a stented patient undergo
surgery?
• Should a patient continue antiplatelet therapy
(APT) during the perioperative period?
• What is the risk for surgical bleeding versus
coronary thrombosis in this population?

40 A N E ST H E S I O LO GY N E WS .CO M
 Stent thrombosis, a potentially fatal complication, is
likely with premature discontinuation of APT due to the
perioperative prothrombotic pro-inflammatory state.
In order to prevent major adverse cardiovascular
events (MACE) and safely manage these patients, it is
imperative for perioperative physicians to be familiar
with stent dynamics. They should have a clear under-
standing of the indications, duration and importance
of APT for the prevention of stent thrombosis. Each
individual patient’s risk for bleeding must be coun-
terbalanced against the risk for life-threatening stent
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thrombosis in patients on APT.
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It’s essential for the entire perioperative team to
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have a clear understanding and agreement so that early
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identification, vigilant care and rapid triage can prevent
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catastrophic outcomes in patients who develop stent
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thrombosis.
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History
20
Since the pioneering success at percutaneous trans-
19
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luminal coronary angioplasty in 1977 by Grüntzig et al,
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stent technology has undergone tremendous evolu-
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tion.3 Plain balloon angioplasty was met with much ini-
tial enthusiasm; however, its limitations soon came to
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light. The use of stand-alone angioplasty without stent-
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ing was associated with high complication rates, rang-
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ing between 15% and 60%, including the risks for early
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vessel closure due to elastic recoil as well as late inflam-
is
matory restenosis.4
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Bare metal stents (BMSs) were introduced in the
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1980s to help avoid the shortcomings of balloon dila-
or
tation. They were approved by the FDA in 1993. These
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in
devices functioned as vascular scaffolds and were
up
pa
regarded as a major advance in the nonsurgical man-
agement of coronary artery disease. Although BMSs
reduced the rates of restenosis, coronary artery recoil
and dissection, they presented several areas of clini-
cal concern. Stent implantation induced trauma to the
vessel wall and initiated complex interactions between
the vessel wall, stent surface and blood components,
leading to thrombogenesis and neointimal hyperplasia,
much like the formation of scar tissue. Neointimal hyper-
plasia in turn resulted in in-stent restenosis (ISR), affect-
ing 10% to 30% of patients with BMS implantations over
the course of three to six months.5 In coronary arteries,
even a small amount of hyperplastic tissue can signifi-
cantly reduce the luminal diameter, resulting in gradual
stent occlusion and ischemia. Numerous pharmacother-
apy trials attempted to address the issue of ISR, but
none was successful in reducing its incidence.6 Com-
pared with drug-eluting stents (DESs), only about 25%
of all stents implanted during PCI are BMSs.7
In the early 2000s, DESs were introduced as a con-
cept and a potential solution for the prevention of ISR.
The metallic scaffold was coated with a drug delivery
polymer embedded with a pharmacologic agent to
discourage scar tissue formation. The antiproliferative
drugs used to coat the stents (of the taxus and limus
families) were successful in preventing the proliferation
of smooth muscle and markedly reduced the rates of
restenosis to a range of 5% to 8%8; however, the success
of DESs came with a price.
The coating of immunosuppressive and antiprolifer-
ative pharmacologic agents found on first-generation
DESs interfered with and delayed the disrupted vascu-
lar endothelium from regenerating. This left the sub-
endothelial substrate exposed for prolonged periods to
circulating platelets and inflammatory mediators. Col-
lagen in the exposed subendothelium, being a potent
stimulus for platelet activation, made these patients
susceptible to stent thrombosis. Whereas reendotheli-
alization after a BMS implantation occurred within the
first six to seven months after the procedure, the first-
generation DESs were not fully endothelialized, even
after three years of implantation.9 As a result, late stent
thrombosis was an alarming problem in patients with
first-generation DESs, especially in the hyperthrom-
botic perioperative period. While ISR is a pathology that
evolves gradually over a period of six to nine months,
stent thrombosis is an abrupt thrombotic vessel occlu-
sion that can lead to an acute myocardial infarction (MI)
with a high mortality rate of 10% to 30%.8,10
Stent architecture, flexibility, apposition to the coro-
