Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis

Sahrish Shah; Meritxell Urtecho; Mohammed Firwana; Tarek Nayfeh; Bashar Hasan; Ahmad Nanaa; Samer Saadi; David N Flynn; Rami Abd-Rabu; Mohamed O Seisa; Noora S Rajjoub; Leslie C Hassett; Alex C Spyropoulos; James D Douketis; M Hassan Murad

doi:10.1016/j.mayocpiqo.2022.09.006

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis

Mayo Clin Proc Innov Qual Outcomes. 2022 Oct 21;6(6):564-573. doi: 10.1016/j.mayocpiqo.2022.09.006. eCollection 2022 Dec.

Authors

Sahrish Shah^{1

2}, Meritxell Urtecho^{1

2}, Mohammed Firwana^{1

2}, Tarek Nayfeh^{1

2}, Bashar Hasan^{1

2}, Ahmad Nanaa^{1

2}, Samer Saadi^{1

2}, David N Flynn³, Rami Abd-Rabu^{1

2}, Mohamed O Seisa^{1

2}, Noora S Rajjoub^{1

2}, Leslie C Hassett⁴, Alex C Spyropoulos⁵, James D Douketis⁶, M Hassan Murad^{1

2}

Affiliations

¹ Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.
² Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
³ University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC.
⁴ Mayo Clinic Libraries, Mayo Clinic, Rochester, MN.
⁵ Institute of Health Systems Science - Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, NY, NY.
⁶ Department of Medicine, McMaster University, Hamilton, Canada.

Abstract

Objective: To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.

Methods: This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible.

Results: In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE).

Conclusion: This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.

Keywords: ACCP/CHEST, American College of Chest Physicians; ASA, acetylsalicylic acid; ATE, arterial thromboembolism; CABG, coronary artery bypass graft; COE, certainty of evidence; CV, cardiovascular; DES, drug-eluting stent; LMWH, low-molecular-weight heparin; MI, myocardial infarction; PE, pulmonary embolism; PICO, patients–interventions–comparators–outcomes; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomized clinical trial; RR, relative risk.