Noncardiac surgery after percutaneous coronary intervention

INTRODUCTION — The management of antiplatelet therapy in patients who need major noncardiac surgery after percutaneous coronary intervention (PCI) with stenting requires consideration of the competing risks of acute coronary events with premature cessation and bleeding with continuation. This topic will focus on the approach to patients scheduled to undergo elective noncardiac surgery after PCI with stenting and who are taking dual antiplatelet therapy (DAPT), which is the combination of aspirin plus a P2Y₁₂ receptor blocker such as clopidogrel, prasugrel, or ticagrelor. After one year, many of these patients will be taking only aspirin. Our recommendations for the perioperative use of aspirin are presented separately.

The approach to antiplatelet therapy in patients scheduled for coronary artery bypass graft surgery is presented separately. (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Preoperative aspirin' and "Coronary artery bypass surgery: Perioperative medical management", section on 'Platelet P2Y12 receptor blocker therapy'.)

The larger discussion of the risk of coronary artery stent thrombosis, one of the potential complications of discontinuing antiplatelet therapy prior to noncardiac surgery, is found elsewhere. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients" and "Coronary artery stent thrombosis: Incidence and risk factors".)

STATEMENT OF THE PROBLEM — For patients taking dual antiplatelet therapy (DAPT) after PCI who need to undergo major noncardiac surgery, continuation of DAPT may increase the risk of major bleeding, while discontinuation of one or both agents may increase risk of a thrombotic event. It is estimated that approximately 5 to 10 percent of patients with coronary stents undergo major noncardiac surgery within one year of stent implantation [1-5]. Thus, the optimal management of DAPT is a common clinical issue.

Major noncardiac surgery is defined as any surgery for which the surgeon might recommend the discontinuation of DAPT due to a concern for an increase in bleeding risk. Most studies that have evaluated this issue have included patients scheduled to undergo peripheral arterial, orthopedic, abdominal, or thoracic surgery, or radical prostatectomy, nephrectomy, or cystectomy.

Perioperative thrombotic cardiac events related to DAPT discontinuation include myocardial infarction (MI), death, stent thrombosis, and the need for urgent repeat revascularization. Stent thrombosis is a proximate cause of death or MI.

The premature cessation of DAPT is the strongest predictor of stent thrombosis, especially discontinuation of both agents (see "Coronary artery stent thrombosis: Incidence and risk factors", section on 'Risk factors'). Stent thrombosis can lead to high rates of MI (50 to 70 percent) and death (10 to 40 percent), both of which are included as components of composite outcomes in the studies discussed below [6]. (See 'Timing, incidence, and predictors of adverse outcomes' below.)

In addition, the prothrombotic and proinflammatory effects of surgery may predispose the coronary circulation to thrombosis, both at the site of prior stent placement and at other sites of atherosclerotic lesions [7-10]. The perioperative prothrombotic state may be mediated by increased platelet aggregation and decreased fibrinolysis [11-13].

TIMING, INCIDENCE, AND PREDICTORS OF ADVERSE OUTCOMES — Multiple observational studies have evaluated the timing, incidence, and clinical predictors of adverse outcomes in stented patients undergoing noncardiac surgery. They have shown that patients who undergo major noncardiac surgery within six weeks, and particularly within two weeks, of PCI with bare-metal (BMS) or drug-eluting stents (DES) have a markedly increased risk of adverse cardiovascular events [1,4,14-19]. In general, they also show that the risk remains relatively higher until approximately six months after PCI. Findings from the following five large studies are representative.

In a case-control study of 24,313 patients who underwent noncardiac surgery (1120 stented patients), the following findings were noted [20]:

●The 30-day rates of major adverse cardiac and cerebrovascular events (death, MI, cardiac arrest, or stroke) were 3.7 and 1.5 percent in stented and unstented patients (p<0.001).

●The risk was related to the time from stent implantation to surgery, with a significantly elevated risk during the first year (adjusted odds ratio [AOR] 2.59, 95% CI 1.36-4.94).

●The risk was increased in patients with DES and BMS.

In a study of over 200,000 patients who underwent PCI and survived to hospital discharge, 3.5 percent were readmitted for noncardiac surgery within six months of PCI, and 41 percent of these hospitalizations were elective [21].

●Surgery was complicated by MI in 4.7 percent of cases, and 21 percent of perioperative MIs were fatal.

