Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Background: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a “closed space” must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption. Methods: Eighty relevant English language papers published in PubMed were reviewed in detail. Results: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement. Conclusion: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.

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Utility of the HAS-BLED Score in Risk Stratifying Patients on Dual Antiplatelet Therapy Post 12 Months After Drug-Eluting Stent Placement

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.26588 ◽

2016 ◽

Vol 89 (4) ◽

pp. E99-E103 ◽

Cited By ~ 6

Author(s):

Ruchit R. Shah ◽

Ajay Pillai ◽

Abdullah Omar ◽

John Zhao ◽

Vishal Arora ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Stent Placement ◽

Dual Antiplatelet Therapy ◽

Drug Eluting Stent ◽

Drug Eluting

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The saga of the duration of dual antiplatelet therapy after drug-eluting stent placement

Archives of Cardiovascular Diseases ◽

10.1016/j.acvd.2015.09.001 ◽

2015 ◽

Vol 108 (10) ◽

pp. 469-471 ◽

Cited By ~ 2

Author(s):

Gérard Helft

Keyword(s):

Antiplatelet Therapy ◽

Stent Placement ◽

Dual Antiplatelet Therapy ◽

Drug Eluting Stent ◽

Drug Eluting

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P2Y12 inhibitor monotherapy after coronary stenting according to type of P2Y12 inhibitor

Heart ◽

10.1136/heartjnl-2020-318821 ◽

2021 ◽

pp. heartjnl-2020-318821

Author(s):

Juwon Kim ◽

Woo Jin Jang ◽

Wang Soo Lee ◽

Ki Hong Choi ◽

Joo Myung Lee ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Primary Endpoint ◽

Dual Antiplatelet Therapy ◽

Randomised Trial ◽

Drug Eluting Stent ◽

Monotherapy Group ◽

P2y12 Inhibitor ◽

P2y12 Inhibitors ◽

Coronary Syndrome ◽

Drug Eluting

ObjectiveTo compare P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) with 12-month DAPT according to the type of P2Y12 inhibitor in patients undergoing percutaneous coronary intervention (PCI).MethodsThe Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) randomised trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT. In this trial, 2993 patients undergoing successful PCI with drug-eluting stent were enrolled in Korea. As a prespecified analysis, P2Y12 inhibitor monotherapy after 3-month DAPT versus 12-month DAPT were compared among patients receiving clopidogrel and those receiving potent P2Y12 inhibitor (ticagrelor or prasugrel), respectively. The primary endpoint was a composite of all-cause death, myocardial infarction or stroke at 12 months after the index procedure.ResultsAmong 2993 patients (mean age 64 years), 58.2% presented with acute coronary syndrome. Clopidogrel was prescribed in 2312 patients (77.2%) and a potent P2Y12 inhibitor in 681 (22.8%). There were no significant differences in the primary endpoint between the P2Y12 inhibitor monotherapy group and the DAPT group among patients receiving clopidogrel (3.0% vs 3.0%; HR: 1.02; 95% CI 0.64 to 1.65; p=0.93) as well as among patients receiving potent P2Y12 inhibitors (2.4% vs 0.7%; HR: 3.37; 95% CI 0.77 to 14.78; p=0.11; interaction p=0.1). Among patients receiving clopidogrel, P2Y12 inhibitor monotherapy compared with DAPT showed consistent treatment effects across various subgroups for the primary endpoint. Among patients receiving potent P2Y12 inhibitors, the rate of bleeding (Bleeding Academic Research Consortium types 2– 5) was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (1.5% vs 5.0%; HR: 0.33; 95% CI 0.12 to 0.87; p=0.03).ConclusionsCompared with 12-month DAPT, clopidogrel monotherapy after 3-month DAPT showed comparable cardiovascular outcomes in patients undergoing PCI.Trial registration numberNCT02079194.

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Longer- Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement

Annals of Internal Medicine ◽

10.7326/m15-0083 ◽

2015 ◽

Vol 163 (2) ◽

pp. 118 ◽

Cited By ~ 36

Author(s):

Frederick A. Spencer ◽

Manya Prasad ◽

Per O. Vandvik ◽

Devin Chetan ◽

Qi Zhou ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Stent Placement ◽

Dual Antiplatelet Therapy ◽

Drug Eluting Stent ◽

Drug Eluting

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Dual Antiplatelet Therapy After Drug-eluting Stent Implantation

Interventional Cardiology Review ◽

10.15420/icr.2016.11.01.51 ◽

2016 ◽

Vol 11 (1) ◽

pp. 51

Author(s):

Giulia Magnani ◽

◽

Marco Valgimigli

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Bleeding Risk ◽

Coronary Intervention ◽

Drug Eluting Stent ◽

P2y12 Inhibitor ◽

Percutaneous Coronary ◽

Drug Eluting ◽

Meta Analyses ◽

Current Guidelines

The current guidelines for percutaneous coronary intervention use recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor after drug eluting stent (DES) implantation. The optimal duration of DAPT is however area of debate. Recent clinical trials and meta-analyses suggest that the choice of DAPT duration should be tailored individually, based on the balance between ischemic and bleeding risk carried by the patient.