nary vessel wall, its polymer coating, and the choice of
pharmacologic agent may all play a significant role in
the reendothelialization process to create an improved
safety profile.
First-Generation DESs
First-generation DESs, approved by the FDA in 2003,
consist of a stainless steel metallic stent platform coated
with a polymer that elutes the antiproliferative pharma-
cologic agent. Sirolimus is an immunosuppressive com-
un ou
pound that reduces neointimal hyperplasia. Elution off
rt
the sirolimus platform is complete in about six weeks.4
w
le
ith
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Paclitaxel is an agent that has antiproliferative and
cytotoxic properties; 10% of the drug is released in the
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first 10 days, and the remainder elutes indefinitely.4 The
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Cypher (Cordis) and Taxus (Boston Scientific) stents
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proved superior to BMSs and successfully lowered the
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incidence of ISR.
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Second-Generation DESs
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Second-generation DESs differ from first-genera-
d.
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tion stents in all three components: metal frame, poly-
pr
mer coating and drug. They consist of thinner, more
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radiopaque and flexible cobalt–chromium or plati-
ib
num–chromium alloy struts coated with a biocompati-
ite
ble polymer with superior reendothelialization kinetics.
d.
Zotarolimus inhibits smooth muscle cell proliferation
and completely disappears after full elution. Everolimus,
similar to sirolimus in its antiproliferative and immuno-
suppressive properties, is more lipophilic, allowing rapid
absorption into the arterial wall.
Polymer-Free and Bioabsorbable Polymer DESs
The polymer coating and the metal frame have
been implicated as potential causes of inflammation
A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 41
and disruption of coronary vasomotor tone. As a con-
sequence, DESs with the elimination of the polymeric
carrier have been developed. Drug-filled hollow frames
made with newer metal alloys allow the drug to be
released from the frame itself. As a result, improved
healing may allow a shorter duration of APT. Trials of
these stents have suggested noninferiority compared
with contemporary DESs.11
Bioabsorbable polymer DESs are coated with a poly-
mer that is absorbed over six to 12 months, eliminating
the source of inflammation.6 Synergy (Boston Scien-
A
tific) was the first of this type to receive FDA approval,
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in 2015. Both the drug, everolimus, and the polymer
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are absorbed shortly after drug elution is completed
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at three months. European registry data have sug-
s
rig ed.
gested the safety and efficacy of this technology com-
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pared with contemporary DESs.6 Synergy has a CE
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mark (European equivalent of an FDA approval) for one
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month of dual APT, which is similar to that of BMSs.6
20
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Bioabsorbable Stents
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Bioabsorbable vascular scaffolds are designed to be
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fully absorbed over a period of two to three years, elim-
inating the presence of foreign material in the vessel.6
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Absorb (Abbott Vascular) consists of a poly-L-lactide
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backbone coated with everolimus. The stent received
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FDA approval in 2016 based on initial results, which
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were promising and theoretically attractive. However,
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the ABSORB III trial unveiled some concerns around
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late-developing stent thrombosis.12 This, along with
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other troubling reports, resulted in a withdrawal of the
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stent from the U.S. commercial market, other than for
research purposes.
Additionally, a warning was issued by the FDA
regarding the risk for late stent thrombosis with bioab-
sorbable vascular scaffolds. Long-term data collection
is ongoing (i.e., the ABSORB IV trial), and additional
studies may be needed to demonstrate long-term ben-
efits.13 Further refinement of bioabsorbable stent design
will likely continue until the hurdle of its first-generation
design has been overcome.
Next-Generation Stents
Stent technology is undergoing an explosion of
research and refinement with the evolution of next-gen-
eration stents with increased safety and biocompatibil-
ity. The development of antibody-coated stents, which
attract circulating endothelial progenitor cells with pro-
healing properties to enhance the repair of endothelial
