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Saeed Darvish-Kazem, MD; James D. Douketis, MD, FCCP
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From the Department of Medicine (Drs Darvish-Kazem and Douketis), Michael G. DeGroote School of Medicine (Dr Douketis), McMaster University; and St. Joseph’s Healthcare Hamilton (Dr Douketis).

Correspondence to: James D. Douketis, MD, FCCP, St. Joseph’s Healthcare Hamilton, Room F-544, 50 Charlton Ave E, Hamilton, ON, L8N 4A6, Canada; e-mail: jdouket@mcmaster.ca


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1174-1175. doi:10.1378/chest.14-0229
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To the Editor:

We thank Drs Bolsin and Gillett for their interest in our article.1 In our review of the clinical practice guidelines pertaining to perioperative antiplatelet therapy in adult patients with coronary stents, we aimed to address four major clinical questions, including the use of bridging strategies. Five guidelines provided advice regarding the perioperative use of bridging with an anticoagulant or antiplatelet agent. Of these guidelines, only the Cardiac Society of Australia and New Zealand provided a corresponding strength of recommendation and level of evidence with its advice.1 The society advised that patients at high risk of stent thrombosis who stop dual-antiplatelet therapy should be considered for bridging with either heparin and/or glycoprotein IIb/IIIa antagonists. However, this guidance was based on low-quality evidence from case series, with a weak (Grade B) recommendation that this particular judgment may not apply to a substantial proportion of patients.2

The rationale for perioperative bridging is anchored on mitigating the risk of major cardiovascular events, including stent thrombosis, in patients who require surgery and in whom the associated risk of bridging-related bleeding is acceptably low. A number of agents, including unfractionated heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa antagonists, direct thrombin inhibitors (bivalirudin), and reversible platelet P2Y12-receptor inhibitors, have been proposed and studied as bridging agents.

We recognize the foundational work at The Geelong Hospital and that carried out by Savonitto et al3 and Bolsin et al.4 These case reports and observational studies provide the impetus and rationale for future study in this area. Further encouraging evidence comes from a recent randomized, placebo-controlled trial of 210 patients with acute coronary syndromes or treated with a coronary stent on a thienopyridine, awaiting coronary artery bypass grafting. In this study, patients received IV cangrelor, a short-acting, reversible P2Y12-receptor inhibitor, or placebo for at least 48 h, which was stopped 1 to 6 h before surgery. Patients in the cangrelor group had lower levels of platelet reactivity with no significant increase in coronary artery bypass grafting-related bleeding.5 Whether this agent can be used safely in the noncardiac surgery setting has yet to be determined.

The current evidence points toward a lack of consensus regarding best practices for patients with coronary stents undergoing noncardiac surgery. This is particularly true for bridging strategies, where the majority of guidelines provide no recommendations. Well-designed prospective observational and randomized trial evidence is needed to help define future management strategies.

References

Darvish-Kazem S, Gandhi M, Marcucci M, Douketis JD. Perioperative management of antiplatelet therapy in patients with a coronary stent who need noncardiac surgery: a systematic review of clinical practice guidelines. Chest. 2013;144(6):1848-1856. [CrossRef] [PubMed]
 
Cardiac Society of Australia and New Zealand. Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery. Heart Lung Circ. 2010;19(1):2-10. [CrossRef] [PubMed]
 
Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285-291. [CrossRef] [PubMed]
 
Bolsin SN, Chin H, Birdsey G, Colson M, Gillet J. Coronary artery stents and surgery; the basis of sound perioperative management. Health. 2013;5(10):1730-1736. [CrossRef]
 
Angiolillo DJ, Firstenberg MS, Price MJ, et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012;307(3):265-274. [CrossRef] [PubMed]
 

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Tables

References

Darvish-Kazem S, Gandhi M, Marcucci M, Douketis JD. Perioperative management of antiplatelet therapy in patients with a coronary stent who need noncardiac surgery: a systematic review of clinical practice guidelines. Chest. 2013;144(6):1848-1856. [CrossRef] [PubMed]
 
Cardiac Society of Australia and New Zealand. Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery. Heart Lung Circ. 2010;19(1):2-10. [CrossRef] [PubMed]
 
Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285-291. [CrossRef] [PubMed]
 
Bolsin SN, Chin H, Birdsey G, Colson M, Gillet J. Coronary artery stents and surgery; the basis of sound perioperative management. Health. 2013;5(10):1730-1736. [CrossRef]
 
Angiolillo DJ, Firstenberg MS, Price MJ, et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012;307(3):265-274. [CrossRef] [PubMed]
 
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