1. Brief overview of peri-operative antiplatelet therapy BJA 2007; 99(3) : 316-28 Nov 9 th 2010 M. Cunningham

2. Standard approach ● Simple ● Complicated by ● Rebound effects ● Prothrombotic effects of surgery ● PCI Stop antiplatelet dugs 7-10 days before surgery

3. Complicated problem ! ● Used for primary and secondary prevention ● > 2 million PCI p.a. in Western Countries. 5% have non-cardiac surgery with 1 year. ● BMS ● DES ● Risk varies with time ● Various agents ● COX ● ADP ● GP IIb/IIIa What is safe ?

4. Antiplatelet agents ● COX-1 antagonist Irreversible - Aspirin Reversible – Ibuprofen etc. ● ADP receptor antagonists Clopidogrel ● GP IIb/IIIa antagonists Abciximab / tirofiban / eptifibatide

5. PCI – Risk of non-cardiac surgery Earl y MI 30% Mortality 20-40% 5-10 fold increase ? Aspirin lifelong

6. Why stop clopidogrel ?

7. BMS v DES

8. So just carry on ? ● Aspirin ● Dual therapy ● No CI to CNB ● Increases risk of haemorrhage by 1.5 but not morbidity. ● Surgeons unable to differentiate. ● Transfusion rate increased by 1.5x in orthopaedics. ● Problems in tonsillectomy (7.2x re- operation) and TURP (2.7x transfusion rate). ● Intra-cranial surgery - danger

9. So just carry on ? ● Aspirin ● Dual therapy ● Evidence poor ● In general: ● Blood loss likely to increase by 30- 50% ● Little impact in transfusion rate (38.5% v 42.6% in selected, major, non-cardiac surgery) ● No impact on morbidity, mortality or outcome. ● Neurosurgery: Fatalities reported with intra-cranial procedures.

10. Summary

11. Risk factors

12. Questions ?

14. Timing ● Aspirin 8.5 days to ACS 14.3 days to CVA