cells, is now being explored.14,15 A further evolution of
design combines the above endothelial progenitor cells
technology with a bioabsorbable polymer matrix, which
has also shown initial promise.
Evolution of Guidelines
With the rapid evolution and advancement in stent
technology, perioperative management guidelines also
have evolved. A lack of uniformity in American and
European guidelines is a reflection of constant updates
42 A N E ST H E S I O LO GY N E WS .CO M
caused by the brisk pace of clinical advancement and
discovery in this area. Most studies agree that there is
an inverse relationship between the time from stent to
surgery and cardiac risk. However, with the advent of
new-generation stents, the safety duration of APT is
getting shortened.
At the time BMSs were approved in 1993, no for-
malized guidelines existed regarding the periopera-
tive management of these patients. Several reports
of adverse events and deaths from stent thrombosis
began to emerge, especially in patients whose APT was
held up for surgery. As a result, guidelines in 2002 rec-
ommended delaying surgery for six weeks after BMS
placement.16 Soon after, DESs were approved by the
FDA in 2003. Similar reports of acute stent thrombosis
after noncardiac surgery began to appear, particularly
in patients with recently implanted DESs. This was asso-
ciated with significant preventable and alarming peri-
operative morbidity and death.
Patient compliance with APT became crucial for low-
ering this risk. Consequently, in 2007, the American Col-
lege of Cardiology/American Heart Association (ACC/
AHA) modified the guidelines for perioperative cardio-
vascular evaluation and care for noncardiac surgery.17
The group recommended that APT should be continued
and elective surgery postponed for four to six weeks
after placement of a BMS and for one year after DES
implantation. They also stated that whenever possible,
urgent surgeries in recently stented patients should
be performed with the continuation of APT, although
doing so may increase the risk for surgical bleeding.
It was generally agreed that the risk for stent throm-
ro
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bosis outweighed the risk for bleeding in patients with
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recently implanted stents.
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In 2009, the American Society of Anesthesiolo-
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gists (ASA) issued a practice alert in accordance with
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the ACC/AHA recommendations.18 The ASA supported
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the 2007 ACC/AHA recommendations and agreed that
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selected patients at high risk for stent thrombosis should
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continue APT beyond the recommended time periods.
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Long-term safety data from second-generation DESs
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were encouraging and led to the liberalization of the
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ACC/AHA guidelines in 2014. The guidelines recom-
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mended delaying noncardiac surgery for 14 days after
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balloon angioplasty, 30 days after BMS implantation,
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and one year after DES implantation. However, if the
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risk for delaying surgery for a year was greater than the
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risk for ischemia, elective surgery could be considered
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at six months as a class IIb recommendation.19
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Safety data continued to be encouraging on newer-
d.
generation stents, and the guidelines were liberalized
yet again in 2016 to recommend delaying noncardiac
surgery for 30 days after BMS and six months after DES
implantation. However, if the risk for delay of six months
was greater than the risk for ischemia, elective surgery
could be considered at three months as a class IIb rec-
ommendation (Figure 1).20
American and European guidelines agree that a mul-
tidisciplinary risk–benefit individualized approach is
warranted when considering timing of surgery after
stenting. European guidelines are, however, more lib-
eral, and in selective cases they recommend considering
surgery as soon as one month after stenting. Addition-
ally, although there is no recommendation on “bridg-
ing therapy” with IV antiplatelet agents in the American
guidelines, the European guidelines support this con-
cept in high-risk patients.21
Risk for Stent Thrombosis
As previously mentioned, stent thrombosis is a sud-
A
• late ST, which occurs from 31 days to one year of
stenting; or
• very late ST, which occurs one year after
stenting.
The FDA’s policy outlining patients suitable for
stent insertion considers those whose three-year risk
for thrombosis is below 2%.23 Approved indications
include stable patients without comorbid conditions
(e.g., diabetes, renal insufficiency, MI, <30% ejection
fraction, left main coronary lesion) with short lesions
(28-30 mm), noncomplex lesions or native coro-