●Bleeding was found in 32 percent of patients, and all-cause mortality occurred in 4.4 percent.

●The risk of death or MI was greatest when noncardiac surgery was performed within the first month after PCI.

In a retrospective cohort study of 28,029 individuals (41,989 operations) who underwent noncardiac surgery within 24 months of stent implantation, the following was noted [5]:

●The rate of major adverse cardiac events (MACE), a combination of all-cause mortality, MI, and cardiac revascularization, was 4.7 percent at 30 days.

●The time between stenting and surgery was associated with MACE (<6 weeks, 11.6 percent; 6 weeks to <6 months, 6.4 percent; 6 to 12 months, 4.2 percent; >12 to 24 months, 3.5 percent). Thus, rates appeared to stabilize after six months; there was only a minor decrease in the risk of MACE between 6 and 12 months.

●The factors most strongly associated with MACE were nonelective surgical admission (AOR 4.77), history of MI in the six months preceding surgery (AOR 2.63), and revised cardiac risk index (table 1) >2 (AOR 2.13).

●The rate of MACE was 5.1 percent for BMS and 4.3 percent for DES (p<0.001). The odds of MACE for surgery between six weeks and six months were actually lower for DES, with no difference before six weeks or after six months.

●In a nested case-control study comparing 284 patients with confirmed MACE who had surgery >6 weeks after stenting with matched pairs who were free of MACE, the likelihood of completely stopping all antiplatelet therapy for at least five days was similar (22.9 versus 25.4 percent). Of note, patients with surgery followed by death as the only MACE event were excluded. Given multiple issues with confounding, we do not believe these data are compelling enough to suggest it is safe to discontinue all antiplatelet therapy prior to surgery. (See 'Summary and recommendations' below.)

In a cohort study of 8116 patients who underwent intermediate- to high-risk elective noncardiac surgery and received coronary stents within 10 years before surgery (approximately one-third were within two years), the following were noted [19]:

●For the 8116 surgical patients who underwent PCI within 10 years, the primary outcome (30-day composite of mortality, readmission for acute coronary syndrome, or repeat revascularization) occurred in 2.1 percent. This rate was comparable to that of intermediate-risk individuals who had never received PCI. Intermediate risk was defined using the revised cardiac risk index [18]. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Using risk assessment tools'.)

●When the interval between stent placement and surgery was less than 45 days, the event rates for BMS and DES were very high, at 6.7 and 20 percent, respectively. Comparing these patients operated on during this time interval with those whose surgery was at least two years after PCI, the AOR for 30-day events was 2.35 (95% CI 0.98-5.64) and 11.58 (95% CI 4.08-32.80), respectively.

●When the interval was 45 to 180 days, the event rates for BMS and DES were 2.6 and approximately 4 percent, respectively. The AOR was 1.06 (95% CI 0.58-1.92) and 1.71 (95% CI 0.73-4.01), respectively.

●When the interval was 181 to 365 days, the event rate for DES was 1.2 percent (AOR 0.64, 95% CI 0.20-2.04). Surprisingly, the event rate for BMS increased to approximately 3.5 percent during this time period, perhaps due to an increased rate of restenosis with BMS.

In a retrospective Veterans Affairs (United States) cohort study of patients treated with coronary stents, outcomes in 20,590 patients who underwent noncardiac surgery within 24 months of stent placement were compared with those in 41,180 nonsurgical patients [22]. The following findings were noted:

●Within 30 days after surgery, the surgical cohort had higher rates of the composite end point of MI and/or cardiac revascularization compared with nonsurgical patients at a similar time interval from stent placement (3.1 versus 1.9 percent; risk difference 1.3 percent, 95% CI 1.0-1.5).

●The risk difference (incremental risk for surgery) was 3.5 percent immediately following stenting, 2.8 percent during the first six weeks, 2 percent between six weeks and six months, and fell to approximately 1 percent at six months, after which the risk difference seemed to remain stable [23].

There are several limitations that impact the usefulness of these studies for guiding timing of surgery and duration of dual antiplatelet therapy (DAPT). These include unmeasured confounding related to the indication for earlier surgery, which in itself may have selected patients at higher risk. There is also limited information as to whether DAPT was interrupted or continued. Finally, most of these data are for first-generation DES, for which risks of interruption of DAPT were higher.

