Drugs For The Heart in Perioperative When To Stop and When To Start

Drugs for The Heart in Perioperative:
When to Stop and When to Start

Hendry Purnasidha Bagaswoto, MD, FIHA
Department of Cardiology and Vascular Medicine
Faculty of Medicine Gadjah Mada University
Sardjito General Hospital - Yogyakarta
What kind of Drugs ?
Especially → Antiplatelet and Anticoagulants

Peri-operative management in patients on
anti-platelet agents
Management of patients on DAPT who are referred for
surgical procedures involves consideration of:
▪ The risk of stent thrombosis (particularly if DAPT needs to be

interrupted);
▪ The consequences of delaying the surgical procedure; and
▪ The increased intra- and periprocedural bleeding risk and
possible consequences of such bleeding if DAPT is continued
Valgimigli M, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in
collaboration with EACTS.
Aspirin
▪ Aspirin should be discontinued if the bleeding risk outweighs

the potential cardiovascular benefit
▪ The use of low-dose aspirin in patients undergoing non-cardiac surgery

should be based on an individual decision, which depends on the peri
operative bleeding risk, weighed against the risk of thrombotic
complications
Kristensen, et al. 2014. ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management.
Dual anti-platelet therapy
▪ Balance between the risk of life-threatening surgical bleeding on anti-

platelet therapy and the risk of life-threatening stent thrombosis off
DAPT
▪ The ‘standard’ duration for DAPT after bare-metal stenting (BMS) is

different to that for drug-eluting stent (DES) treatment
▪ DAPT be administered for at least 1 month after BMS

implantation in stable CAD, for 6 months after new-generation
DES implantation, and for up to 1 year in patients after ACS,
irrespective of revascularization strategy
▪ Elective surgery should be postponed for a minimum of 4

weeks and ideally for up to 3 months after BMS implantation.
Importantly, whenever possible, aspirin should be continued
throughout surgery
▪ In patients needing surgery within a few days, current ESC

Guidelines recommend with holding clopidogrel and ticagrelor
for five days and prasugrel for seven days prior to surgery
unless there is a high risk of thrombosis
▪ For patients with a very high risk of stent thrombosis, bridging

therapy with intravenous, reversible glycoprotein inhibitors,
such as eptifibatide or tirofiban, should be considered
▪ Dual anti-platelet therapy should be resumed as soon as possible

after surgery and, if possible, within 48 hours
Rossini R, et al. 2014. Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-
cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. Euro Intervention 2014; 10: 38-46.
Fleisher LA, et al. 2014 ACC/AHA Perioperative Guideline
Valgimigli M, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS
Valgimigli M, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS
Peri-operative management in patients on
anticoagulants agents
Vitamin K-antagonist
▪ INR is ≤ 1.5, surgery can be performed safely
▪ Patients with a high risk of thrombo-embolism :

✓ AF with a CHA2DS2-VASc [Cardiac failure, Hypertension, Age ≥75 (Doubled),
Diabetes, Stroke (Doubled) – Vascular disease, Age 65–74 and Sex category
(Female)] score of ≥4]
✓ Mechanical prosthetic heart valves, newly inserted biological prosthetic heart valves
✓ Mitral valvular repair (within the past 3 months)
✓ Recent venous thrombo-embolism (within 3 months)
✓ Thrombophilia
Discontinuation of VKAs is hazardous and these patients will need bridging

therapy with unfractionated heparin (UFH) or therapeutic-dose LMWH
Vitamin K-antagonist
▪ VKA treatment be stopped 3–5 days before surgery (depending

on the type of VKA), with daily INR measurements, until ≤1.5 is
reached, and that LMWH or UFH therapy be started one day after
discontinuation of VKA—or later, as soon as the INR is <2.0
▪ Mechanical prosthetic heart valves, intravenous UFH is more solid;

UFH until four hours before surgery, and treatment with UFH is
resumed after surgery until the INR is within the therapeutic
range
UFH versus LMWH
▪ Efficacy and safety of LMWH >> UFH, in bridging to surgery
▪ LMWH is usually administered subcutaneously and weight-adjusted for

once- or twice-daily administration without laboratory monitoring
▪ In patients with a high thrombo-embolic risk, therapeutic doses of

