• Online Features  This Article  • Full text  • PDF  • Reply to article  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (18)  • Contact me when this article is cited  Related Content  • Related letters  • Related article  • Similar articles in this journal  Topic Collections  • Venous Thromboembolism  • Cardiovascular System  • Surgery  • Surgical Physiology  • Blood/ Coagulation  • Review  • Drug Therapy  • Drug Therapy, Other  • Alert me on articles by topic  Social Bookmarking   What's this?

James M. O’Riordan, MD; Ronan J. Margey, MB; Gavin Blake, MD; P. Ronan O’Connell, MD

Arch Surg. 2009;144(1):69-76.

Objective  To determine the use of the 3 major classes of antiplatelet drugs (aspirin, thienopyridines, and glycoprotein IIb/IIIa inhibitors), their management in the perioperative period, and the risks associated with premature withdrawal.

Data Sources  We reviewed the PubMed, EMBASE, and Cochrane databases using the terms antiplatelet agents in the perioperative period, antiplatelet agents and management of bleeding, drug-eluting stents and stent thrombosis, substitutes for antiplatelet agents, and premature withdrawal of antiplatelet agents.

Study Selection  Randomized, double-blind, placebo-controlled trials; prospective observational studies; review articles; clinical registry data; and guidelines of professional bodies pertaining to antiplatelet agents were included.

Data Extraction and Synthesis  Two researchers independently read the selected abstracts and selected the studies that matched the inclusion criteria. Any discordance between the 2 researchers was resolved by discussion so that 99 articles were finally included.

Conclusions  Aspirin use should not be stopped in the perioperative period unless the risk of bleeding exceeds the thrombotic risk from withholding the drug. With the exception of recent drug-eluting stent implantation, clopidogrel bisulfate use should be stopped at least 5 days prior to most elective surgery. Use of glycoprotein IIb/IIIa inhibitors must be discontinued preoperatively for more than 12 hours to allow normal hemostasis. Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events. Following drug-eluting stent implantation, withdrawal is associated with stent thrombosis and potentially fatal consequences. No definitive guidelines exist to manage patients who are actively bleeding while taking these drugs.

Author Affiliations: Departments of Surgery (Drs O’Riordan and O’Connell) and Cardiology (Drs Margey and Blake), Mater Misericordiae University Hospital, and School of Medicine and Medical Science, University College Dublin (Drs O’Riordan and O’Connell), Dublin, Ireland.

CiteULike    Connotea    Delicious    Digg    Facebook    Reddit    Technorati    Twitter     What's this?

RELATED LETTERS

Test Before You Stop
Abhishek Kumar and David H. Roberts
Arch Surg. 2009;144(8):787.
EXTRACT | FULL TEXT  

Test Before You Stop—Reply
James M. O’Riordan, Ronan J. Margey, Gavin Blake, and P. Ronan O’Connell
Arch Surg. 2009;144(8):787.
EXTRACT | FULL TEXT  

RELATED ARTICLE

Antiplatelet Agents in the Perioperative Period—Invited Critique
Grace S. Rozycki
Arch Surg. 2009;144(1):76.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial
Mantz et al.
Br J Anaesth 2011;107:899-910.
ABSTRACT | FULL TEXT  

Review Article: Emergency Cardiac Surgery in Patients with Acute Coronary Syndromes: A Review of the Evidence and Perioperative Implications of Medical and Mechanical Therapeutics
Brown et al.
Anesth. Analg. 2011;112:777-799.
ABSTRACT | FULL TEXT  

Cessation of Clopidogrel Before Major Abdominal Procedures
Chernoguz et al.
Arch Surg 2011;146:334-339.
ABSTRACT | FULL TEXT  

Differences in the In Vitro Antiplatelet Effect of Dexibuprofen, Ibuprofen, and Flurbiprofen in Human Blood
De La Cruz et al.
Anesth. Analg. 2010;111:1341-1346.
ABSTRACT | FULL TEXT  

Optimal medical management around the time of surgery
Voute et al.
Heart 2010;96:1842-1848.
FULL TEXT  

To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial
Oscarsson et al.
Br J Anaesth 2010;104:305-312.
ABSTRACT | FULL TEXT  

Perioperative medication management: General principles and practical applications
WHINNEY
Cleveland Clinic Journal of Medicine 2009;76:S126-S132.
ABSTRACT | FULL TEXT  

Test Before You Stop
Kumar and Roberts
Arch Surg 2009;144:787-787.
FULL TEXT