Trust Guideline for the Management of Adult Patients on Antiplatelet Therapy

who require Elective Surgery or an Invasive Procedure

A clinical guideline recommended for use
In: All clinical areas

By: All medical and nursing staff

Adult patients who require surgery or an invasive procedure
For:
and are taking anticoagulants or antiplatelet therapy
Division responsible for
Medicine
document:
Aspirin, clopidogrel, dipyridamole, stent, perioperative
Key words: anticoagulation, prasugrel, surgery, ticagrelor, invasive
procedure
Name and job title of Dr Hamish Lyall, Consultant Haematologist
document authors: Dr Anna Lipp Consultant Anaesthetics
Name and job title of
document author’s line Dr Lawes, Clinical Director
manager:
Peter Woodhouse (Thrombosis & Thromboprophylaxis
Supported by: Committee Chair)
Felicity Meyer (Consultant Vascular Surgeon)
Thrombosis and Thromboprophylaxis Committee 25/09/2018
Assessed and approved Clinical Guidelines Assessment Panel (CGAP)
by: If approved by committee or Governance Lead Chair’s Action;
tick here 
Date of approval 05 March 2019
To be reviewed before: 05 March 2022
To be reviewed by: Dr Hamish Lyall/Dr Anna Lipp
Reference/Trust docs ID: 9836
Version No. 6
Description of changes: Reviewed and amended to current practice
Compliance Links nil
If yes, does it deviate from
the recommendations of n/a
NICE?

This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the
diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits
neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the
light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional
judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from
relevant guidance should be documented in the patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve
the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no
responsibility for any misunderstanding or misapplication of this document.

Clinical Guideline for: Adult patients requiring elective surgery or an invasive procedure who are prescribed antiplatelet therapy
Author/s: Dr Hamish Lyall, Consultant Haematologist, Dr Anna Lipp Consultant Anaesthetics
Approved by: CGAP Date approved: 05/03/2019 Review date: 05/03/2022
Available via Trust Docs Version: 6 Trust Docs ID: 9836 Page 1 of 5
 Trust Guideline for the Management of Adult Patients on Antiplatelet Therapy
who require Elective Surgery or an Invasive Procedure

For patients on anticoagulation

See guideline CA2060 Trustdocs Id 1215 or click below
CA2060 Adults patients on therapeutic anticoagulation who require elective surgery or
an invasive procedure

For patients having regional anaesthesia

See guideline CA2031 Trustdocs id 1193 or click below
CA2031 Regional Anaesthesia Patients Venous Thromboprophylaxis with
Anticoagulant and Antiplatelet Drugs

Exclusions from this guideline

 Procedures with low bleeding risk which can be performed without interruption
of antiplatelet surgery (e.g. biopsy of compressible site, joint aspiration,
cataract surgery)
 Endoscopy. The British Society for Gastroenterology has produced national
guidelines for the management of warfarin and antiplatelet therapy in patients
undergoing endoscopic procedures. This guidance can be accessed at
https://www.bsg.org.uk/resource/bsg_esge_anticoag_16.html
 Dental surgery Patients on anti-platelet drugs should continue them when
having dental procedures unless otherwise instructed by dental surgeon