den, devastating complication that can lead to MI or nary lesions. In reality, only a minority (25%-40%) of
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death. It may result from stent malposition, coro- patients meet these criteria, and the majority of cor-
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nary dissection or incomplete endothelial healing in onary stents are placed in “off-label” patients, which
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the face of withdrawal of APT. According to the Aca- automatically places them in the high-risk category.
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demic Research Consortium, for the purposes of consis- Although most patients in this high-risk category have
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tency with reporting, stent thrombosis can be classified good long-term outcomes, it’s important to ensure that
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according to its timing of occurrence as22: APT is not terminated prematurely in these patients.
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• acute ST, which occurs within 24 hours of An informed, multidisciplinary, thorough risk–benefit
20

stenting; analysis should be undertaken for this patient popula-

19
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• subacute ST, which occurs from 24 hours to 30 tion, especially in the thrombogenic, vulnerable peri-
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days of stenting; operative setting.

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Patients treated with PCI undergoing

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elective noncardiac surgery

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BMS treated with DAPT DES treated with DAPT

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<30 d ≥30 d
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since BMS since BMS

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implantation implantation
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30 d
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≥30 d
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Class III: Class I: since BMS

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Harm. Proceed with implantation

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Delay surgery 3-6 mo since DES

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surgery implantation, dis-

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3 mo Class III: continue DAPT;

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Harm. delayed surgery risk

Delay is greater than stent
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surgery ≥6 mo since DES

thrombosis risk
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implantation,
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6 mo discontinue DAPT
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Class IIb:
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Proceeding with
surgery may be Class I:
d.

