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Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis
Sahrish Shah1,2, Meritxell Urtecho1,2, Mohammed Firwana1,2
1Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.
Mayo Clinic Proceedings. Innovations, Quality & Outcomes
|October 28, 2022
Summary
Managing long-term antiplatelet therapy during surgery requires careful consideration. Continuing aspirin increases bleeding and thromboembolism risks, while bridging with heparin raises bleeding concerns.
Area of Science:
- Cardiology
- Pharmacology
- Surgical Management
Background:
- Long-term antiplatelet therapy is increasingly common.
- Managing these patients undergoing elective procedures presents a clinical challenge.
- Evidence-based guidelines are needed for perioperative care.
Purpose of the Study:
- To systematically review evidence on perioperative management of antiplatelet therapy.
- To inform clinical practice guidelines for patients on long-term antiplatelet agents.
Main Methods:
- Systematic literature search of major databases (MEDLINE, EMBASE, Scopus, Cochrane).
- Inclusion of studies up to July 16, 2020.
- Meta-analyses performed where feasible.
Main Results:
- No significant difference in major bleeding with shorter vs. longer antiplatelet interruption (low certainty of evidence).
- Aspirin continuation increased major bleeding (high certainty) and decreased major thromboembolism (moderate certainty) compared to placebo.
- Heparin bridging increased major bleeding risk versus no bridging (very low certainty).
- Antiplatelet continuation for minor procedures showed no significant increase in major bleeding (very low certainty).
Conclusions:
- Current evidence on perioperative antiplatelet management is limited.
- Further research is urgently needed due to rising antiplatelet use.
- Clinical decisions require careful risk-benefit assessment.
Keywords:
ACCP/CHEST, American College of Chest PhysiciansASA, acetylsalicylic acidATE, arterial thromboembolismCABG, coronary artery bypass graftCOE, certainty of evidenceCV, cardiovascularDES, drug-eluting stentLMWH, low-molecular-weight heparinMI, myocardial infarctionPE, pulmonary embolismPICO, patients–interventions–comparators–outcomesPRISMA, Preferred Reporting Items for Systematic Reviews and Meta-AnalysesRCT, randomized clinical trialRR, relative risk
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