Clinical question: Can one or both antiplatelet agents be held in a patient requiring surgery who is on dual antiplatelet therapy to manage a drug-eluting stent?

Background: Data suggest that cessation of antiplatelet therapy within one year of placement of a drug-eluting stent, even for brief time periods, is associated with rapid development of stent thrombosis (ST). However, continuation of antiplatelet agents increases perioperative risk related to hemostasis. No published data is available regarding how long one or both antiplatelet agents can be stopped to allow for safer surgery.

Study design: Case review.

Setting: Cases identified through literature search.

Synopsis: In patients with drug-eluting stents, stopping aspirin presents more risk than stopping thienopyridines. Patients who stopped both antiplatelet agents had ST at seven days (median time to event). If a patient stopped thienopyridines but not aspirin, mean time to ST was 122 days. If a patient stopped thienopyridines then subsequently stopped aspirin, the median time to ST was seven days. This suggests a potential seven-day window when both agents might be stopped, and a longer window when thienopyridines might be stopped if aspirin is continued.

The study only looked at ST cases, not the incidence of ST in all patients undergoing surgery for drug-eluting stents while on dual-antiplatelet therapy, so these results only describe the small fraction of patients who actually have surgery when antiplatelet agents are stopped.

The study design, analyzing existing cases without controls, is limited by the infrequency of the event, resulting in huge sample sizes needed to detect a significant result. The study also describes a median time to ST, which does not provide a true window of protection for the entire duration of the window.

Bottom line: The risks of bleeding complications need to be weighed against the risk of stent thrombosis in individual patients. This study also suggests that the risk of thrombosis is lower if a patient is continued on aspirin while thienopyridines are held.

Citation Eisenberg MJ, Richard PR, Libersan D, Filion KB. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119:1634-1642.

Reviewed for TH eWire by Erin A. Egan, MD, JD, Ethan Cumbler, MD, Jodie Grout, RN, MS, ANP-C, Jeannette Guerrasio, MD, Nichole Zehnder, MD, and Judy Zerzan, MD, MPH, Hospital Medicine Group, University of Colorado Denver.