AHA 2016 periprocedural recommendations for dual antiplatelet therapy
Elective, noncardiac surgery
  • Drug-eluting stents (DES)
    • < 3 months since DES implantation
      • Delay surgery
    • 3 - 6 months since DES implantation
      • Proceeding with surgery may be considered
      • If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial
    • ≥ 6 months since DES implantation
      • Proceed with surgery
      • Discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [1]

  • Bare metal stents (BMS)
    • < 30 days since BMS implantation
      • Delay surgery
    • ≥ 30 days since BMS implantation
      • Proceed with surgery
      • If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [1]
Coronary artery bypass graft surgery (CABG)
  • Urgent on-pump CABG
    • Aspirin - do not stop aspirin before surgery
    • P2Y12 inhibitor:
      • Clopidogrel - stop clopidogrel 24 hours before surgery if possible
      • Ticagrelor - stop ticagrelor 24 hours before surgery if possible [7]

  • Elective CABG
    • Aspirin
      • Do not stop aspirin before surgery
    • P2Y12 inhibitor:
      • Clopidogrel - stop clopidogrel 5 days before surgery
      • Ticagrelor - stop ticagrelor 5 days before surgery
      • Prasugrel - stop prasugrel 7 days before surgery [8]








  • Reference [1]
Factors associated with increased bleeding risk
History of prior bleeding
Oral anticoagulant therapy
(See triple therapy above
)
Female sex
Advanced age (> 65 years)
Low body weight
Chronic kidney disease
Diabetes
Anemia
Chronic steroid or NSAID therapy




  • Reference [1]
Factors associated with increased ischemic risk
Advanced age
Acute coronary syndrome presentation
Multiple prior myocardial infarctions
Extensive coronary artery disease
Chronic kidney disease
Diabetes
Factors associated with increased risk of stent thrombosis
Acute coronary syndrome presentation
Diabetes
Left ventricular ejection fraction < 40%
First-generation DES
Stent undersizing
Stent underdeployment
Small stent diameter
Greater stent length
Bifurcation stents
In-stent restenosis