When Should Antiplatelet Agents Be Withheld for Bronchoscopy?
How should antiplatelet agents be managed in patients undergoing bronchoscopy?
Oral antiplatelet agents such as aspirin and clopidogrel are used to prevent strokes, heart attacks, and other atherothrombotic events. Certain invasive procedures carry a degree of bleeding risk that is increased in the presence of antithrombotic therapy. The need to withhold antiplatelet therapy depends on the risks of bleeding with the procedure weighed against the potential for thrombotic events while withholding antiplatelet therapy.
A study by Herth and colleagues evaluated bleeding in over 1200 patients undergoing bronchoscopy with transbronchial biopsy, 285 of whom had taken aspirin within 24 hours of the procedure. Most of the patients taking aspirin took it daily for primary or secondary prevention of cardiovascular disorders. The risk for severe bleeding was < 1% in all patients, with no difference in bleeding, even severe, in patients taking aspirin.
In contrast, Ernst and colleagues assessed bleeding in over 600 patients undergoing transbronchial biopsy, 30 of whom had taken clopidogrel (with or without aspirin) within 24 hours of bronchoscopy. Patients in the clopidogrel group were taking clopidogrel daily for primary or secondary prevention of coronary heart disease or prevention of graft occlusion following coronary artery bypass surgery. This study was stopped after 6 months due to an excessive rate of bleeding in the clopidogrel group. Sixteen of 18 (89%) patients taking clopidogrel and all 12 (100%) patients taking both clopidogrel and aspirin had bleeding compared with 3.4% of patients not receiving an antiplatelet agent. Bleeding was controlled with topical endoscopic treatment. No deaths occurred in the study and no patients required intubation or critical care admission.
When considering interruption of antiplatelet therapy for bronchoscopy, consideration must be given to risk for thrombotic events. Not all patients should interrupt antiplatelet (particularly clopidogrel) therapy. The American College of Chest Physicians' (ACCP) evidence-based clinical practice guidelines for the perioperative management of antithrombotic therapybreaks down risk into 3 populations: (1) patients at low risk for cardiac events, (2) patients at high risk for cardiac events but without coronary stents, and (3) patients at high risk for cardiac events with recent coronary stents.
The ACCP guidelines suggest that patients taking antiplatelet therapy as primary prevention of myocardial infarction or stroke could be considered at low risk for perioperative cardiovascular events with interruption of antiplatelet therapy. In these patients, the ACCP recommendation is to withhold aspirin or clopidogrel for 7-10 days before surgery and resume these agents 24 hours postoperatively (or the next morning).
For patients at high risk for cardiac events, but without stents, ACCP guidelines recommend continuing aspirin and withholding clopidogrel for at least 5 days, and up to 10 days before surgery, and resuming clopidogrel 24 hours after surgery, or the next morning, if hemostasis is adequate. On the other hand, patients taking antiplatelet therapy to prevent stent thrombosis following recent bare metal or drug-eluting stent placement are considered to be at high risk for catastrophic stent thrombosis if antiplatelet therapy is interrupted.
A joint advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association urges avoidance of interruption of dual antiplatelet therapy with aspirin and a thienopyridine (eg, clopidogrel) for a minimum of 1 month following bare metal stent and 12 months following placement of a drug-eluting coronary stent. The advisory recommends that in the event a surgical procedure cannot be postponed for these time periods, then aspirin should be continued if possible and the thienopyridine restarted as soon as possible. The ACCP guidelines give a different recommendation of continuing aspirin and clopidogrel throughout the perioperative period if within 6 weeks of bare metal stent or within 12 months of a drug-eluting stent.
Prasugrel is a thienopyridine antiplatelet agent with irreversible platelet inhibition. As with clopidogrel, there is a high risk for coronary stent thrombosis when interrupting prasugrel therapy prematurely. If it is to be interrupted, the manufacturer recommends prasugrel be discontinued at least 7 days before any surgery when possible.
Platelet transfusion can be considered in the event emergency surgery is needed in a patient taking antiplatelet agents.
In conclusion, taking into consideration the bleeding outcomes identified with bronchoscopy and antiplatelet agents, along with the risk stratification for thrombotic complications from interruption of antiplatelet agents, it would seem reasonable to continue aspirin, but withhold clopidogrel before bronchoscopy in the majority of patients receiving these agents for primary or secondary prevention of cardiovascular events, other than those with recent coronary stent placement. For patients within 12 months of drug-eluting stent or 1 month of bare metal stent placement who require bronchoscopy, a discussion of the risks for and benefits of clopidogrel interruption should take place between the cardiologist and pulmonologist.
