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Dual Antiplatelet Management in the Perioperative Period: A Systematic Review

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 Dual Antiplatelet Management in the Perioperative Period: A Systematic Review

Recommended citation:
Shekelle P, Maggard-Gibbons M, Girgis MD, et al. Dual Antiplatelet Management in the Perioperative Period: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2023.



Download PDF: Complete Report, Executive Summary, Report, Appendices

Takeaway

The evidence base on the benefits and risks of different perioperative DAPT strategies for patient with stents is extremely thin. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for at least 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Data about other surgical procedures, other DAPT strategies, patients with non-cardiac stents, and other outcomes were so thin that no conclusions could be drawn.

Context

Antiplatelet agents are central in the management of cardiovascular and cerebrovascular disease. The optimal perioperative management of antiplatelet agents for patients on DAPT is not clear. VA ESP reports in 2016 and 2017 found only observational studies that did not support strong conclusions. This review summarizes current evidence since that time regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period.

Key Findings

Eighteen observational studies met inclusion criteria. No RCTs were identified and no studies were judged to be at low risk of bias. Twelve studies were about CABG. The preponderance of these studies favor less blood loss with more than 2 days or longer duration of suspension of DAPT therapy. For transfusions, there appeared to be a slight trend favoring >2 days DAPT withdrawal. Surgical re-exploration data for CABG studies showed a similar pattern. Among 5 observational CABG studies there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively about CABG, included 1 combined analysis of cardiac and non-cardiac surgery and 5 studies about non-cardiac surgical procedures. Data from these demonstrated mixed findings with respect to DAPT strategy and bleeding and ischemic outcomes. No studies were found that reported limb outcomes.

See also

Dual Antiplatelet Management in the Perioperative Period: A Systematic Review (Management eBrief)

Premji AM, Blegen MB, Corley AM, et al. Dual Antiplatelet Management in the Perioperative Period: Updated and Expanded Systematic Review. Systematic Reviews. 2023;12. DOI: https://doi.org/10.1186/s13643-023-02360-9.


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