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Noncardiac Surgery After PCI

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In these slides I discuss what to do with the patient post stent who needs noncardiac surgery and I discuss what to do with anti-platelet therapy in the perioperative period. Watch my YouTube description of these slides at http://youtu.be/z8Okm3_GFbU.

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Noncardiac Surgery After PCI

  1. 1. Noncardiac Surgery After PCI What to do? Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine
  2. 2. You must balance… Stent Thrombosis Bleeding
  3. 3. Adverse Cardiac Events Following Noncardiac Surgery in Patients With Stents Hawn, et al. JAMA 2013;310:1462
  4. 4. • Class I • Elective noncardiac surgery should be delayed • 14 D after balloon angioplasty • 30 D after BMS implantation • 365 D after DES implantation • Class IIb • Elective noncardiac surgery after DES implantation may be considered after 180 D if risk of further delay > risk of stent thrombosis 2014 ACC/AHA Perioperative Guidelines
  5. 5. • Class III (Harm) • Elective noncardiac surgery in which DAPT will need to be discontinued should not be performed within • 30 D after BMS • 365 D after DES • If elective noncardiac surgery is needed within 1- 12 months then place BMS with 4-6 wks of DAPT with continuation of ASA perioperatively 2014 ACC/AHA Perioperative Guidelines
  6. 6. Approach to patients who need surgery after PCI Wait 4-6 weeks Wait 12 months Continue dual antiplatelet therapy if surgery needed before completion of recommended therapy No matter what continue at least aspirin* * Except for neurosurgery, post eye, middle ear, and prostate
  7. 7. • Aspirin (and aspirin/dipyridamole) • POISE-2 trial (N Engl J Med 2014; 370:1494-1503) suggests that aspirin is of no benefit in patients at moderate to high risk for cardiovascular events who are undergoing noncardiac surgery • Stop 7-10 days prior to surgery • Bleeding time is a poor predictor of perioperative hemorrhage Managing antiplatelet agents in the perioperative period
  8. 8. • Platelet P2Y12 receptor blockers • Clopidogrel and ticagrelor: stop at least 5 days before surgery • Prasugrel: stop at least 7 days before surgery • Cilostazol • Selective phosphodiesterase-3 enzyme inhibitor with weak, reversible antiplatelet activity • Stop 5 days before surgery Managing antiplatelet agents in the perioperative period

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