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Antiplatelet agents and perioperative bleeding

[Les inhibiteurs plaquettaires et le saignement périopératoire]

Thomas Lecompte, MD^* and Jean-François Hardy, MD FRCPC

^* From the Service d’Hématologie Biologique, Centre Hospitalier Universitaire de Nancy, Université Henri Poincaré de Nancy, Nancy, France; and the
Centre Hospitalier de l’Université de Montréal,Montréal, Québec, Canada.

Address correspondence to: Dr. Thomas Lecompte, Hémostase - Service d’Hématologie Biologique, Centre Hospitalier Universitaire de Nancy, 54035 Nancy Cedex, France. E-mail: thomas.lecompte{at}chu-nancy.fr

Purpose: To briefly review the risks, in patients presenting for surgery, associated with the available antiplatelet agents, and to present the principles that should guide the evaluation of these risks and how to manage them.

Methods: A narrative review of the current medical literature in English and French.

Main findings: Antiplatelet agents [mainly acetylsalicylic acid, clopidogrel and glycoprotein (GP) IIb/IIIa inhibitors] are used increasingly to prevent arterial thrombosis. Clinicians are confronted with the hemorrhagic risk associated with the continuation of antiplatelet agents throughout surgery or, conversely, with the thrombotic risk associated with their discontinuation. Most experts recommend surgery while maintaining acetylsalicylic acid for most vascular procedures and in several additional settings where the bleeding risk has been shown (or is likely) to be low. It is commonly recommended that clopidogrel be stopped five days before surgery to allow replacement of half the platelet pool. This approach has been associated with thrombotic events in patients waiting for urgent myocardial revascularization. In this context, aprotinin may reduce blood losses and transfusion requirements. Withdrawal of the competitive GPIIb/IIIa inhibitors at the beginning of surgery will decrease the risk of bleeding, less so for abciximab owing to its avid binding to platelet receptors. Platelets should not be transfused prophylactically, but only to those few patients with abnormal bleeding thought to be related to the persisting effect of antiplatelet therapy.

Conclusions: Unfortunately, data regarding the management of antiplatelet agent-treated patients undergoing surgery, especially non-cardiovascular, are scarce. Further clinical trials must be conducted to guide the clinical management of these patients.

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