The following observations regarding the timing and incidence of adverse outcomes following the premature discontinuation of antiplatelet therapy in patients not undergoing surgery also help inform our recommendations for managing antiplatelet therapy in patients who require noncardiac surgery:

●In patients with stable coronary artery disease, aspirin is recommended indefinitely to prevent recurrent cardiovascular events and discontinuation of aspirin has been estimated to be responsible for at least 15 percent of all recurrent events in this population [24,25]. (See "Perioperative medication management", section on 'Aspirin' and "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease".)

●Most cases of stent thrombosis occur within the first 30 days after placement, irrespective of stent type. (See "Coronary artery stent thrombosis: Incidence and risk factors", section on 'Timing and incidence'.)

The importance of the continuation of antiplatelet therapy in the perioperative period was evaluated and confirmed in a multicenter, retrospective study of 666 patients with prior coronary stenting who subsequently underwent cardiac or noncardiac (86 percent) surgery [26]. Of these, 371 (55.7 percent) discontinued all or part of their antiplatelet therapy (aspirin, clopidogrel, or both) ≥5 days before surgery. The primary efficacy end point was the 30-day incidence of MACE, a combination of cardiac death, MI, or stroke, and the primary safety end point was 30-day Bleeding Academic Research Consortium (BARC) bleeding ≥2 (table 2). The overall mean time from PCI to surgery was approximately 500 days, and the mean time from discontinuation of antiplatelet therapy to surgery was five days. Among those who discontinued some antiplatelet therapy, approximately 10 percent remained on aspirin. Comparing those who discontinued therapy to those who did not, the following findings were noted:

●The rate of MACE was higher (7.5 versus 0.3 percent; p = 0.027).

●After adjustment, perioperative antiplatelet discontinuation was the strongest independent predictor of MACE (odds ratio [OR] 25.8, 95% CI 3.37-198).

●Continuation of aspirin was associated with a significantly lower risk of MACE (AOR 0.27, 95% CI 0.11-0.71).

●After adjustment, there was no significant difference in the rate of the safety end point.

Another study compared outcomes in 847 patients who underwent noncardiac surgery after coronary artery stenting. There was no difference in the risk of MACE between no antiplatelet treatment and monotherapy (hazard ratio 1.03, 95% CI 0.31-3.46). In a propensity-matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (95% CI 0.69-4.85) [27]. The finding of no difference in MACE is unexpected. This study does not influence our recommendations given the small number of patients.

BLEEDING — The risk of a serious complication related to perioperative bleeding in patients taking one or two antiplatelet agents is not well studied, except in patients undergoing coronary artery bypass graft surgery (CABG). In these patients, preoperative dual antiplatelet therapy (DAPT) increases that rate of bleeding as well as the need for reoperation and transfusion. Given concerns for the need for reoperation, discontinuation of P2Y₁₂ receptor blocker at least five days for clopidogrel, seven days for prasugrel, and three to five days for ticagrelor before surgery is recommended. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding'.)

For patients undergoing non-CABG noncardiac surgery, aspirin alone or with P2Y₁₂ receptor blocker increases the risk of bleeding by as much as 20 and 50 percent, respectively, and these rates are dependent on the location of the surgery [28,29]. This excess bleeding leads to an increase in red blood cell transfusion but not to an increase in surgical mortality or morbidity [30].

Despite the lack of definitive evidence of an increase in surgical mortality or morbidity in patients taking DAPT, many surgeons recommend discontinuing P2Y₁₂ receptor blocker before surgery. In some situations, such as neurosurgery, where the consequence of bleeding might be catastrophic, both aspirin and P2Y₁₂ therapy are stopped.

OUR APPROACH — The following discussion applies to patients scheduled to undergo noncardiac surgery who have undergone PCI with stenting within the prior 12 months.

In such patients, it may be necessary to stop one or both antiplatelet agents prior to our recommended minimum duration of such therapy for the general population, which is at least six months after either bare metal stenting (BMS) or drug-eluting stenting (DES). In patients at high bleeding risk, we sometimes shorten the duration of dual antiplatelet therapy (DAPT) to one to three months. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on 'Summary and recommendations'.)

Noncardiac surgery impacts our minimum duration recommendations based on whether or not the surgery can be deferred, but in general is not different for BMS and DES. Although noncardiac surgery which cannot be deferred is itself considered a criterion for high bleeding risk [31], we favor deferring truly elective surgery for six months rather than adopting shorter-term DAPT strategies after either BMS or DES. For nonemergency noncardiac surgery that cannot be deferred, we believe that durations from one to three months may be acceptable depending on the urgency of surgery. As with other high bleeding risk indications, and consistent with the majority of data above, there is not a preference for BMS over DES in these shorter DAPT strategies.

