Management of Antiplatelet Therapy in Patients with Coronary Stents Undergoing Surgery

Introduction to Management Principles

The British Journal of Anaesthesia recommends that for patients with coronary stents undergoing appendectomy, aspirin should be maintained throughout the perioperative period whenever possible, while clopidogrel may be discontinued 5 days before surgery and resumed as soon as possible postoperatively 1, 2

The American Heart Association, as published in Circulation, notes that the time since stent placement is a significant risk factor, with the highest risk being less than 6 months for drug-eluting stents 3
The British Journal of Anaesthesia suggests that patient-specific factors, including history of stent thrombosis, multiple stents, long stents, or stents at bifurcations, increase thrombosis risk 2, 1
The British Journal of Anaesthesia also indicates that incomplete revascularization, diabetes, or low ejection fraction are patient-specific factors that increase thrombosis risk 2

For patients with drug-eluting stents placed less than 6-12 months prior, the British Journal of Anaesthesia recommends ideally postponing elective surgery until after this period, but if surgery cannot be delayed, maintaining aspirin throughout the perioperative period and discontinuing clopidogrel 5 days before surgery, then resuming it as soon as possible postoperatively 2, 6, 1, 7
For patients with bare-metal stents placed less than 4-6 weeks prior, Circulation suggests postponing surgery if possible, but if emergency appendectomy is required, maintaining both aspirin and clopidogrel 3

The British Journal of Anaesthesia emphasizes the importance of a multidisciplinary approach involving the surgeon, anesthesiologist, and cardiologist for optimal management 2, 6
The British Journal of Anaesthesia warns against substituting antiplatelet agents with heparin or low-molecular-weight heparin, as it does not adequately protect against stent thrombosis 7

Circulation and the British Journal of Anaesthesia advise against discontinuing both aspirin and clopidogrel simultaneously in patients with recent stent placement, as it significantly increases thrombosis risk 3, 4
The British Journal of Anaesthesia and Praxis Medical Insights caution against failing to consider the specific type of stent and time since placement when making management decisions, and against substituting antiplatelet therapy with anticoagulants, which do not provide adequate protection against stent thrombosis 2, 4, 7