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• W1933500828 abstract "A significant proportion of patients undergoing otolaryngological surgery take antiplatelet therapy for a variety of conditions, including coronary artery disease and angina; following cardiac procedures, stroke, or transient ischemic attacks; and peripheral vascular disease. However, continuation of antiplatelet therapy may lead to increased risk of bleeding, whereas discontinuation could cause cardiovascular complications. Deciding if and when to hold antiplatelet therapy for elective surgery can be difficult because surgeons must balance the patient's cardiovascular health, the thromboembolic risk of interrupting antiplatelet therapy, and the perioperative bleeding risk for the particular procedure.1 Several prospective and retrospective studies have investigated the consequences of continuing or interrupting antiplatelet therapy in the perioperative period. These studies are summarized in Table 1. Devereaux et al.2 conducted a randomized, controlled trial of 10,010 patients undergoing noncardiac surgery. Patients were randomized to aspirin or placebo. Patients with recently placed coronary stents (< 6 weeks for bare metal stent or < 1 year for drug-eluting stent) were excluded. Preoperatively, all patients received 200 mg aspirin or a placebo, and postoperatively, they received 100 mg aspirin daily. Patients previously taking aspirin took 100 mg daily for 7 days and then resumed their prior daily aspirin dose. Patients not previously taking aspirin took 100 mg daily for 30 days postoperatively. The incidence of major adverse cardiac events (MACEs), defined as mortality, nonfatal myocardial infarction, or coronary revascularization, was compared between aspirin and control groups. The incidence of major or life-threatening bleeding within 30 days after surgery was also analyzed. Aspirin did not have a protective effect on MACEs (hazard ratio [HR] in the aspirin group, 0.99; 95% confidence interval [CI], 0.86–1.15; P = 0.92). However, aspirin was associated with an increased risk of major bleeding (HR, 1.23; 95% CI, 1.01–1.49; P = 0.04). Francis et al.3 performed a retrospective analysis of 234 patients who underwent 287 microlaryngeal surgeries. Of these, 66 surgeries were for patients on antiplatelet regimens, including aspirin alone, clopidogrel alone, nonsteroidal antiinflammatory drugs (NSAIDs) alone, aspirin and clopidogrel, and aspirin and NSAIDs. Antiplatelet therapy was maintained in 41 cases and interrupted perioperatively in 25 cases. Rates of perioperative bleeding complications and thromboembolic events were compared. Antiplatelet therapy status did not significantly affect the rate of bleeding complications (4.9% of cases maintained on therapy, 8.0% of cases with interrupted therapy; P = 0.63). No thromboembolic events occurred in either group. This small retrospective study suggests that aspirin continuation is safe in microlaryngeal surgery. Although prospective evidence is lacking, this may also be applicable to other otolaryngological procedures associated with low bleeding risk. Wilson et al.4 performed a retrospective analysis of 207 patients who underwent noncardiac surgery within 2 months after coronary bare metal stent (BMS) placement. Rates of MACEs were compared with respect to number of weeks between stenting and surgery. Antiplatelet regimens and perioperative bleeding complications were also analyzed. All deaths, nonfatal myocardial infarctions, or stent thromboses occurred in patients who underwent surgery within 6 weeks of stent placement (4.8% of patients; 95% CI, 2.1–9.2), whereas no events occurred in patients whose surgeries took place greater than 6 weeks after stent placement (0% of patients; 95% CI, 0.0–9.0). Interestingly, no clear relationship between type of antiplatelet therapy and amount of surgical bleeding was observed. Van Kuijk et al.5 performed a retrospective analysis of 550 patients who underwent noncardiac surgery after coronary stent placement. Rates of MACEs were compared by timing of surgery after stent placement; bleeding rates with respect to type of antiplatelet therapy were also analyzed. In the BMS group, rates of MACEs during intervals of < 1 month, 30 days to 3 months, and > 3 months were 50%, 14%, and 4%, respectively (overall P < 0.001). In the drug-eluting stent (DES) group, rates of MACEs during intervals of < 1 month, 30 days to 3 months, 3 to 6 months, 6 to 12 months, and > 12 months were 35%, 13%, 15%, 6%, and 9% (overall P < 0.001). At the time of surgery, 45% of patients were receiving single antiplatelet therapy and 55% were receiving dual antiplatelet therapy. With respect to bleeding, patients receiving dual antiplatelet therapy were also observed to have severe bleeding in 21% of cases, compared to 4% of patients on single antiplatelet therapy (P < 0.001). In these two retrospective studies, the high rate of MACEs in patients who underwent surgery soon after stent placement suggests that patients have better outcomes when surgery is delayed, allowing time for the stent to endothelialize. These studies demonstrate that, in patients with no history of coronary stenting taking aspirin as single antiplatelet therapy, aspirin interruption is safe and reduces bleeding. In otolaryngological procedures with low bleeding risk, aspirin continuation may be safe; but until stronger evidence is gathered, the most conservative recommendation is to interrupt aspirin. However, aspirin should be continued in select patients whose thromboembolic risk outweighs bleeding risk. To minimize MACE risk in patients with coronary stents taking dual antiplatelet therapy, noncardiac surgery should be postponed, if possible, at least 6 weeks after BMS placement or 1 year after DES placement. If surgery must be performed within this time frame, dual antiplatelet therapy should be continued due to the high MACE rate associated with surgery soon after stenting.4, 5 If the surgical bleeding risk mandates interruption, according to the 2014 American College of Cardiology/American Heart Association guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery, the thienopyridine should be held and aspirin continued if possible.1 Optimal management for each patient should be decided in conjunction with the patient's cardiologist and anesthesiologist. Because aspirin and thienopyridines are irreversible platelet inhibitors, the interval between the last dose and surgery should be 7 to 10 days, allowing approximately 90% of the platelet pool to be replaced. Antiplatelet therapy should be resumed 24 hours after surgery, once adequate hemostasis has been achieved. Reversible antiplatelet agents such as cilostazol or NSAIDs should be stopped approximately five elimination half-lives before surgery to allow 95% platelet recovery. The decision to interrupt antiplatelet therapy must balance the patient's thromboembolic risk and perioperative bleeding risk and is therefore best made in conjunction with the patient's cardiologist and anesthesiologist. In most cases, aspirin can be safely interrupted for patients without stents; for patients with stents on dual antiplatelet therapy, surgery should be delayed 6 weeks after BMS or 1 year after DES, at which time thienopyridines can be interrupted. Prospective studies on perioperative antiplatelet management, stratifying otolaryngological procedures by bleeding risk, are necessary to further guide individual recommendations. One level 1B,2 two level 2B,4, 5 and one level 43 study were evaluated in this review." @default.
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• W1933500828 date "2015-11-04" @default.
• W1933500828 modified "2023-09-27" @default.
• W1933500828 title "What is the optimal perioperative management of antiplatelet therapy?" @default.
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• W1933500828 doi "https://doi.org/10.1002/lary.25776" @default.
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