Question
How should antiplatelet agents be managed in patients undergoing bronchoscopy?
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Response from Laura S. Lehman, PharmD Pharmacist, Carroll Hospital Center, Westminster, Maryland |
Oral antiplatelet agents such as aspirin and clopidogrel are used to prevent strokes, heart attacks, and other atherothrombotic events. Certain invasive procedures carry a degree of bleeding risk that is increased in the presence of antithrombotic therapy. The need to withhold antiplatelet therapy depends on the risks of bleeding with the procedure weighed against the potential for thrombotic events while withholding antiplatelet therapy.
A study by Herth and colleagues evaluated bleeding in over 1200 patients undergoing bronchoscopy with transbronchial biopsy, 285 of whom had taken aspirin within 24 hours of the procedure. Most of the patients taking aspirin took it daily for primary or secondary prevention of cardiovascular disorders. The risk for severe bleeding was < 1% in all patients, with no difference in bleeding, even severe, in patients taking aspirin.
In contrast, Ernst and colleagues assessed bleeding in over 600 patients undergoing transbronchial biopsy, 30 of whom had taken clopidogrel (with or without aspirin) within 24 hours of bronchoscopy. Patients in the clopidogrel group were taking clopidogrel daily for primary or secondary prevention of coronary heart disease or prevention of graft occlusion following coronary artery bypass surgery. This study was stopped after 6 months due to an excessive rate of bleeding in the clopidogrel group. Sixteen of 18 (89%) patients taking clopidogrel and all 12 (100%) patients taking both clopidogrel and aspirin had bleeding compared with 3.4% of patients not receiving an antiplatelet agent. Bleeding was controlled with topical endoscopic treatment. No deaths occurred in the study and no patients required intubation or critical care admission.
When considering interruption of antiplatelet therapy for bronchoscopy, consideration must be given to risk for thrombotic events. Not all patients should interrupt antiplatelet (particularly clopidogrel) therapy. The American College of Chest Physicians' (ACCP) evidence-based clinical practice guidelines for the perioperative management of antithrombotic therapybreaks down risk into 3 populations: (1) patients at low risk for cardiac events, (2) patients at high risk for cardiac events but without coronary stents, and (3) patients at high risk for cardiac events with recent coronary stents.
The ACCP guidelines suggest that patients taking antiplatelet therapy as primary prevention of myocardial infarction or stroke could be considered at low risk for perioperative cardiovascular events with interruption of antiplatelet therapy. In these patients, the ACCP recommendation is to withhold aspirin or clopidogrel for 7-10 days before surgery and resume these agents 24 hours postoperatively (or the next morning).
For patients at high risk for cardiac events, but without stents, ACCP guidelines recommend continuing aspirin and withholding clopidogrel for at least 5 days, and up to 10 days before surgery, and resuming clopidogrel 24 hours after surgery, or the next morning, if hemostasis is adequate. On the other hand, patients taking antiplatelet therapy to prevent stent thrombosis following recent bare metal or drug-eluting stent placement are considered to be at high risk for catastrophic stent thrombosis if antiplatelet therapy is interrupted.
A joint advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association urges avoidance of interruption of dual antiplatelet therapy with aspirin and a thienopyridine (eg, clopidogrel) for a minimum of 1 month following bare metal stent and 12 months following placement of a drug-eluting coronary stent. The advisory recommends that in the event a surgical procedure cannot be postponed for these time periods, then aspirin should be continued if possible and the thienopyridine restarted as soon as possible. The ACCP guidelines give a different recommendation of continuing aspirin and clopidogrel throughout the perioperative period if within 6 weeks of bare metal stent or within 12 months of a drug-eluting stent.
Prasugrel is a thienopyridine antiplatelet agent with irreversible platelet inhibition. As with clopidogrel, there is a high risk for coronary stent thrombosis when interrupting prasugrel therapy prematurely. If it is to be interrupted, the manufacturer recommends prasugrel be discontinued at least 7 days before any surgery when possible.
Platelet transfusion can be considered in the event emergency surgery is needed in a patient taking antiplatelet agents.
In conclusion, taking into consideration the bleeding outcomes identified with bronchoscopy and antiplatelet agents, along with the risk stratification for thrombotic complications from interruption of antiplatelet agents, it would seem reasonable to continue aspirin, but withhold clopidogrel before bronchoscopy in the majority of patients receiving these agents for primary or secondary prevention of cardiovascular events, other than those with recent coronary stent placement. For patients within 12 months of drug-eluting stent or 1 month of bare metal stent placement who require bronchoscopy, a discussion of the risks for and benefits of clopidogrel interruption should take place between the cardiologist and pulmonologist.
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