Urological Surgery and Antiplatelet Drugs After Cardiac and Cerebrovascular Accidents

Incidence of major adverse cardiac events (MACE) according to delay (months) between stent implantation and noncardiac surgery. Events include MI, stent thrombosis, target vessel revascularization and death.

Mortality of patients with coronary stents taken off AP drugs for noncardiac surgery according to delay since coronary revascularization (Artang R: Am J Cardiol 2007; 99: 1039; Brotman DJ: J Hosp Med 2007; 2: 378; Rhee SJ: Int Heart J 2008; 49: 135; Kim HL: Int J Cardiol 2008; 123: 353). Two studies have comparative data on mortality of patients operated on without cessation of AP drugs (5% and 0%, respectively).

Algorithm for preoperative treatment of patients on AP therapy adapted and updated from Chassot et al.^{40 1} Aspirin given after previous event (MI, ACS, PCI and stent, CABG, peripheral arterial disease and stroke) or for documented cardiovascular disease, and high risk patients include diabetics and those with multiple risk factors. ² Multiple stents, long stents, proximal location (left main) and bifurcation lesions, and patients with previous stent thrombosis. ³ Operations mandatory for long-term survival. Recommended delay between drug interruption and surgery is 5 days for aspirin and clopidogrel. ⁴ Risk-to-benefit ratio of maintaining vs withdrawing aspirin, clopidogrel and prasugrel must be evaluated for each case, and withdrawing postoperative reinstitution (with clopidogrel loading dose 300 mg) within 24 hours is important. ⁵ Stop clopidogrel for 5 days and substitute with 3 to 5 days of intravenous perfusion of eptifibatide or tirofiban. SCA, sudden cardiac arrest.

Algorithm of strategies to decrease risk of stent thrombosis in case of coronary revascularization and urgent or semi-urgent noncardiac surgery. Asterisk indicates except in closed space surgery (intracranial neurosurgery, surgery of medullary canal, surgery of posterior chamber of eye), and invasive surgery with severe bleeding and difficult hemostasis.