Periprocedural use of antiplatelet drugs

The periprocedural use of antiplatelet drugs is complex. Manage patients taking these drugs who require a procedure in conjunction with the surgeon or proceduralist, the clinician who started the antiplatelet therapy, and the clinician supervising the periprocedural care.

If antiplatelet drugs are prescribed for a specific period (eg dual antiplatelet therapy for 12 months following an acute coronary syndrome or implantation of a drug-eluting stent), delay elective procedures until after this period whenever possibleHalvorsen, 2022. Early interruption of antiplatelet therapy may increase the risk of ischaemic events and thrombosis. Consult the clinician who started the treatment for advice; it might be safe to withhold or stop one or more of the patient’s antiplatelet drugsKeeling, 2016Smilowitz, 2020.

If a patient has been prescribed dual antiplatelet therapy and the procedure cannot be delayed, interruption of P2Y₁₂ inhibitor therapy (clopidogrel, prasugrel, ticagrelor) may be required; however, continuation of aspirin therapy is advisedDouketis, 2022. Proceed with emergency or semi-elective procedures with caution and under specialist advice.

Aspirin increases the incidence of postprocedural bleeding, but it does not increase the severity of bleeding complications. This suggests aspirin can be continued for many procedures (notable exceptions are intracranial surgery and prostatectomy)Burger, 2005. Consult the proceduralist for advice on whether to continue aspirin in patients at increased risk of bleeding.

If aspirin therapy needs to be interrupted, there is debate regarding the optimal timing to withdraw therapy. Platelet function recovers by around 10% per day after withdrawing aspirin, with full restoration of platelet function after 7 to 10 daysDouketis, 2012Lordkipanidze, 2009. Haemostasis can be achieved with as little as 20% of normal platelet function, so if temporary interruption of aspirin is required, it may be sufficient to withhold therapy 2 to 3 days before the procedureLordkipanidze, 2009Song, 2017. For patients undergoing a procedure with a high risk of bleeding, consider withholding aspirin for 7 days before the procedureHalvorsen, 2022.

If temporary interruption of P2Y₁₂ inhibitor therapy is required, withhold ticagrelor 3 to 5 days before the procedure, clopidogrel 5 days before the procedure, and prasugrel 7 days before the procedureDouketis, 2022Halvorsen, 2022Song, 2017. Bridging therapy with a parenteral anticoagulant is not used if P2Y₁₂ inhibitor therapy is interrupted. Occasionally a specialist may substitute P2Y₁₂ inhibitor therapy for aspirin monotherapy.

Restart antiplatelet therapy as soon as possible after the procedure, ideally within 24 hoursDouketis, 2022.

For further considerations, see General principles of periprocedural management of antithrombotic therapy.