considered Proceed with

surgery

Figure 1. Treatment and timing algorithm for elective noncardiac surgery in

patients with coronary stents.
BMS, bare metal stent; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; PCI, percutaneous coronary intervention
Based on reference 20.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 43
Antiplatelet Therapy
Activation of platelets is recognized as the primary
source of stent thrombosis. Multiple pathways must
be blocked in order to achieve effective APT. It is well
known that there is significant crossover between the
various receptors on the surface of the platelets; hence,
dual antiplatelet therapy (DAPT) is recommended as
the cornerstone of antithrombotic prophylaxis.
The antiplatelet agents most frequently used are a
combination of aspirin and clopidogrel, both of which
are irreversible platelet inhibitors, have been exten-
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sively studied and have the most favorable risk–ben-
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efit profile. However, both aspirin and clopidogrel may
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be partially ineffective in as many as 30% of patients.4
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Pharmacogenomic and genetic polymorphism mecha-
s
rig ed.
nisms play a major role in this drug resistance. With a
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half-life of six hours, clopidogrel is a prodrug that must
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be metabolized to the active drug in the liver by cyto-
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chrome P450 (CYP).4 Genetic variability and interaction
20
with other drugs metabolized by this mechanism may
19
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interfere with the effectiveness of clopidogrel. Pharma-
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cogenetic testing (CYP2C19 genotyping) for drug resis-
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tance is routine in some institutions to tailor the choice
of APT in high-risk patients. Fortunately, many other
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safe and efficacious antiplatelet agents with reduced
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risks for pharmacogenetic drug resistance are now
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available to us. It’s helpful to be familiar with the vari-
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ous antiplatelet agents that are being used.
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The currently available antiplatelet drugs fall into
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four main categories:
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• Thromboxane inhibitors (including aspirin):
or
According to the guidelines, aspirin is recom-
mended as a lifelong therapy that should never
be interrupted for patients with coronary stents
unless the bleeding risk far exceeds the risk for
stent thrombosis.
• Glycoprotein IIb/IIIa inhibitors (including tirofiban
[Aggrastat, Medicure International], eptifibatide
and abciximab [Reopro, Janssen]): Interventional
cardiologists generally use these IV medica-
tions in the cardiac catheterization suite during
the placement of coronary stents. As an off-
label indication, these drugs also can be used to
bridge the gap between discontinuation of DAPT
and surgery in selected high-risk patients.24 Tiro-
fiban and eptifibatide have a half-life of two
hours, and bleeding times return to normal
about four hours after stopping infusions.4 How-
ever, bleeding risks with these agents are higher
than with oral drugs, and their effects cannot be
reversed with platelet transfusions.
• P2Y12 or adenosine diphosphate receptor block-
ers (including clopidogrel, prasugrel, ticagre-
lor and cangrelor [Kengreal, Chiesi]): Prasugrel,
a third-generation thienopyridine, was approved
by the FDA in 2000. It’s more potent than clop-
idogrel and has a lower rate of drug resistance
with a more predictable antiplatelet response.
These effects come at the cost of a higher risk
44 A N E ST H E S I O LO GY N E WS .CO M
for bleeding and greater expense. Ticagre-
lor is an orally active reversible P2Y12 recep-
tor antagonist that was approved by the FDA in
2011. It does not require metabolic activation for
its clinical effect. Cangrelor, an ultra–short-act-
ing, reversible IV platelet inhibitor, was approved
by the FDA in 2015 and has been evaluated as a
bridging APT in the perioperative setting.24,25
• The protease-activated receptor 1 antagonist
vorapaxar (Zontivity, Aralez) was approved by
the FDA in 2011, and is used as an oral reversible
agent with a peak effect attained in one to two
hours and a terminal half-life of eight days.26
High-risk patients or patients with resistance to
aspirin or clopidogrel may be placed on the above-
mentioned alternate drugs. Heparins possess an insig-
nificant antiplatelet effect and are therefore unsuitable
as “bridge therapy” when DAPT is discontinued in the
perioperative setting. However, other innovative and
effective bridging strategies have been proposed for
selective high-risk situations (Figure 2).24
Perioperative Considerations
Patients with freshly placed coronary stents present-
ing for noncardiac surgery pose a significant challenge
to anesthesiologists. It is important to manage these
patients using a multidisciplinary team approach with
open communication and accept input from the anes-
thesiologist, surgeon and interventional cardiologist.
The perioperative period is particularly risky for
patients with coronary stents because of the stress
response to surgery, which activates the sympathetic
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in
system. It results in the release of inflammatory medi-
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ators and stress hormones, and causes platelet activa-
un ou
tion, vasospasm and decreased fibrinolysis. Together,
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these effects lead to the development of a hypercoag-
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ulable state in a patient who may already have a dis-
rupted coronary endothelial lining and is predisposed
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to stent thrombosis. Pain and anxiety may result in
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tachycardia and hypertension leading to an increased
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cardiac demand–supply ratio, which can add additional
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shear stress to the coronary plaques.
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Fearful of the risk for surgical bleeding, well-mean-
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on
ing surgeons or other medical providers may inappro-
te
priately advise patients to discontinue their DAPT while
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they are still within the high-risk period after coronary
pr
stenting. There is evidence to show that an abrupt dis-
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continuation of DAPT not only reverses the antiplatelet
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effect but also leads to an exaggerated rebound throm-
ite
bogenic effect. These patients are susceptible to MACE
d.
in the perioperative period, with some studies report-
ing high mortality rates.
Sharma et al evaluated outcomes in patients with
BMS undergoing noncardiac surgery.27 They found that
patients in whom DAPT was discontinued prematurely
had a mortality rate of approximately 85%, compared
with 5% for patients in whom therapy was continued.
Retrospective studies that evaluated the risk for peri-
operative MACE in patients presenting for noncardiac
surgery showed that the risk decreases 90 days after with the institution of pharmacologic bridge therapy.30
PCI in patients who receive a BMS but remains high More recently, Rossini et al created a multidisciplinary
even after one year in patients who receive a DES.28 task force and published a consensus document as well
Similar reviews of second-generation DESs show a as a mobile phone app (“Stent & Surgery”) to provide
higher risk of MACE during the first six months of stent recommendations for patients with coronary stents
implantation.29 undergoing surgery.31
Successful management of DAPT must evaluate the A fundamental trade-off occurs between reduced
patient’s risk for bleeding against that for stent throm- coronary ischemic risk and increased risk for surgical
bosis. During the vulnerable period, the risk for stent bleeding with the perioperative continuation of DAPT.
thrombosis in patients with recent PCI outweighs that This multidisciplinary decision must be made on an
of surgical bleeding. Ideally, DAPT should be continued individual basis, thoughtfully weighing the coronary
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throughout the perioperative period in freshly stented risk factors and bleeding risks for each patient.
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patients. If DAPT must be discontinued due to a high Patients who remain on APT intraoperatively may
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risk for surgical bleeding, all efforts should be made to experience excessive bleeding. Adequate preparation
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at least continue aspirin. Procedures with a high risk with large-bore IV access and the availability of blood
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rig ed.

for bleeding include intracranial, intramedullary spi- must be planned beforehand. If a platelet transfusion
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nal, prostate, middle ear, ophthalmologic and aortic is necessary, it can be safely performed approximately
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surgeries. four hours after the discontinuation of clopidogrel. The

