Antiplatelet and Anticoagulant Drug Management Before Surgery: New Guidance and Implications
Antiplatelet and Anticoagulant Drug Management Before Surgery: New Guidance and Implications
Hello, I'm Dr. David Johnson, a Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. I wanted to discuss with you 3 papers that have just been published in the last couple of weeks as relates to the use of antiplatelet agents in patients undergoing GI procedures.
I'll [reference] these at the end of this video, so refer to those individual documents for full discussions. But let me give you some of the highlights. The clinical scenario would come in that your patient is going through an endoscopic procedure. The parochial teaching has been that we stop these patients' antiplatelet agents 5-7 days before their endoscopic therapy because of the concern of intervention or risks of bleeding. That, in fact, plays out the same for anticoagulation. We'll typically stop Coumadin for 3-5 days prior to the procedure. We may, in some circumstances, bridge them with low-molecular-weight heparin, but again this is all done in anticipation of an endoscopy with a therapeutic procedure, or at least biopsies.
Now is that the best recommendation?
The data have changed considerably here in the last couple of weeks. In particular, if you haven't seen what the withdrawal of aspirin can do, I'll invite you to a very recent review by Dr. Sung and his colleagues in Hong Kong, a paper in the Annals of Internal Medicine. I'll also refer you back to another video update that I just recently posted for Medscape, looking at the effects of acute aspirin withdrawal in patients who came in with ulcer-related bleeding due to aspirin.
What about the patients who are going to have elective procedures? In our office, the standard had been to stop all antiplatelet agents in these patients who routinely have this in their instructions. Well, the guidelines have changed considerably, and I'm going to focus particularly on the antiplatelet agents because I think this is what really plays out, and I bet all of your practices are still doing something that probably needs to be changed; it certainly needs to be changed.
The data show that the withdrawal of antiplatelet agents is probably not as safe as we think -- certainly not in the acute bleeding study that I just posted looking at bleeding in patients with cardiovascular complications after an ulcer bleed. In elective procedures, we do know that for patients receiving these for secondary prophylaxis, stent patency, for example, in the cardiac patient, or neurologic complication potentials, there may be additive benefit to continuing the antiplatelet agent. In fact, the guidelines are fairly strong, as reported in the recent ASGE [American Society for Gastrointestinal Endoscopy] guidelines, the consensus guideline that was done in consortium in an expert document from the American College of Cardiology and the American College of Gastroenterology, and also an expert document by 2 evidence-based experts that was just posted as well.
The recommendation is that if [patients are] on aspirin, keep them on aspirin if they need it for secondary prophylaxis. If they're taking it for primary prophylaxis, meaning that they really don't necessarily have to have it, certainly you could consider stopping it. Basically the bottom line here is that you shouldn't stop aspirin if [patients] ever need it for any procedure. Keep them on the aspirin.
If they're on an antiplatelet agent, like clopidogrel, that's more formidable; also, a lot of our patients are on dual [antiplatelet] therapy. The recommendation here is to be careful. For elective procedures, we try and keep them on their medications, and you may want to do a diagnostic study. If they're on clopidogrel, you're very limited as far as what you can do for any major high-risk therapeutic intervention, polypectomy, sphincterotomy, pneumatic dilation, PEG [percutaneous endoscopic gastrostomy] procedure, those types of things. So those patients should be evaluated in the context that if this can wait, they should wait for probably 6 months. If it's really urgent, you can probably negotiate with your cardiologist at 3 months, particularly if it's a bare metal stent. With a drug-eluting stent, the data are quite strong that if you stop the clopidogrel, there is a high risk for stent thrombosis.
Now what does that mean to your patient?
Stent thrombosis can occur in approximately 30% of those patients within a month of stopping the clopidogrel. For a bare metal stent, the recommendation is that you've got to continue the clopidogrel for 30 days, and after that it probably doesn't need to be kept on board. [Patients] continue on aspirin. For drug-eluting stents, the data are strong for 6 months and probably a lot longer than that. You can negotiate with your cardiologist to stop at the end of 6 months for elective procedures. Remember that the cardinal rule is you need to stay on aspirin.