Clinical Guideline for: Adult patients requiring elective surgery or an invasive procedure who are prescribed antiplatelet therapy
Author/s: Dr Hamish Lyall, Consultant Haematologist, Dr Anna Lipp Consultant Anaesthetics
Approved by: CGAP Date approved: 05/03/2019 Review date: 05/03/2022
Available via Trust Docs Version: 6 Trust Docs ID: 9836 Page 2 of 5
 Trust Guideline for the Management of Adult Patients on Antiplatelet Therapy
who require Elective Surgery or an Invasive Procedure
Quick reference guideline - Assess Thrombotic risk
High
 NSTEMI/STEMI ≤1 year
 Cardiac drug eluting stent ≤1
year
 Elective cardiac bare metal
stent ≤1/12
 Carotid surgery planned or
≤6/12
 Infra inguinal arterial stent
(superficial femoral, popliteal
or distal arteries) ≤3/12
 Visceral arterial stent (renal,
coeliac, sma, fevar) ≤3/12
 Stroke/TIA ≤6/12
 Discuss deferral of surgery
with surgeon
If surgery to proceed:
 Continue all anti-platelet
medication
 Alert anaesthetists in case
local anaesthesia planned
Aspirin alone
If patient on aspirin alone this
does not appear to add significant
risk of bleeding and so may be
continued for the majority of
surgery nor does it appear to
represent an added significant
risk for the development of spinal
hematoma. Aspirin (up to
300mg) can be continued for all
patients unless surgeon
specifically requests cessation
Prasugrel or ticagrelor
If on prasugrel or ticagrelor
always discuss with
cardiologists/vascular surgeon
Clinical Guideline for: Adult patients requiring elective surgery or an invasive procedure who are prescribed antiplatelet therapy
Author/s: Dr Hamish Lyall, Consultant Haematologist, Dr Anna Lipp Consultant Anaesthetics
Approved by: CGAP
Available via Trust Docs Version: 6
Moderate
 NSTEMI/STEMI >1 year
 Cardiac drug eluting stent >1
year
 Elective cardiac bare metal
stent >1/12
 Infra inguinal arterial stent
(superficial femoral, popliteal
or distal arteries) > 3/12
 Visceral arterial stent (renal,
coeliac, sma, fevar) > 3/12
 All other vascular surgery
patients not considered high
risk (this includes evar, iliac
stents, aaa repair, bypass
grafts)
 Stroke/tia >6/12
Clopidogrel
Take last dose 8 days before
surgery
Start aspirin 75 mg
Post op stop aspirin and restart
clopidogrel. If epidural present
delay switching until after removal
Dipyridamole. Omit day before
surgery. Discuss with stroke
physician regarding switch to
clopidogrel monotherapy on
discharge or ask gp to consider
switching to clopidogrel
monotherapy on discharge in
liaison with stroke physicians
Aspirin alone
If patient on aspirin alone this
does not appear to add significant
risk of bleeding and so may be
continued for the majority of
surgery nor does it appear to
represent an added significant
risk for the development of spinal
hematoma. Aspirin (up to 300mg)
can be continued for all patients
unless surgeon specifically
requests cessation
Ticagrelor 60mg bd
Stop Ticagrelor 5 days pre op and
continue( or add) aspirin 75mg od
while ticagrelor discontinued.
Date approved: 05/03/2019
Trust Docs ID: 9836
Standard
 Patients not falling into high or
moderate risk group
Clopidogrel
Take last dose 8 days before
surgery
Post op restart clopidogrel. If
epidural present delay restarting
until after removal
Dipyridamole. Omit day before
surgery surgery. Discuss with
stroke physician regarding switch
to clopidogrel monotherapy on
discharge or ask gp to consider
switching to clopidogrel
monotherapy on discharge in
liaison with stroke physicians
Aspirin alone
If patient on aspirin alone this
does not appear to add significant
risk of bleeding and so may be
continued for the majority of
surgery nor does it appear to
represent an added significant risk
for the development of spinal
hematoma. Aspirin (up to 300mg)
can be continued for all patients
unless surgeon specifically
requests cessation
Ticagrelor 60mg bd
Stop Ticagrelor 5 days pre op and
continue( or add) aspirin 75mg od
while ticagrelor discontinued
Review date: 05/03/2022
Page 3 of 5
 Trust Guideline for the Management of Adult Patients on Antiplatelet Therapy
who require Elective Surgery or an Invasive Procedure

Objective

This revised guideline applies to patients taking antiplatelet therapy who require
surgery or an invasive procedure. It aims to standardise their management across the
Trust to minimise morbidity and mortality from thrombosis or haemorrhage.

