Antiplatelet Therapy in Stented Patients Needing Surgery: Italian Experience Provides Direction

Adhering to Italian national consensus recommendations on the perioperative management of antiplatelet therapy in stented patients undergoing cardiac and noncardiac surgery is not only safe and feasible but also results in risks of ischemic events and bleeding that fall within the generally accepted surgical standards, according to a new study.

For 1,082 patients enrolled in the Surgery After Stenting (SAS) registry, the incidence of net adverse clinical events (NACE) during the surgical admission—a composite that included all-cause mortality, MI, probable/definite stent thrombosis, and bleeding complications—was 12.7%, while the 30-day rates of major adverse cardiovascular events and stent thrombosis were 3.5% and 0.2%, respectively.  

“For a number of years, there has been a lot of debate on the optimal management of antiplatelet therapy in patients who have undergone coronary stenting and require noncardiac surgery,” said Dominick Angiolillo, MD (University of Florida, Jacksonville). “And because of this, investigators in Italy among various medical and surgical subspecialties developed a national consensus document. They made a monumental effort to come up with recommendations where the surgeons and interventional cardiologists all agreed upon what would be the optimal management of the patient with stents.”

Angiolillo, who coauthored the SAS registry paper and the consensus document, told TCTMD the recommendations are based on the thrombotic risk of the patient, the type of surgery, and the bleeding risk of that surgery. “There is an app where physicians can plug in information—literally almost any type of surgery—and it will provide you with information on how to best manage the antiplatelet treatment in that patient undergoing that specific surgery,” he said.

The study, which was led by Roberta Rossini, MD (ASST Papa Giovanni XXIII, Bergamo, Italy) and published online last week in Catheterization and Cardiovascular Interventions, applies the 2014 consensus recommendations from 16 professional societies, including those representing invasive cardiology, surgery, and anesthesiology, to determine if use is feasible in real-world clinical practice. Generally speaking, the recommendations state aspirin should be continued perioperatively in the majority of surgeries and that dual antiplatelet therapy should not be stopped in surgeries with a low risk of bleeding. For the patient at high risk of bleeding and ischemic events, if the withdrawal of oral antiplatelet is needed, the experts recommend the consideration of bridging with short-acting intravenous glycoprotein IIb/IIIa inhibitors.

Overall, 85% of patients enrolled in the SAS registry were treated according to the consensus recommendations, with perioperative aspirin maintained in 69.7% of patients and dual antiplatelet therapy in 10.5% of patients. Regarding NACE, the rate was significantly higher among patients undergoing cardiac surgery (36.3% vs 7.3% in noncardiac surgery; P < 0.01), a difference driven by an increase in BARC 3 bleeding, which is overt bleeding requiring a transfusion, surgical intervention, or an intracranial hemorrhage/bleeding compromising vision. The 30-day rate of major adverse cardiac events was similar in patients undergoing cardiac surgery or noncardiac surgery (3.5%).

“Essentially, what the study shows is that, yes, it is feasible to use the national consensus document in real-world clinical practice, with over 1,000 stented patients undergoing surgery,” said Angiolillo. “It showed, overall, what we might call a certain safety profile, although this wasn’t a randomized trial and wasn’t designed to show safety or efficacy. But in applying these recommendations, the event rates would be considered within the acceptable range.”

Overall, Angiolillo had high praise for the Italian consensus document and real-world application of the recommendations, noting the United States could benefit from such an effort. The request for help managing antiplatelet therapy in stented patients requiring surgery is a common issue, “something we face on a daily basis,” he added. The consensus recommendations, particularly the app itself, can help the practicing cardiologist who might not always know what to do, especially since they are not always familiar with the specific bleeding risk of a certain surgery. “The input of surgeons has been instrumental,” said Angiolillo.

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