We believe that our recommendations (below) for the management of these patients who need nonemergency noncardiac surgery are based on low-quality evidence [32]. These recommendations are based on the observations presented above regarding the rates of stent thrombosis in patients with premature cessation of DAPT and rates of adverse cardiovascular events found in studies of patients undergoing noncardiac surgery (see 'Timing, incidence, and predictors of adverse outcomes' above). No randomized trials comparing different times for surgery after PCI or differing antiplatelet strategies have been performed. These recommendations attempt to take into account what is known about the risk of perioperative bleeding on one or two antiplatelet agents.

The continuation of DAPT should be made on a case-by-case basis, taking into account the relative benefits and risks [33]. Prior to surgery, the patient, primary care physician, cardiologist, anesthesiologist, and surgeon should be involved in decision making.

An occasional patient may be scheduled for both nonemergency noncardiac surgery and PCI. It is critically important for all managing clinicians to discuss the optimal timing of each procedure. Prior to a decision for PCI and selection of PCI strategy, the timing and need for noncardiac surgery should be considered. Given the balanced risks of discontinuation of DAPT and proceeding with surgery despite DAPT, the first critical decision is the absolute need for PCI. As in other situations, a decision for appropriate PCI should be based on evidence of clinically significant ischemia and size of the territory at risk and not on angiographic findings alone. Once this decision is made, consideration should be given to timing of surgery. (See 'Timing, incidence, and predictors of adverse outcomes' above.)

In cases where PCI cannot be deferred and noncardiac surgery is urgent (<30 days), balloon angioplasty may be reasonable to avoid risk of stent thrombosis or absolute requirement for DAPT, as long as a successful result is obtained. When stenting is required prior to urgent (<30 days) noncardiac surgery for which discontinuation of P2Y₁₂ receptor blocker is likely, many of our experts still prefer DES over BMS, extrapolating from studies showing safety of reduced DAPT duration with second-generation DES and otherwise superior outcomes of DES versus BMS among patients not undergoing noncardiac surgery (see "High bleeding risk patients undergoing percutaneous coronary intervention", section on 'BMS versus DES'). Other experts favor BMS <30 days, based on reports above of higher risk for major adverse cardiac events (MACE) for DES within six weeks. After 30 days, most of our experts prefer DES [34]. Recommendations for minimum DAPT prior to noncardiac surgery according to stent type or after POBA are included in the sections below.

Nonemergency noncardiac surgery — For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we prefer to defer planned nonemergency, nonurgent noncardiac surgery until at least six months after stent implantation. The risks of noncardiac surgery before six months are increased after both BMS and DES.

For patients whose surgery requires cessation of one or both antiplatelet agents and cannot wait six months, and where the risks of delaying surgery outweigh the benefits, our recommended minimal duration of DAPT is four to six weeks, depending on the urgency of surgery and risk of thrombotic complication [35]. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES [34,36]. Although we prefer to wait at least six weeks when possible, in patients for whom earlier surgery is in their best interest after weighing risks and benefits, we sometimes refer patients as early as four weeks after stent placement.

The proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT and regardless of stent type during this early period after stenting. We believe this risk to be higher prior to the minimum duration of DAPT recommended above, but the final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and patient has taken place. In many cases, DAPT can be continued in the perioperative period, although for some surgeries, such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis.

In these patients who undergo noncardiac surgery before the recommended minimum duration of DAPT, a platelet P2Y₁₂ receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. The rationale to continue aspirin comes in part from the POISE-2 trial (PCI subgroup analysis) [37], which is discussed separately. However, as many neurosurgical patients, for whom bleeding might be life threatening or lead to severe adverse outcomes, were not enrolled in POISE-2, the optimal strategy is not known [37]. (See "Perioperative medication management", section on 'Aspirin'.)

Additional points to consider include:

●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy.

●With regard to stopping P2Y₁₂ inhibitor prior to noncardiac surgery, we generally follow recommendations found in the manufacturer's package insert for each drug.

For clopidogrel, we stop five days before surgery; that is, the last dose is taken on the sixth day before surgery.

For prasugrel, we stop seven days before surgery.

