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Management eBrief no. 137

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Management eBriefs
Issue 137November 2017

The report is a product of the VA/HSR&D Evidence Synthesis Program.

Systematic Review: Management of Antiplatelet Therapy among Patients Undergoing Elective Non-Cardiac Surgery

The perioperative management of antiplatelet therapy (APT) for patients with cerebrovascular or peripheral vascular diseases remains unclear. All patients with symptomatic peripheral artery disease are recommended to be on APT, typically monotherapy with either aspirin or clopidogrel. However, dual APT (DAPT, typically with aspirin and clopidogrel) is common, especially among the highest-risk patients – those following endovascular procedures for critical limb ischemia. The duration of APT for vascular disease is usually life-long unless a significant bleeding event occurs. The perioperative management of APT in the setting of elective non-cardiac surgery, specifically the decision about whether to stop APT before surgery and for how long, requires balancing overall thrombotic risk against the risk of bleeding with surgery.

To help clinicians, patients, and policymakers with this important decision, this systematic review examined the risks and benefits of APT in the perioperative period for patients on APT for cerebrovascular or peripheral vascular diseases. Investigators with VA's Evidence-based Synthesis Program Center at the West Los Angeles VA Medical Center conducted a systematic review of the literature (PubMed) from inception to October 18, 2016. From 613 citations, no study met all of their inclusion criteria. However, 13 publications provided some insight into the management of APT in patients with cerebrovascular or peripheral vascular diseases. Of these included studies, there were no randomized trials and the samples were generally small (fewer than 1,000 patients). Two studies were conducted in a VA setting.

Summary of Review
The overall finding from this systematic review is that the available evidence regarding perioperative APT management in patients with cerebrovascular or peripheral vascular diseases undergoing elective non-cardiac surgery is insufficient to conclusively guide clinical practice. The studies that have been published have challenging methodologic limitations and heterogeneous results – and do not provide sufficient evidence to moderately or strongly support any clinical recommendation.

When the initial literature search was conducted, which focused on patients with cerebrovascular or peripheral vascular stents, investigators identified no relevant studies so the search was expanded to include any study that did not focus exclusively on patients with coronary stents. The 13 observational studies included were generally small, indications for APT were both inadequately described and deviated substantially from the target population, and APT management was heterogeneous with significant contamination issues. This heterogeneity limits the ability to assess the impact of the different management aspects of APT such as timing of cessation, restarting therapy, type of APT, and bridging therapies. The results also suggest that clinical factors other than perioperative APT management may be more responsible for bleeding and thrombotic outcomes. It is likely that a clinical trial of large size would be needed to provide evidence that definitely guides these clinical decisions. Specific findings include:

  • Only 3 of the 13 studies showed an adverse association between APT agent and bleeding outcomes, primarily seen as a need for intraoperative transfusion. There was no consistent difference in thrombotic, readmission, or mortality outcomes based on pre- and perioperative management of APT.
  • The timing of discontinuing APT varied both within and between studies, with no studies systematically assessing the impact of timing on clinical outcomes.
  • Few studies stratified patients based on type of surgical procedure, and among those that did, there was no clear difference in thrombotic or bleeding outcomes depending on perioperative APT strategy.
  • Studies were too small and did not include enough detail to associate type of APT with clinical outcomes.
  • No study evaluated the timing of APT resumption on clinical outcomes.

Future Research
There is obviously a large research gap, as investigators were unable to find evidence sufficient to reach conclusions for any of the key questions. The evidence suggests that differences in outcomes due to perioperative antiplatelet management are likely to be smaller than those due to other clinical factors. This suggests that definitive answers to these questions are going to require clinical trials, and since the differences in outcomes are likely to be small, these studies will need to be large – on the order of many hundreds or even more than 1,000 patients in each arm.

Reference
Childers CP, Mak S, Miake-Lye IM, O'Neil S, Shanman R, Beroes JM, Maggard-Gibbons M, Shekelle PG. Management of antiplatelet therapy among patients on antiplatelet therapy for cerebrovascular or peripheral vascular diseases undergoing elective non-cardiac surgery. VA ESP Project #05-226; 2017.

View the full report
https://www.hsrd.research.va.gov/publications/esp/antiplatelet.cfm


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Read past HSR&D Management e-Briefs on the HSR&D website.

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.

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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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