Management of Tracheostomy in Patients on Dual Antiplatelet Therapy with Recent ACS

Risk Assessment and Timing Considerations

• For patients on dual antiplatelet therapy with recent acute coronary syndrome requiring tracheostomy, the European Society of Cardiology recommends continuing aspirin perioperatively if bleeding risk allows, and resuming the recommended antiplatelet therapy as soon as possible post-operatively 1
• DAPT discontinuation within the first month after ACS/PCI is not recommended due to high risk of stent thrombosis and recurrent cardiac events, as stated by the European Heart Journal 1, 2
• The American College of Cardiology suggests that if it's been less than 1 month since ACS, elective tracheostomy should be postponed if possible, while if it's been 1-6 months, the procedure should proceed with caution, maintaining at least partial antiplatelet coverage 1, 2
• The Journal of the American College of Cardiology indicates that if it's been more than 6 months since ACS, the thrombotic risk is lower, allowing more flexibility 3

Perioperative Management Algorithm

• The European Heart Journal recommends continuing aspirin throughout the perioperative period for urgent/emergent tracheostomy, and considering temporary interruption of P2Y12 inhibitor based on the specific agent 1, 2
• For patients at high bleeding risk, the European Heart Journal suggests considering shortening DAPT to 6 months before elective procedures, in line with the American College of Cardiology guidelines 1, 3

Special Considerations

• The European Heart Journal and the American College of Cardiology recommend using proton pump inhibitors in combination with DAPT to reduce bleeding risk 1, 3
• The European Heart Journal suggests considering percutaneous rather than open surgical approach when appropriate to minimize bleeding risk, and meticulous hemostasis during the procedure 1, 2

Balancing Thrombotic and Bleeding Risks

• The American College of Cardiology states that patients with recent ACS have a high thrombotic risk that decreases over time, with the first month after ACS/PCI carrying the highest risk for stent thrombosis if DAPT is interrupted 3, 1
• The American College of Chest Physicians recommends individualized decisions for patients requiring long-term anticoagulation in addition to DAPT, considering bleeding risk regarding continuation of DAPT alongside anticoagulation 4

Post-Tracheostomy Management

• The European Heart Journal recommends resuming full DAPT as soon as hemostasis is secure after tracheostomy 1