LMWH twice daily are recommended, and prophylactic once-daily
doses in low-risk patients.
▪ The last dose of LMWH should be administered no later than 12

hours before the procedure
▪ On the day of the procedure, the INR should be checked.
Consideration should be given to postponing if INR is >1.5
▪ LMWH or UFH is resumed at the pre-procedural dose 1–2 days after

surgery, depending on the patient’s haemostatic status, but at least
12 hours after the procedure
▪ VKAs should be resumed on day 1 or 2 after surgery— depending on

adequate haemostasis—with the pre-operative maintenance dose
plus a boosting dose of 50% for two consecutive days; the
maintenance dose should be administrated thereafter
▪ LMWH or UFH should be continued until the INR returns to therapeutic
levels.
▪ Furthermore, the type of surgical procedure should be taken into

consideration, as the bleeding risk varies considerably and affects
haemostatic control.
▪ Procedures with a high risk of serious bleeding complications are those

where compression cannot be performed. In these cases, discontinuation
of oral anticoagulants and bridging therapy with LMWH are warranted.
▪ In patients undergoing surgery with a low risk of serious bleeding, such

as cataract- or minor skin surgery, no change in oral anticoagulation
therapy is needed; however, it is wise to keep INR levels in the lower
therapeutic range
Non Vitamin K-antagonist
▪ Non-VKA direct oral anticoagulants (NOACs) dabigatran (a

direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban
(all direct factor Xa inhibitors), all of which have a well-defined
‘on’ and ‘off’ action, ‘bridging’ to surgery is in most cases
unnecessary, due to their short biological half-lives
Reversal of anticoagulant therapy
▪ In patients who are receiving VKAs and who require reversal of the
anticoagulant effect for an urgent surgical procedure, low-dose (2.5
–5.0 mg) intravenous or oral vitamin K is recommended.
▪ The effect of vitamin K on INR will first be apparent after 6–12

hours. If more immediate reversal of the anticoagulant effect of
VKAs is needed, fresh-frozen plasma or
treatment with
prothrombin complex concentrate (PCC), is recommended, in
addition to low-dose intravenous or oral vitamin K
▪ In patients receiving UFH and requiring reversal of the anticoagulant

effect for an urgent surgical procedure, cessation of therapy is
sufficient, because coagulation is usually normal four hours
after cessation
▪ When UFH is given subcutaneously, the anticoagulant effect is more

prolonged. For immediate reversal, the antidote is protamine
sulphate.
▪ The dose of protamine sulphate for reversal of a heparin infusion is 1

U per 1 U of heparin sodium
▪ In patients who are receiving LMWHs, the anticoagulant effect may

be reversed within eight hours of the last dose because of the
short half-life.
▪ If immediate reversal is required, intravenous protamine sulphate

can be used, but anti-Xa activity is never completely neutralized
(maximum 50%)
-Matur Nuwun-

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Drugs for The Heart in Perioperative:

When to Stop and When to Start

Especially → Antiplatelet and Anticoagulants

▪ The risk of stent thrombosis (particularly if DAPT needs to be

▪ Aspirin should be discontinued if the bleeding risk outweighs

▪ The use of low-dose aspirin in patients undergoing non-cardiac surgery

▪ Balance between the risk of life-threatening surgical bleeding on anti-

▪ The ‘standard’ duration for DAPT after bare-metal stenting (BMS) is

▪ DAPT be administered for at least 1 month after BMS

▪ Elective surgery should be postponed for a minimum of 4

▪ In patients needing surgery within a few days, current ESC

▪ For patients with a very high risk of stent thrombosis, bridging

▪ Dual anti-platelet therapy should be resumed as soon as possible

▪ INR is ≤ 1.5, surgery can be performed safely

▪ Patients with a high risk of thrombo-embolism :

Discontinuation of VKAs is hazardous and these patients will need bridging

▪ VKA treatment be stopped 3–5 days before surgery (depending

▪ Mechanical prosthetic heart valves, intravenous UFH is more solid;

▪ LMWH is usually administered subcutaneously and weight-adjusted for

▪ In patients with a high thrombo-embolic risk, therapeutic doses of

▪ The last dose of LMWH should be administered no later than 12

▪ LMWH or UFH is resumed at the pre-procedural dose 1–2 days after

▪ VKAs should be resumed on day 1 or 2 after surgery— depending on

▪ Furthermore, the type of surgical procedure should be taken into

▪ Procedures with a high risk of serious bleeding complications are those

▪ In patients undergoing surgery with a low risk of serious bleeding, such

▪ Non-VKA direct oral anticoagulants (NOACs) dabigatran (a

unnecessary, due to their short biological half-lives

▪ The effect of vitamin K on INR will ﬁrst be apparent after 6–12

▪ In patients receiving UFH and requiring reversal of the anticoagulant

▪ When UFH is given subcutaneously, the anticoagulant effect is more

▪ The dose of protamine sulphate for reversal of a heparin infusion is 1

▪ In patients who are receiving LMWHs, the anticoagulant effect may

▪ If immediate reversal is required, intravenous protamine sulphate

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