Rationale

Optimal perioperative management of patients taking anti-platelet agents must

balance the risk of a thrombotic event associated with interruption of therapy and the
risk of haemorrhage associated with the procedure. This balance of risks will vary
between individual patients. Large, prospective trials do not exist to guide
management of perioperative management. This guideline is a consensus document
It will be applicable to the majority of patients undergoing elective surgery at NNUHFT.

Definitions

Antiplatelet therapy
 Aspirin, clopidogrel, dipyridamole, prasugrel, tricagrelor

Preoperative assessment
 Establish indication for antiplatelet therapy and which drug(s) patient is taking
 Assess the haemorrhagic risk of the surgical procedure

General comments

Antiplatelet agents
 Increasing numbers of patients are being prescribed antiplatelet agents with an
expanding list of types of agent and indication.
 Historical series have shown that continuing aspirin perioperatively is
associated with a low rate of bleeding. For most procedures it is safe to
continue aspirin continuing perioperatively.
 Clopidogrel is a newer antiplatelet agent with less perioperative experience
available for continuing this drug. Perioperative bleeding rates appear to be
higher with clopidogrel compared to aspirin. For this reason it is usually
advisable to discontinue preoperatively.

Regional anaesthesia
 NB. Specific care must be taken if regional/epidural anaesthesia is
planned. The case must be discussed with the anaesthetist performing the
anaesthetic and the trust guideline ‘CA2031 Regional Anaesthesia Patients
Venous Thromboprophylaxis with Anticoagulant and Antiplatelet Drugs
Trustdocs ID 1193 should be consulted.

Clinical Guideline for: Adult patients requiring elective surgery or an invasive procedure who are prescribed antiplatelet therapy
Author/s: Dr Hamish Lyall, Consultant Haematologist, Dr Anna Lipp Consultant Anaesthetics
Approved by: CGAP Date approved: 05/03/2019 Review date: 05/03/2022
Available via Trust Docs Version: 6 Trust Docs ID: 9836 Page 4 of 5
 Trust Guideline for the Management of Adult Patients on Antiplatelet Therapy
who require Elective Surgery or an Invasive Procedure

Clinical audit standards

Any audit should monitor rates of haemorrhagic or thrombotic complications

Summary of development and consultation process undertaken before

registration and dissemination

This guideline has had developed with input from cardiology, stroke physicians,
vascular surgeons interventional radiologists and anaesthetists. Its content agreed by
the NNUH Thrombosis and Thromboprophylaxis Committee. This version has been
endorsed by the Clinical Guidelines Assessment Panel.

Distribution list / dissemination method

This guideline will be available on the Trust intranet.

References / source documents

Perioperative management of antithrombotic therapy: antithrombotic therapy and

prevention of thrombosis, 9th ed: American College of Chest Physicians evidence –
based Clinical Practice Guidelines. Chest 2012; 141: e326S-320S

Changes made

Date Updated Previous Page Details

version version number/section
number number (updated version)
Removal of unused
12/02/14 V1.1 V1 Page 4
glossary table
Removal of Plastics
19/02/14 V2 V1.1 Page 2
exclusions
Clarification of moderate
24/09/17 V3 V2 Page 3
risk vascular surgery
Updated endoscopy link.
Definition of high risk
vascular stents changed
30/08/18 V4 V3 Page 1, 3
from 6/12 to 3/12.
Definition of moderate risk
changed from 6/12 to 3/12.
25/09/18 V5 V4 Page 2 Dental guidance updated
Document reviewed and
05/03/19 V6 V5 amended to current
practice.

Clinical Guideline for: Adult patients requiring elective surgery or an invasive procedure who are prescribed antiplatelet therapy
Author/s: Dr Hamish Lyall, Consultant Haematologist, Dr Anna Lipp Consultant Anaesthetics
Approved by: CGAP Date approved: 05/03/2019 Review date: 05/03/2022
Available via Trust Docs Version: 6 Trust Docs ID: 9836 Page 5 of 5