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In reply: Perioperative interruption of dual antiplatelet therapy

In Reply: We reported on publications from 2016–2017 and, unfortunately, at the time we were writing our paper, the European Society of Cardiology (ESC) update on dual antiplatelet therapy1 had not yet been published. We presented the recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA),2 which differ from the recently published ESC guidelines. The ESC suggests that the minimum waiting period after drug-eluting stent placement before noncardiac surgery should be 1 month rather than 3 months but acknowledges that in the setting of complex stenting or recent acute coronary syndrome, 6 months is preferred. The recommendation in this latter scenario is a class IIb C recommendation—essentially expert consensus opinion.

Further, in the study by Egholm et al,3 the event rates in patients undergoing noncardiac surgery in the 1- to 2-month period were numerically higher than in the control group, and no adjusted odds ratios were given. The numbers of events were very low, and a change of only 1 or 2 events in the other direction in the groups would likely make it statistically significant.

All of these recommendations are based on observational studies and registry data, as there are no randomized controlled trials to address this issue. There are many complexities to be accounted for including the type of stent, timing, circumstances surrounding stenting, anatomy, number of stents, patient comorbidities (particularly age, diabetes mellitus, cardiac disease), type of surgery and anesthesia, and perioperative management of antiplatelet therapy. While we acknowledge the ESC recommendation, we would urge caution in the recommendation to wait only 1 month, and in the United States most would prefer to wait 3 months if possible.

References
  1. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260. doi:10.1093/eurheartj/ehx419
  2. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. Circulation 2016; 134(10):e123–e155. doi:10.1161/CIR.0000000000000404
  3. Egholm G, Kristensen SD, Thim T, et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol 2016; 68(24):2622–2632. doi:10.1016/j.jacc.2016.09.967
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Ryan Munyon
Penn State University, Hershey, PA; rmunyon@pennstatehealth.psu.edu

Steven L. Cohn, MD, FACP, SFHM
University of Miami Miller School of Medicine, Miami, FL

Barbara Slawski, MD, MS, SFHM
Medical College of Wisconsin, Milwaukee

Gerald W. Smetana, MD, MACP
Harvard Medical School, Boston, MA

Kurt Pfeifer, MD, FACP, SFHM
Medical College of Wisconsin, Milwaukee

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Cleveland Clinic Journal of Medicine - 85(4)
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261-262
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dual antiplatelet therapy, DAPT, drug-eluting stent, DES, surgery, perioperative care, perioperative bridging, European Society of Cardiology, ESC, guidelines, Ryan Munyon, Steven Cohn, Barbara Slawski, Gerald Smetana, Kurt Pfeifer
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Ryan Munyon
Penn State University, Hershey, PA; rmunyon@pennstatehealth.psu.edu

Steven L. Cohn, MD, FACP, SFHM
University of Miami Miller School of Medicine, Miami, FL

Barbara Slawski, MD, MS, SFHM
Medical College of Wisconsin, Milwaukee

Gerald W. Smetana, MD, MACP
Harvard Medical School, Boston, MA

Kurt Pfeifer, MD, FACP, SFHM
Medical College of Wisconsin, Milwaukee

Author and Disclosure Information

Ryan Munyon
Penn State University, Hershey, PA; rmunyon@pennstatehealth.psu.edu

Steven L. Cohn, MD, FACP, SFHM
University of Miami Miller School of Medicine, Miami, FL

Barbara Slawski, MD, MS, SFHM
Medical College of Wisconsin, Milwaukee

Gerald W. Smetana, MD, MACP
Harvard Medical School, Boston, MA

Kurt Pfeifer, MD, FACP, SFHM
Medical College of Wisconsin, Milwaukee

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In Reply: We reported on publications from 2016–2017 and, unfortunately, at the time we were writing our paper, the European Society of Cardiology (ESC) update on dual antiplatelet therapy1 had not yet been published. We presented the recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA),2 which differ from the recently published ESC guidelines. The ESC suggests that the minimum waiting period after drug-eluting stent placement before noncardiac surgery should be 1 month rather than 3 months but acknowledges that in the setting of complex stenting or recent acute coronary syndrome, 6 months is preferred. The recommendation in this latter scenario is a class IIb C recommendation—essentially expert consensus opinion.

