The Anesthesia Pain Service Guidelines presented earlier call for stopping clopidogrel seven days prior to surgery if neuraxial anesthesia is desired. It is important to note, however, there have been a number of reported cases of coronary artery occlusion in patients with drug eluting stents after temporary cessation of either aspirin or clopidogrel. Bengeri (1) and Bolsin et al (2) argue that the risks of cessation outweigh the risk of increased surgical bleeding and that these antiplatelet drugs should be continued into the perioperative period. Bolsin notes that they surveyed 24 patients with drug eluting stents who presented for a total of 43 non-cardiac surgery procedures. On 15 occasions clopidogrel was stopped though aspirin was continued. Three patients experienced myocardial infarction secondary to in-stent thrombosis. Two of the three infarcts occurred prior to surgery. Only one patient of the 24 experienced excessive bleeding.
The American College of Cardiology/American Heart Association joint guidelines for reducing the risk of a perioperative cardiac event (3) emphasized the need to continue anti-platelet drugs perioperatively. The cases presented by Bengeri and by Bolsin et al together with the recommendations found in the ACC/AHA guidelines force the conclusion that antiplatelet drugs should not be discontinued prior to surgery in patients receiving these drugs after coronary stenting. The Anesthesia Pain Service notes that epidural analgesia can be safely provided to patients taking aspirin. In patients on clopidogrel, the drug should be continued preoperatively but epidural analgesia should not be offered.
1) Bengeri S: Successful management of patients with a drug-eluting coronary stent presenting for elective surgery (letter). BJA 2007;98:841-8
2) Bolsin S et al: Comment on Bengeri 2007 (letter): BJA 2007;98:842
3) Fleisher LA et al: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non cardiac surgery. http://circ.ahajournals.org
David S. Smith, M.D., Ph.D.
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