So the guidelines, the consensus document, and the evidence-based assessment all concur basically the same. Keep them on their aspirin if they need it, stop the clopidogrel only if you have an additive window of time for elective procedures; for emergent procedures, you're just going to have to pay the consequences. Take whatever risk and assessment you need to take. Perhaps use dual therapy, or hemoclip somebody if they really need to undergo a procedure while on the clopidogrel. Again, try and prolong it for as long as you can for elective procedures.
[In regard to] emergent procedures as they relate to anticoagulants, certainly [that is a situation in which] we need to always reverse the anticoagulants if [patients are] actively bleeding, but again start them back on their Coumadin almost right away after their procedure. It may bridge the therapy with low-molecular-weight heparin, but that's not an option for clopidogrel patients. Low-molecular-weight heparin works differently from clopidogrel. So the patients on the clopidogrel need to stay on that as long as they can.
I'd invite you to go back and look. If you're an endoscopist, go back and look at your office records and look at what your patient information says when you talk about endoscopic procedures. Be very careful that it doesn't say stop aspirin, stop antiplatelet agents, stop anticoagulants. All these things are carte blanche rules. Be very careful, in particular, as it relates to the antiplatelet therapies, because I think that there is some medical/legal implication for secondary consequences, and you don't want this in your standard recommendations.
We tell our patients the following: Don't stop anything until you talk to your cardiologist or your neurologist, and make sure that it's okay to stop. Continue the aspirin if they tell you that it is needed. Beware, because I think some of these rules are changing. I invite you to look at the individual documents that I cite as [references] for this discussion. The evidence says that antiplatelet agents really do have a significant benefit. Stent thrombosis acutely carries with it a 50% myocardial infarct rate and a 20% death rate within 30 days. Stent thrombosis is a significantly greater risk than any of the risks that we talk about when we talk about bleeding from our standard endoscopic procedures, and there are a number of things that we can do to ensure hemostasis, or at least augment the likelihood for hemostasis, even after high-risk procedures.
Think about it, go back and look at your office notes, what your recommendations for your standard endoscopies are, and beware, because the rules have changed. Hopefully this will steer you well and keep your patients in a more balanced risk assessment.
Thanks for listening. I'm Dr. David Johnson.
Hello, I'm Dr. David Johnson, a Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. I wanted to discuss with you 3 papers that have just been published in the last couple of weeks as relates to the use of antiplatelet agents in patients undergoing GI procedures.
I'll [reference] these at the end of this video, so refer to those individual documents for full discussions. But let me give you some of the highlights. The clinical scenario would come in that your patient is going through an endoscopic procedure. The parochial teaching has been that we stop these patients' antiplatelet agents 5-7 days before their endoscopic therapy because of the concern of intervention or risks of bleeding. That, in fact, plays out the same for anticoagulation. We'll typically stop Coumadin for 3-5 days prior to the procedure. We may, in some circumstances, bridge them with low-molecular-weight heparin, but again this is all done in anticipation of an endoscopy with a therapeutic procedure, or at least biopsies.
Now is that the best recommendation?
The data have changed considerably here in the last couple of weeks. In particular, if you haven't seen what the withdrawal of aspirin can do, I'll invite you to a very recent review by Dr. Sung and his colleagues in Hong Kong, a paper in the Annals of Internal Medicine. I'll also refer you back to another video update that I just recently posted for Medscape, looking at the effects of acute aspirin withdrawal in patients who came in with ulcer-related bleeding due to aspirin.
What about the patients who are going to have elective procedures? In our office, the standard had been to stop all antiplatelet agents in these patients who routinely have this in their instructions. Well, the guidelines have changed considerably, and I'm going to focus particularly on the antiplatelet agents because I think this is what really plays out, and I bet all of your practices are still doing something that probably needs to be changed; it certainly needs to be changed.
The data show that the withdrawal of antiplatelet agents is probably not as safe as we think -- certainly not in the acute bleeding study that I just posted looking at bleeding in patients with cardiovascular complications after an ulcer bleed. In elective procedures, we do know that for patients receiving these for secondary prophylaxis, stent patency, for example, in the cardiac patient, or neurologic complication potentials, there may be additive benefit to continuing the antiplatelet agent. In fact, the guidelines are fairly strong, as reported in the recent ASGE [American Society for Gastrointestinal Endoscopy] guidelines, the consensus guideline that was done in consortium in an expert document from the American College of Cardiology and the American College of Gastroenterology, and also an expert document by 2 evidence-based experts that was just posted as well.
