Volume 190 - Issue 3
Very late stent thrombosis after discontinuation of clopidogrel therapy
Authors: Simon J Pattullo and Rohan Jayasinghe
Med J Aust 2009; 190 (3): 163-164. || doi: 10.5694/j.1326-5377.2009.tb02328.x
Published online: 2 February 2009
Published online: 2 February 2009
To the Editor: The recent article by Barthwal and Herman highlights the problem of late stent thrombosis in a patient with a drug-eluting stent (DES) undergoing non-cardiac surgery (NCS).1 While the authors stated that clopidogrel therapy was ceased preoperatively and not restarted postoperatively, they did not say whether or not aspirin therapy was continued. In addition, emphasis was not placed on the role the surgical procedure played in this adverse cardiac outcome.
Perioperative stent thrombosis as a result of discontinuation of dual antiplatelet therapy has been well described, to such an extent that the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association issued a joint advisory regarding the risk of premature cessation of dual antiplatelet therapy perioperatively.2
A prothrombotic state is well described in the perioperative period, as is a rebound hypercoagulable period following cessation of therapy with antiplatelet agents.3 Preoperative cessation of antiplatelet therapy by interventional teams is common in both routine and emergency procedures; this is sometimes unnecessary and not based on any evidence. Practitioners involved in ceasing antiplatelet therapy for procedures should be aware of the increased risk of major adverse cardiac events in patients with cardiac stents whose antiplatelet therapy is ceased prematurely.2 Duration of antiplatelet therapy following DES implantation is still a contentious issue, but the prothrombotic effect of NCS in addition to the baseline risk of late stent thrombosis in these patients is becoming less easy to ignore.4
Evidence-based guidelines for the perioperative management of patients with cardiac stents undergoing NCS are still to be established. Careful consideration should be given before perioperative cessation of therapy with antiplatelet agents in patients with coronary stents. Undertaking non-emergency surgery within 12 months of DES implantation should be avoided if possible.4,5
References
- Barthwal R, Herman BA. Very late stent thrombosis after discontinuation of clopidogrel therapy. Med J Aust 2008; 189: 229-230. <eMJA full text>
- Grines C, Bonow R, Casey D, et al. AHA/ACC/SCAI/ACS/ADA Science Advisory: prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. Circulation 2007; 115: 813-818. 0_BHADGCIJ
- Cassot PG, Delabays A, Spahan D. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007; 99: 316-328. 0_CBBEEBGJ
- Emmanouil S. Perioperative management of patients with coronary stents. J Am Coll Cardiol 2007; 49: 2145-2150. 0_CBBBEDAA
- Rade J, Hogue C. Noncardiac surgery for patients with coronary artery stents. Anesthesiology 2008; 109: 573-575. 0_CBBEAHCF