Thread by @SGuptaMD

As a cardiologist, every day I see 2-3 patients who need clearance for surgery 🔪

ALL of them are on blood thinners🩸

Every surgeon wants to stop these medicines💊

The patients ask:
Is it safe?
Should I stop?

Let's see how to deal with blood thinners before surgery
🧵👇

1/18 🩺 The management of patients on blood thinners undergoing procedures is a common clinical challenge

Blood thinners are of 2 types:

a)Anticoagulants - eg: warfarin
b)Antiplatelets - eg: Aspirin, clopidogrel etc

In this thread, we will discuss only antiplatelets

2/18 Antiplatelets are divided into 2 groups based on mechanism of action 💪

a) NSAID Group
👉Aspirin

b) The P2Y12 Group:
👉Clopidogrel
👉Prasugrel
👉Ticagrelor
👉Cangrelor

Directly or indirectly they act on the platelet surface and make it less sticky

3/18 The duration and characteristics of onset and offset vary with each agent.

4/18 💡 When evaluating patients, we need to understand the type of surgery based on the bleeding risk:

✅ High Risk
✅ Low to moderate risk
✅ Minimal Risk

5/18 Ok, so my patient is on Aspirin needs non-cardiac surgery like a hernia?

Should I continue or stop the Aspirin?

That depends on why it was started 🧐

6/18 In stable coronary artery disease patients studied in PEP and POISE 2 trial there was not much benefit

Meta-analysis also found no benefit with ⬆️ bleeding

But,these trials had limitations - it was felt that peri-operative NSAID use may have negated some of the benefits

7/18 So it generally felt that if your patient is not on Aspirin then do not start it (no benefit) ❌

and if they are taking it, then ✅continue it(marginal benefit) unless high bleeding risk surgery.

journal.chestnet.org/article/S0012-…

8/18 and What if my patient has STENTS? ⛓️

Is there a role of Aspirin? 🧐

The substudy of POISE 2 studied this:

Those patients with stents where aspirin was continued had a lower cardiac event rate albeit increased risk of bleeding (approx 1%)

9/18 so to summarize:

if you have a stent or not, try and continuine Aspirin in the peri-operative period

but WAIT ⌛

What about the other antiplatelets? The ones that the cardiologist prescribes after stents like Clopidogrel ?

10/18 This is a bit more complex. It depends on a lot of factors:

✅ Type of stent
✅ Location of stent
✅ Number of stents
✅ Length of stents
✅ Timing of surgery

Risk is highest between 6-12 weeks of stent placement and may persist for a year

11/18 In the early phase after stent placement it is a bit tricky,

Stopping these antiplatelets can cause the stent to thombose/close 🤯

The risk of thrombosis is high (8-10%) with a high mortality (>50%)☠️

12/18 To reduce this,various bridging strategies with IV antiplatelets and anti-thrombotics llike LMWH, UFH, Gp2b-3a etc have been studied with no clear consensus of their use.

sciencedirect.com/science/articl…

13/18 And if more than 3 months since the stents, then the P2Y12 can usually be safely stopped in the perioperative period

Once again, it is on case-by-case review ⚖️

14/18 Ok, so when to restart?

At the earliest after surgery ⚡

Peak action 🗻depends on the medicine:

Aspirin : within minutes
Ticagrelor: 2 hours
Prasugrel:3 days
Clopdogrel(75mg): 4-5 days

15/18 To summarize:

👉 Continue Aspirin with or without a stent
👉 Stent < 3 months
a) Try and continue both Aspirin + P2Y12 if possible.
b) If not, bridging therapies can be considered(case by case)
👉 Stent > 3-12 months
a) Ok to stop one antiplatelet if needed

⬇️

16/18..(Contd)
👉 Whenever possible delay elective surgeries for a year after stent placement
👉 In minor dental and skin procedures continue both anti-platelets

Chart below details when to stop and restart

17/18 🗣️ Consultation with a cardiologist and surgeon is advised in high-risk situations, like surgery within 6-12weeks of stenting.

Important to customize therapies depending on patient and surgery ☯️⚖️

18/18 That's all for now. Hope you learned something new today. Don't forget to share and retweet so your followers can learn as well.

https://twitter.com/SGuptaMD/status/1662785804047884289