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CLINICIAN REFERENCE

Aspirin / P2Y12 inhibitors

Antiplatelet medicines do not have a universal perioperative hold time. Management depends heavily on indication, bleeding risk, prior PCI/stent type and timing, and the consequences of interrupting dual antiplatelet therapy.

Patients without prior PCI

In patients without prior PCI, continuation of aspirin may be reasonable when cardiac risk outweighs bleeding risk. Routine initiation of aspirin solely for elective noncarotid surgery is not beneficial.

Patients with coronary stents

Premature interruption of dual antiplatelet therapy (DAPT) after coronary stenting is associated with stent thrombosis. Key considerations:

  • Timing after stenting: the AHA/ACC 2024 guideline describes elective surgery requiring antiplatelet interruption within 30 days of a bare-metal or drug-eluting stent as potentially harmful. For drug-eluting stents, its suggested delay depends on whether PCI treated an acute coronary syndrome or chronic coronary disease, and on whether surgery is elective or time-sensitive. These decisions require the exact guideline recommendation and specialist assessment.
  • Aspirin: AHA/ACC generally recommends continuation after prior PCI when possible. Bleeding risk and the consequences of interruption remain part of the individual assessment.
  • Decision-making: involving the cardiologist, surgeon and anaesthesiologist is recommended when interruption is being considered within the high-risk period.
  • Restarting: a clear plan for restarting the P2Y12 inhibitor after surgery, once haemostasis allows, reduces the period of risk.

P2Y12 interruption and platelet recovery

When interruption is appropriate, AHA/ACC 2024 Table 12 gives the following minimum times from interruption to restoration of platelet function: clopidogrel 5–7 days, prasugrel 7–10 days and ticagrelor 3–5 days. These are not universal stop instructions. CHEST 2022 separately favours aspirin continuation over interruption for elective non-cardiac surgery. Neither statement removes the need to assess stent thrombosis and procedural bleeding risk.

Neuraxial and deep regional anaesthesia

Neuraxial and deep regional procedures raise separate concerns about bleeding into a confined or poorly compressible space. ASRA’s fifth-edition recommendations provide drug-specific guidance for these procedures; a surgical interruption schedule alone does not establish suitability for a block.

  • The assessment includes the exact antiplatelet agent, concurrent anticoagulants and other factors that may increase bleeding risk.
  • Needle placement, an indwelling catheter and catheter removal each need consideration. The relevant ASRA recommendation distinguishes drugs and loading-dose regimens.
  • The postoperative plan includes haemostasis, catheter status and the intended maintenance or loading dose before antiplatelet treatment resumes.

For superficial procedures, the compressibility and vascularity of the site and the consequences of bleeding are relevant. Deep blocks may require precautions comparable to neuraxial procedures.

A longer interruption may reduce one bleeding risk while increasing thrombotic risk. The appropriate response may include a different anaesthetic technique or procedure timing, decided with the treating team, rather than simply choosing the longest interval.

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