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|Issue 121||December 2016|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Management of Antiplatelet Therapy among Patients with Coronary or Cerebrovascular Disease: A Systematic Review
The perioperative management of antiplatelet therapy (APT) for patients with coronary stents remains unclear. Patients who have coronary stents placed are at risk of stent thrombosis and, therefore, are nearly all recommended to receive prolonged antiplatelet therapy: dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) followed by indefinite single antiplatelet therapy (almost always aspirin). Historically, clopidogrel and aspirin have been prescribed; however, the use of newer agents (i.e., ticagrelor and prasugrel) is increasing. Patients undergoing non-cardiac surgery with a prior history of percutaneous coronary intervention (PCI) and placement of coronary stents or balloon angioplasty are at increased risk of perioperative cardiac events. The risk of perioperative adverse events (i.e., major adverse cardiac event, bleeding) is associated with time from PCI, operative urgency, and antiplatelet therapy.
Current guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) recommend elective non-cardiac surgery be delayed one year after drug-eluting stent placement, and 30 days after bare metal stent placement. When considering urgent non-cardiac operative intervention, ACC/AHA recommendations are to continue dual antiplatelet therapy in the perioperative period for four to six weeks after PCI, unless the risks of bleeding outweigh the risks of stent thrombosis.
To help clinicians, patients, and policymakers with this important decision, investigators with VA's Evidence-based Synthesis Program Center located at the West Los Angeles VA Medical Center conducted a systematic review of the literature (PubMed, Web of Science, and Scopus) from inception to December 17, 2015. From more than 4,000 citations, 14 publications (several studies, including the largest, specifically assessed Veterans) were used to answer the following key questions.
Summary of Review
Please feel free to forward this information to others!
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.
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