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Perioperative management of antithrombotic drugs

ESC Congress 2010

Cardiovascular Pharmacotherapy

The lecture room was filled to 100% with cardiologists that listened to and discussed the perioperative management of antithrombotic drugs.

Dr Noll first pointed out that aspirin as secondary prevention reduces the risk of CV events by 20%. Aspirin induces a small but significant risk of bleeding with OR between 1.2-2.0 and with increased risk at higher doses, i.e. 250 mg or more. Also the risk factors for bleeding and thrombotic events are very similar. Few randomized clinical studies are today available concerning aspirin treatment, bleeding propensity and surgery. Summarizing these studies the risk of bleeding on aspirin is small and can be handled. However Dr. Noll concluded that aspirin should be stopped at intracranial surgery.

Concerning platelet P2Y12 receptor inhibitors, Dr Storey discussed the importance of balancing the perioperative risks for bleeding and thrombosis. He showed data from animal studies demonstrating that the levels of P2Y12 receptor blockage clearly correlate with bleeding time. In the onset/offset study clopidogrel high responders had significantly higher inhibition of platelet aggregation in comparison to patients on ticagrelor at three days. Ticagrelor has a half-life of 12 hours and the platelets were fully recovered after three days. The variable response to clopidogrel gives variable time to recovery of the platelet function. The point of care instrument VerifyNow may be helpful for the clinical decision. The reversible binding of ticagrelor is associated with more predictable offset of effect and allows cessation of treatment closer to surgery compared to clopidogrel. However, the optimal strategy for perioperative P2Y12 inhibition remains to be defined.

Dr Husted, presenting the new anticoagulants, discussed how to evaluate the risk of perioperative bleeding and thromboembolism. Patient characteristics, type and intensity of antithrombotic treatment and the type of surgery are important factors for the evaluation of perioperative bleeding risk. Low bleeding risk surgery includes diagnostic endoscopy, oral surgery/dental extraction while high-risk includes major abdominal and orthopedic surgery and very high-risk neurosurgical procedures. He stated that individual perioperative treatment in patients using the direct oral FXa inhibitors, apixaban and rivaroxaban or direct thrombin inhibitors should be based on the evaluation of high/low risk of thrombosis in combination with high/low risk of bleeding. There are no antidotes to the new oral direct FXa and thrombin inhibitors. Reversal of anticoagulant activity at short notice in case of bleeding, overdose or urgent invasive procedures can be achieved by plasma, prothrombin complex concentrates or rFVIIa (Novoseven).




Perioperative management of antithrombotic drugs
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.