Management of Antiplatelet Regimen During Surgical Procedures: a Report from the MARS Registry

Optimal perioperative management of patients on dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains controversial, with substantial variability in current clinical practice. The MARS registry is a prospective multicenter observational study evaluating perioperative outcomes in post-PCI patients on DAPT undergoing surgery within 2 years of PCI. We assessed the incidence of Net Adverse Cardiovascular Events (NACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction (MI), ischemic stroke, urgent coronary revascularization, or Bleeding Academic Research Consortium (BARC) type ≥3 bleeding. A total of 132 consecutive patients undergoing moderate- to high-risk surgery were followed from 14 days preoperatively to 30 days postoperatively. Of the 132 patients, 79 underwent non-cardiac surgery (NCS) and 53 underwent cardiac surgery (CS). The mean age was 66 years, and 68% were male. Diabetes mellitus was present in 48%, chronic kidney disease in 29%, and 42% had undergone PCI for an acute coronary syndrome. Mean time from PCI to surgery was 269 ± 217 days. Prior bleeding and stent thrombosis were reported in 11% and 5% of patients, respectively. Aspirin was continued in 60% and P2Y12 inhibitors in 36%, with mean discontinuation 4 and 6 days preoperatively, respectively. Intravenous antiplatelet bridging with cangrelor was used in 12 patients (9.1%) and unfractionated heparin as anticoagulant therapy in 15 patients (11.0%). NACE occurred more frequently after CS compared with NCS (18.9% vs. 10.1%, p=0.17). Major bleeding (BARC ≥3) occurred in 5.3% with no difference between CS and NCS. There were no cardiovascular deaths and no difference in all-cause mortality. Compared with no bridging, cangrelor bridging was associated with numerically higher NACE (25.0% vs. 12.5%, p=0.22), without differences in bleeding. On multivariable logistic regression, cangrelor bridging was not independently associated with NACE (adjusted OR 2.18, 95% CI 0.43-8.71, p=0.34). In conclusion, among post-PCI patients on DAPT undergoing moderate- to high-risk surgery, aspirin was continued in 60%, cangrelor bridging was used in 9.1%, and although NACE rates were numerically higher after cardiac surgery and with bridging, these differences were not significant after multivariable adjustment, consistent with confounding by indication.