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DAPT should be reinstituted as soon as possible after short half-life of clopidogrel and its metabolites will
20

surgery if it has been held for the procedure. The four- not interfere with the function of transfused platelets.
19
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quadrant approach suggested by Metzler et al is still Optimal intraoperative management of these

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valid, where the risk for thrombosis is plotted against patients requires tight hemodynamic control to bal-
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the risk for bleeding.30 The subset of patients who fall ance the cardiac demand–supply ratio and minimize
into the quadrant with a high risk for bleeding and stent
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the shear stress on coronary arteries. When consid-

ah in w

thrombosis may benefit from extra caution. Metzler et ering regional or neuraxial anesthesia in patients
tio

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al suggest that DAPT should be stopped in this subset with coronary stents, a risk–benefit analysis must be
n

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ho

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Low-dose aspirin continued throughout

or

RESUME
G

START STOP
ro

small-molecule GPI small-molecule GPI Surgery small-molecule GPI

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(tirofiban, eptifibatide) (tirofiban, eptifibatide) (tirofiban, eptifibatide)

up
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STOP STOP RESUME

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clopidogrel, ticagrelor
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prasugrel clopidogrel
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Day -7 -6 -5 -4 -3 -2 -1 -4-6 h 0 +4-6 h Follow-up until discharge

tp

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Low-dose aspirin continued throughout

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WASH OUT START STOP RESUME

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Surgery
oral P2Y12 inhibitors cangrelor cangrelor cangrelor
d.
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STOP STOP RESUME

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prasugrel clopidogrel, ticagrelor clopidogrel

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d.

Day -7 -6 -5 -4 -3 -2 -1 -1-6 h 0 +1-6 h Follow-up until discharge

Figure 2. Bridging protocol for patients referred to surgery on dual antiplatelet

therapy with aspirin plus a P2Y12 receptor inhibitor who are taking (top) small-
molecule GPIs or (bottom) cangrelor (Kengreal, Chiesi USA).
GPI, glycoprotein inhibitor

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 45
carefully undertaken, keeping in mind that the patient
may require an emergency perioperative PCI interven-
tion with the administration of additional highly potent
APT.
As with any high-risk cardiac patient, the anesthe-
siologist must remain vigilant for signs of cardiac isch-
emia and stent thrombosis. Surgical procedures in
patients with coronary stents should be performed at
institutions with prompt access to around-the-clock
interventional cardiology services.
Intraoperative stent thrombosis, a true medi-
A
Conclusion
The 2016 ACC/AHA guidelines recommend postpon-
ing elective surgery for four weeks after implantation
of a BMS, and three to six months after implantation
of a DES.20 These periods may be extended in high-
risk patients or those in whom unapproved stents were
used, such as multiple overlapping stents in bifurcating
vessels. Aspirin therapy should be continued indefinitely
in patients with PCI, particularly in the perioperative
period. Whenever possible, APT should be continued
for urgent surgeries that must be performed within the

cal emergency, may present as hemodynamic insta- high-risk period. If DAPT must be stopped for urgent
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bility with dysrhythmias and ECG changes. The procedures, clinicians could consider bridging therapy
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recommended treatment for an MI is acute reperfu- with a short-acting IV antiplatelet agent and restart the
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sion therapy with fibrinolytic agents, depending on the DAPT as soon as possible after surgery.
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risk for bleeding, or an urgent PCI (i.e., within 90 min- The anesthesiologist, as a perioperative physician, is
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utes). In the setting of stent thrombosis, it is imper- uniquely poised to play a pivotal role in ensuring patient
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ative to immediately reperfuse the myocardium to safety. Vigilant care and rapid triage to the interven-
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avert a transmural MI. Thrombolytic therapy may be tional cardiology suite in case of myocardial ischemia
20

prohibitive in the perioperative period because of the can prevent catastrophic outcomes. Early periopera-
19
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risk for bleeding. PCI along with hemodynamic sup- tive identification and use of a multidisciplinary team
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port is therefore the definitive treatment in this set- approach, along with well-publicized institutional poli-
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ting, requiring emergent action. cies and management guidelines, ensure patient safety.
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