For ticagrelor, we stop three to five days before surgery.

Some experts are willing to recommend shorter discontinuation periods for procedures less likely to be associated with major bleeding.

●Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting [38].

●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage [38]. (See "Management of cardiac risk for noncardiac surgery", section on 'Revascularization before surgery'.)

Urgent or emergency noncardiac surgery — For patients who require surgery prior to the minimal durations of DAPT discussed above, such as those who require urgent or emergency noncardiac surgery, two issues need to be discussed among all managing practitioners:

●The relative risks and benefits of continuing DAPT.

●The role of platelet transfusion. For patients who are at increased risk of bleeding, there will not be time to discontinue one or both antiplatelet agents. While platelet transfusion may be necessary for excessive bleeding after surgery, the role of prophylactic platelet transfusion has not been well studied. (See "Inherited platelet function disorders (IPFDs)", section on 'Platelet transfusion'.)

Patients with prior balloon angioplasty — Less than 5 percent of all PCIs are performed using balloon angioplasty without stenting. In these patients, 14 days of DAPT is generally recommended. (See "Antithrombotic therapy for elective percutaneous coronary intervention: General use", section on 'Patients undergoing balloon angioplasty'.)

There are no high-quality studies that address the optimal approach to these patients who need noncardiac surgery. If possible, we and others suggest waiting at least 14 days before performing surgery [39]. For patients who must undergo surgery in a shorter time frame, and, in particular, when antiplatelet therapy must be stopped (eg, neurosurgical procedures), we suggest deferring surgery for at least 48 hours after balloon angioplasty if possible.

RECOMMENDATIONS OF OTHERS — Our recommendations for patients with coronary stents undergoing noncardiac surgery are generally consistent with those from the American College of Cardiology/American Heart Association (ACC/AHA), and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) [35,40].

The 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery (endorsed by the European society of interventional cardiology) recommend:

●After implantation of modern drug-eluting stent (DES), delay time-sensitive noncardiac surgery until a minimum of one month of dual antiplatelet therapy (DAPT) treatment has been effectuated.

●High-risk cardiovascular patients, including those with acute coronary syndrome, should take DAPT for at least three months prior to being considered for time-sensitive noncardiac surgery.

●High risk of perioperative stent thrombosis is defined by at least one of the following: history of recurrent myocardial infarction, history of stent thrombosis under antiplatelet therapy, reduced left ventricular ejection fraction (40 percent), poorly controlled diabetes, severely impaired renal function or hemodialysis, recent complex PCI (ie, severely calcified lesion, left main coronary artery PCI, chronic total occlusion, bifurcational or crush technique, bypass graft PCI), stent malapposition/residual dissection.

The 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease contains the following text [40]:

●Elective noncardiac surgery should be delayed 30 days after bare metal stent (BMS) implantation and optimally six months after drug-eluting stent (DES) implantation. Based on more recent data, we have not distinguished BMS and DES based on dual antiplatelet therapy (DAPT) duration, and most of our experts do not prefer use of BMS to reduce DAPT duration to 30 days. Generally, we prefer six months delay for noncardiac surgery that can be deferred after either BMS or DES.

●Elective noncardiac surgery after DES implantation, in patients for whom P2Y₁₂ inhibitor therapy will need to be discontinued, may be considered after three months if the risk of further delay of surgery is greater than the expected risks of stent thrombosis.

The 2017 ESC focused update on DAPT in coronary artery disease, developed in collaboration with EACTS, contains the following text [35]:

●After coronary stent implantation, elective surgery requiring discontinuation of the P2Y₁₂ inhibitor should be considered after one month, irrespective of the stent type, if aspirin can be maintained throughout the perioperative period.

The 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology focused update on guidelines for the use of antiplatelet therapy made the following recommendations [41]:

●In patients undergoing PCI who are treated with a BMS and who require elective noncardiac surgery, delay surgery for at least one month after PCI.

●In patients undergoing PCI who are treated with a DES and who require elective noncardiac surgery, delay surgery for at least three months after PCI. If there is a need for semiurgent noncardiac surgery, delay surgery for at least one month after PCI.

●In patients undergoing PCI who are treated with either a BMS or DES and who require elective noncardiac surgery, continue aspirin perioperatively whenever possible.

●In patients undergoing PCI who are treated with a BMS or DES and who require elective noncardiac surgery, withhold clopidogrel and ticagrelor for five to seven days preoperatively, and prasugrel for 7 to 10 days preoperatively.