The recommendation is that if [patients are] on aspirin, keep them on aspirin if they need it for secondary prophylaxis. If they're taking it for primary prophylaxis, meaning that they really don't necessarily have to have it, certainly you could consider stopping it. Basically the bottom line here is that you shouldn't stop aspirin if [patients] ever need it for any procedure. Keep them on the aspirin.
If they're on an antiplatelet agent, like clopidogrel, that's more formidable; also, a lot of our patients are on dual [antiplatelet] therapy. The recommendation here is to be careful. For elective procedures, we try and keep them on their medications, and you may want to do a diagnostic study. If they're on clopidogrel, you're very limited as far as what you can do for any major high-risk therapeutic intervention, polypectomy, sphincterotomy, pneumatic dilation, PEG [percutaneous endoscopic gastrostomy] procedure, those types of things. So those patients should be evaluated in the context that if this can wait, they should wait for probably 6 months. If it's really urgent, you can probably negotiate with your cardiologist at 3 months, particularly if it's a bare metal stent. With a drug-eluting stent, the data are quite strong that if you stop the clopidogrel, there is a high risk for stent thrombosis.
Now what does that mean to your patient?
Stent thrombosis can occur in approximately 30% of those patients within a month of stopping the clopidogrel. For a bare metal stent, the recommendation is that you've got to continue the clopidogrel for 30 days, and after that it probably doesn't need to be kept on board. [Patients] continue on aspirin. For drug-eluting stents, the data are strong for 6 months and probably a lot longer than that. You can negotiate with your cardiologist to stop at the end of 6 months for elective procedures. Remember that the cardinal rule is you need to stay on aspirin.
So the guidelines, the consensus document, and the evidence-based assessment all concur basically the same. Keep them on their aspirin if they need it, stop the clopidogrel only if you have an additive window of time for elective procedures; for emergent procedures, you're just going to have to pay the consequences. Take whatever risk and assessment you need to take. Perhaps use dual therapy, or hemoclip somebody if they really need to undergo a procedure while on the clopidogrel. Again, try and prolong it for as long as you can for elective procedures.
[In regard to] emergent procedures as they relate to anticoagulants, certainly [that is a situation in which] we need to always reverse the anticoagulants if [patients are] actively bleeding, but again start them back on their Coumadin almost right away after their procedure. It may bridge the therapy with low-molecular-weight heparin, but that's not an option for clopidogrel patients. Low-molecular-weight heparin works differently from clopidogrel. So the patients on the clopidogrel need to stay on that as long as they can.
I'd invite you to go back and look. If you're an endoscopist, go back and look at your office records and look at what your patient information says when you talk about endoscopic procedures. Be very careful that it doesn't say stop aspirin, stop antiplatelet agents, stop anticoagulants. All these things are carte blanche rules. Be very careful, in particular, as it relates to the antiplatelet therapies, because I think that there is some medical/legal implication for secondary consequences, and you don't want this in your standard recommendations.
We tell our patients the following: Don't stop anything until you talk to your cardiologist or your neurologist, and make sure that it's okay to stop. Continue the aspirin if they tell you that it is needed. Beware, because I think some of these rules are changing. I invite you to look at the individual documents that I cite as [references] for this discussion. The evidence says that antiplatelet agents really do have a significant benefit. Stent thrombosis acutely carries with it a 50% myocardial infarct rate and a 20% death rate within 30 days. Stent thrombosis is a significantly greater risk than any of the risks that we talk about when we talk about bleeding from our standard endoscopic procedures, and there are a number of things that we can do to ensure hemostasis, or at least augment the likelihood for hemostasis, even after high-risk procedures.
Think about it, go back and look at your office notes, what your recommendations for your standard endoscopies are, and beware, because the rules have changed. Hopefully this will steer you well and keep your patients in a more balanced risk assessment.
Thanks for listening. I'm Dr. David Johnson.
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