Further, in the study by Egholm et al,3 the event rates in patients undergoing noncardiac surgery in the 1- to 2-month period were numerically higher than in the control group, and no adjusted odds ratios were given. The numbers of events were very low, and a change of only 1 or 2 events in the other direction in the groups would likely make it statistically significant.

All of these recommendations are based on observational studies and registry data, as there are no randomized controlled trials to address this issue. There are many complexities to be accounted for including the type of stent, timing, circumstances surrounding stenting, anatomy, number of stents, patient comorbidities (particularly age, diabetes mellitus, cardiac disease), type of surgery and anesthesia, and perioperative management of antiplatelet therapy. While we acknowledge the ESC recommendation, we would urge caution in the recommendation to wait only 1 month, and in the United States most would prefer to wait 3 months if possible.

In Reply: We reported on publications from 2016–2017 and, unfortunately, at the time we were writing our paper, the European Society of Cardiology (ESC) update on dual antiplatelet therapy1 had not yet been published. We presented the recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA),2 which differ from the recently published ESC guidelines. The ESC suggests that the minimum waiting period after drug-eluting stent placement before noncardiac surgery should be 1 month rather than 3 months but acknowledges that in the setting of complex stenting or recent acute coronary syndrome, 6 months is preferred. The recommendation in this latter scenario is a class IIb C recommendation—essentially expert consensus opinion.

Further, in the study by Egholm et al,3 the event rates in patients undergoing noncardiac surgery in the 1- to 2-month period were numerically higher than in the control group, and no adjusted odds ratios were given. The numbers of events were very low, and a change of only 1 or 2 events in the other direction in the groups would likely make it statistically significant.

All of these recommendations are based on observational studies and registry data, as there are no randomized controlled trials to address this issue. There are many complexities to be accounted for including the type of stent, timing, circumstances surrounding stenting, anatomy, number of stents, patient comorbidities (particularly age, diabetes mellitus, cardiac disease), type of surgery and anesthesia, and perioperative management of antiplatelet therapy. While we acknowledge the ESC recommendation, we would urge caution in the recommendation to wait only 1 month, and in the United States most would prefer to wait 3 months if possible.

References
  1. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260. doi:10.1093/eurheartj/ehx419
  2. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. Circulation 2016; 134(10):e123–e155. doi:10.1161/CIR.0000000000000404
  3. Egholm G, Kristensen SD, Thim T, et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol 2016; 68(24):2622–2632. doi:10.1016/j.jacc.2016.09.967
References
  1. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260. doi:10.1093/eurheartj/ehx419
  2. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. Circulation 2016; 134(10):e123–e155. doi:10.1161/CIR.0000000000000404
  3. Egholm G, Kristensen SD, Thim T, et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol 2016; 68(24):2622–2632. doi:10.1016/j.jacc.2016.09.967
Issue
Cleveland Clinic Journal of Medicine - 85(4)
Issue
Cleveland Clinic Journal of Medicine - 85(4)
Page Number
261-262
Page Number
261-262
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In reply: Perioperative interruption of dual antiplatelet therapy
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In reply: Perioperative interruption of dual antiplatelet therapy
Legacy Keywords
dual antiplatelet therapy, DAPT, drug-eluting stent, DES, surgery, perioperative care, perioperative bridging, European Society of Cardiology, ESC, guidelines, Ryan Munyon, Steven Cohn, Barbara Slawski, Gerald Smetana, Kurt Pfeifer
Legacy Keywords
dual antiplatelet therapy, DAPT, drug-eluting stent, DES, surgery, perioperative care, perioperative bridging, European Society of Cardiology, ESC, guidelines, Ryan Munyon, Steven Cohn, Barbara Slawski, Gerald Smetana, Kurt Pfeifer
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