●In patients undergoing PCI who are treated with a BMS or DES and who have undergone noncardiac surgery, restart maintenance-dose DAPT after surgery, as soon as it is deemed safe by the surgeon.

POTENTIAL ALTERNATIVES TO DUAL ANTIPLATELET THERAPY — The concept of bridging a gap in platelet P2Y₁₂ receptor blocker therapy using an intravenous glycoprotein IIb/IIIa inhibitor such as tirofiban or eptifibatide has been studied [42,43]. Some academic medical centers have used such a bridging strategy in patients at high risk for stent thrombosis [44]. However, such a strategy is likely to be associated with a higher risk of bleeding and is not recommended by our experts.

Parenteral anticoagulants such as heparin do not decrease the risk of stent thrombosis and should not be used as a substitute to antiplatelet therapy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Perioperative cardiovascular evaluation and management".)

SUMMARY AND RECOMMENDATIONS

●Background – Noncardiac surgery is often proposed or required in patients taking dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stenting. Cessation of DAPT prior to the recommended duration of its use and the prothrombotic and proinflammatory state associated with surgery contribute to an increased risk of adverse cardiovascular events such as stent thrombosis, myocardial infarction (MI), or death. On the other hand, for some patients, such as those undergoing neurosurgical procedures, the risk of bleeding attributable to DAPT may be greater than the risk of an adverse cardiovascular event off such therapy. (See 'Introduction' above and 'Statement of the problem' above.)

●Our approach

•Patients at low bleeding risk – For patients undergoing noncardiac surgery at low bleeding risk, with proposed surgery at an anatomic location such that bleeding would be manageable if it occurs, and who are taking DAPT because they have not reached the recommended minimum duration of such therapy, we suggest continuing DAPT, as opposed to stopping it prior to surgery (Grade 2C).

•Emergency noncardiac surgery – The following are our recommendations for patients receiving DAPT after PCI with stenting for whom major nonemergency, noncardiac surgery is needed and the surgeon believes it is in the patient’s best interest to stop one or both antiplatelet agents in the perioperative period because of bleeding risk. The rationale for the durations presented below is given above (see 'Nonemergency noncardiac surgery' above):

-We recommend deferring nonemergency, not time-sensitive surgery for at least six months as opposed to a shorter time period (Grade 1B). This recommendation applies to drug-eluting (DES) and bare metal stents (BMS).

-For patients who must undergo major nonemergency, time-sensitive surgery prior to six months, we suggest an attempt to defer surgery for at least one month, and preferably three months, after BMS or DES placement (Grade 2C).

-For patients undergoing major noncardiac surgery before the recommended minimum duration of such therapy and in whom the surgeon recommends stopping antiplatelet therapy, we recommend interrupting P2Y₁₂ therapy for the minimum time necessary based on the P2Y₁₂ agent (see 'Bleeding' above) and continuing aspirin without interruption as opposed to stopping both agents (Grade 2C).

In patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate, or posterior eye procedures, stopping both antiplatelet agents might be necessary. (See 'Timing, incidence, and predictors of adverse outcomes' above.)

●Patients taking DAPT after PCI with balloon angioplasty – For these patients who are scheduled to undergo elective noncardiac surgery, we suggest waiting 14 days after PCI (Grade 2C) if possible. If surgery is more urgent, then we recommend at least 48 hours to confirm stable PCI result prior to surgery. (See 'Patients with prior balloon angioplasty' above.)

●Multidisciplinary team – Given the low level of evidence and unique factors in each case, we suggest that all recommendations for minimum DAPT duration and timing of surgery involve a multidisciplinary team including at least the cardiologist, interventional cardiologist, and surgeon. Such recommendations should be followed by a detailed discussion of the balance of risks and benefits of reduced DAPT duration and delays in surgery.

●Aspirin monotherapy – Recommendations for patients taking long-term aspirin monotherapy undergoing noncardiac surgery and for patients undergoing coronary artery bypass graft (CABG) surgery on DAPT are found elsewhere. (See "Perioperative medication management", section on 'Aspirin' and "Coronary artery bypass surgery: Perioperative medical management", section on 'Preoperative aspirin' and "Coronary artery bypass surgery: Perioperative medical management", section on 'Platelet P2Y12 receptor blocker therapy'.)