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Published on: March 15, 2022
Decision making after aspirin, clopidogrel and GPIIb/IIIa inhibitor use
Antonio Maria Calafiore1, Angela Lorena Iacò, Adel Tash
1Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
Insights
Discontinuing antiplatelet drugs like aspirin and clopidogrel before coronary bypass grafting surgery requires careful timing to balance bleeding risks and treatment benefits. Specific stopping guidelines exist for different antiplatelet agents, with acute coronary syndrome patients often continuing treatment.
Area of Science:
- Cardiology
- Pharmacology
- Surgical Medicine
Background:
- Expanding use of antiplatelet agents in patients undergoing coronary bypass grafting (CABG) surgery presents a challenge in managing bleeding risks.
- Balancing the therapeutic benefits of antiplatelet therapy against the increased risk of postoperative bleeding is crucial.
- Aspirin and clopidogrel, common antiplatelet agents, share irreversible inhibition mechanisms, necessitating specific discontinuation protocols.
Purpose of the Study:
- To provide guidance on the optimal timing for discontinuing various antiplatelet agents before CABG surgery.
- To address the need for balancing antiplatelet therapy benefits with surgical bleeding risks.
- To review discontinuation strategies for aspirin, clopidogrel, and GPIIb/IIIa inhibitors.
Main Methods:
- Review of current literature and clinical recommendations regarding antiplatelet agent discontinuation before cardiovascular surgery.
- Analysis of the pharmacokinetic profiles and mechanisms of action of different antiplatelet drugs.
- Comparison of recommended discontinuation intervals for aspirin, clopidogrel, abciximab, tirofiban, and eptifibatide.
Main Results:
- Discontinuation of aspirin 2-3 days and clopidogrel 5 days before surgery is generally recommended, though shorter intervals for clopidogrel are being considered.
- Glycoprotein IIb/IIIa inhibitors have shorter action profiles: abciximab typically stopped 12-24 hours prior, tirofiban at skin incision, and eptifibatide 2-4 hours before surgery.
- Patients with acute coronary syndrome generally do not require discontinuation of antiplatelet treatment before surgery.
Conclusions:
- Tailored discontinuation schedules for antiplatelet agents are essential for optimizing outcomes in CABG patients.
- The timing of drug cessation should consider the specific agent's properties and the patient's clinical condition.
- Further research may refine discontinuation intervals, particularly for clopidogrel, to enhance safety and efficacy.
Abstract:
The expanding use of antiplatelet agents in patients who undergo coronary bypass grafting raises the problem of balancing the benefit of this treatment and the risk of increased bleeding after surgery. Aspirin and clopidogrel have different mechanisms of actions, but have in common the irreversibility of the inhibition mechanism. Even if platelets half-life is around 10 days, it is not necessary to wait for this period of time. It can be reasonable to discontinue aspirin two to three days and clopidogrel five days before surgery, even if it was recently suggested to reduce the discontinuation interval to two to three days for the clopidogrel as well. GPIIb/IIIa inhibitors have a short acting action. Reasonably, abciximab has to be stopped, when possible, at least 12 hours before surgery, preferably before 24 hours. On the contrary, tirofiban can also be stopped at the moment of skin incision without harmful effects. Very little is known of eptifibatide, but it seems that it is safe to stop it two to four hours before surgery. Patients with acute coronary syndrome do not need to discontinue any antiplatelet treatment.
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