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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.
Insights
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.
Objective:
To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.
Methods:
This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible.
Results:
In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE).
Conclusion:
This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.
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