Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week

Area of Science:

• Cardiology
• Cardiovascular Surgery
• Pharmacology

Background:

• Patients with coronary stents face increased mortality risk from ischemic and bleeding complications if surgery occurs soon after stent implantation.
• Discontinuing dual antiplatelet therapy (DAPT) before surgery poses risks, and the optimal strategy for patients unable to stop DAPT remains undefined.
• Current guidelines offer risk stratification for bridging therapy but lack definitive recommendations, relying heavily on expert opinion.

Purpose of the Study:

• To review perioperative risk factors influencing the decision to discontinue DAPT in patients with coronary stents.
• To summarize existing data on intravenous bridging therapies used when DAPT cannot be stopped before surgery.
• To address the uncertainty surrounding the optimal antiplatelet strategy in this high-risk patient population.

Main Methods:

• Literature review of published reports on perioperative management of patients on DAPT after coronary stent implantation.
• Analysis of available data on intravenous antiplatelet agents, including glycoprotein IIb/IIIa inhibitors and cangrelor.
• Synthesis of information regarding perioperative risk factors and bridging strategies.

Main Results:

• Published data include bridging options like glycoprotein IIb/IIIa inhibitors (eptifibatide, tirofiban) and cangrelor (an intravenous P2Y12 inhibitor).
• No randomized controlled trials exist to guide optimal management, leading to conflicting evidence for or against perioperative bridging therapy.
• Multidisciplinary risk assessment is crucial for managing these complex surgical patients.

Conclusions:

• Optimal management for patients requiring surgery shortly after coronary stenting and unable to discontinue DAPT is unclear due to a lack of definitive evidence.
• Both the use and non-use of perioperative intravenous bridging therapy can be argued in the absence of randomized controlled data.
• A comprehensive, multidisciplinary approach to risk assessment is essential for guiding perioperative care in these patients.