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Faculty Opinions recommendation of Longer- Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement: A Systematic Review and Meta-analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725513215.793508406 ◽

2015 ◽

Author(s):

Wilbert Aronow

Keyword(s):

Systematic Review ◽

Antiplatelet Therapy ◽

Stent Placement ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Drug Eluting Stent ◽

Drug Eluting

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Duration of dual antiplatelet therapy and subsequent monotherapy type in patients undergoing drug-eluting stent implantation: a network meta-analysis

European Heart Journal - Cardiovascular Pharmacotherapy ◽

10.1093/ehjcvp/pvaa127 ◽

2020 ◽

Cited By ~ 1

Author(s):

Stefano Benenati ◽

Gabriele Crimi ◽

Claudia Canale ◽

Fabio Pescetelli ◽

Vincenzo De Marzo ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Major Bleeding ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Drug Eluting Stent ◽

P2y12 Inhibitor ◽

Major Bleeding Rate ◽

Safety Endpoint ◽

Secondary Efficacy Endpoint ◽

Drug Eluting

Abstract Aims To compare the safety and efficacy of very short (≤3 months), short (6 months), standard (12 months), and extended (>12 months) dual antiplatelet therapy (DAPT), and of subsequent monotherapies, after coronary drug-eluting stent (DES) implantation. Methods and results Twenty-two randomized control trials (n = 110 059 patients/year) were selected and included in a Bayesian network meta-analysis. The primary efficacy endpoint (PEP) was a composite of cardiac death, myocardial infarction (MI), and stent thrombosis (ST), with each of the components of the PEP being a secondary efficacy endpoint. The primary safety endpoint was major bleeding rate. Compared to standard, we found a lower rate of MI [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.44–0.77] in extended, a lower rate of major bleeding (OR 0.61, 95% CI 0.39–0.87) in very short, and a lower rate of any bleeding (OR 0.61, 95% CI 0.38–0.90) in short DAPT. All DAPT durations were comparable regarding the secondary efficacy endpoints. Very short DAPT followed by P2Y12 inhibition was the treatment of choice to reduce both major bleeding and MI. In the ACS subgroup, extended DAPT (as compared to standard) reduced PEP and ST rates (but not MIs). Conclusion The efficacy of short and very short is comparable with that of standard DAPT after DES implantation, whereas extended DAPT reduces MI rate. Very short DAPT is associated with lower haemorrhagic events and, followed by a P2Y12 inhibitor monotherapy, should be preferred in order to pursue a trade-off between major bleeding and ischaemic events.

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Study protocol for a randomised controlled trial: harmonising optimal strategy for treatment of coronary artery stenosis — coronary intervention with next-generation drug-eluting stent platforms and abbreviated dual antiplatelet therapy (HOST-IDEA) trial

BMJ Open ◽

10.1136/bmjopen-2017-016617 ◽

2017 ◽

Vol 7 (10) ◽

pp. e016617 ◽

Cited By ~ 2

Author(s):

Chi-Hoon Kim ◽

Jung-Kyu Han ◽

Han-Mo Yang ◽

Kyung Woo Park ◽

Hae-Young Lee ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Controlled Trial ◽

Coronary Intervention ◽

Target Lesion ◽

Clinical Event ◽

Drug Eluting Stent ◽

Open Label ◽

Stent Type ◽

Drug Eluting

IntroductionWe have recently seen the introduction of newer generation drug-eluting stents with ultrathin struts that use advanced polymer technologies. However, the efficacy and safety of these newest stents have not yet been fully explored. In addition, there are still controversies over the optimal duration of dual antiplatelet therapy (DAPT) after stent implantation, particularly for ultrathin stents with the newest polymer technologies.Methods and analysisThe HOST-IDEA trial is a randomised, open-label, multicentre, non-inferiority trial and the first study to directly compare two of these ultrathin sirolimus-eluting stents: Orsiro stent with biodegradable polymer, and polymer-free Coroflex ISAR (CX-ISAR) stent. This study has a scheme of 2×2 factorial design according to the stent type and DAPT duration (3 vs 12 months). A total of 2152 patients will be randomised and stratified to demonstrate the non-inferiority of CX-ISAR to Orsiro, or of the abbreviated DAPT duration to the conventional 12 months (both in 1:1 ratio). For the comparison of stent type, the primary endpoint is target lesion failure (TLF), which is a composite of cardiac death, target vessel-related myocardial infarction and clinically driven target lesion revascularisation. For the comparison of DAPT duration, the net adverse clinical event is the coprimary endpoint, which is defined as a composite of TLF, definite/probable stent thrombosis and major bleeding.Ethic approval and disseminationAll the institutions involved in this study are required to have ethical approval prior to patient enrolment. This multicentre study will recruit patients through competitive registration, but institutions that have not yet obtained ethical approvals have made it impossible to enrol patients in a centralised web database. The final results will be presented at relevant international conferences and will be materialised in the form of papers.Trial registration numberNCT02601157; Pre-results.

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