Risk of Bleeding in Patients with Continued Dual Antiplatelet Therapy During Orthopedic Surgery
Percutaneous coronary intervention (PCI) is a widely used treatment for coronary atherosclerotic heart disease, with millions of stents implanted globally each year. To prevent the risk of life-threatening stent thrombosis, patients are typically prescribed dual antiplatelet therapy (DAPT) for at least 6 weeks to 12 months following stent implantation. However, when these patients require noncardiac surgery, such as orthopedic procedures, the continuation of DAPT poses a significant risk of severe bleeding at the surgical site. Conversely, discontinuing DAPT increases the risk of stent thrombosis, creating a complex clinical dilemma. This study aimed to evaluate the risk of bleeding in patients who continued DAPT during orthopedic surgery, while also assessing the potential for cardiovascular complications when antiplatelet therapy is interrupted.
The study retrospectively analyzed the clinical data of 78 patients with coronary heart disease who underwent orthopedic surgery between February 2006 and July 2018. Twelve patients were excluded due to undergoing minimally invasive procedures, such as transforaminal endoscopy and vertebroplasty. The remaining 66 patients were divided into three groups based on their perioperative antiplatelet therapy regimen: Group I (16 patients) continued DAPT throughout the perioperative period; Group II (24 patients) received single antiplatelet therapy or were switched from DAPT to single antiplatelet therapy; and Group III (26 patients) had all antiplatelet therapies suspended and were administered low-molecular-weight heparin for more than 5 days preoperatively. Perioperative blood loss was calculated using Nadler’s formula and Gross’ formula, and intraoperative bleeding volume, total volume of intraoperative bleeding plus postoperative drainage, and total blood loss were compared between the groups.
The results showed no significant differences between the three groups in terms of age, intraoperative bleeding volume, total volume of intraoperative bleeding plus postoperative drainage, and total perioperative blood loss calculated by Nadler’s and Gross’ formulas. This suggests that continuing DAPT or single antiplatelet therapy during orthopedic surgery does not increase the risk of bleeding compared to switching to low-molecular-weight heparin. However, the study did identify a significant risk of cardiovascular complications in patients who discontinued antiplatelet therapy. Six patients experienced postoperative cardiovascular complications due to the delayed restart of antiplatelet therapy, with one patient in Group III dying from myocardial infarction.
The study highlights the importance of balancing the risks of bleeding and thrombosis in patients on DAPT who require orthopedic surgery. While the continuation of DAPT or single antiplatelet therapy does not increase perioperative bleeding, the discontinuation of antiplatelet therapy significantly elevates the risk of serious cardiac events. This is particularly relevant for patients who require urgent or emergency orthopedic surgery, such as those with spinal cord compression or hip fractures, where delaying surgery to discontinue antiplatelet therapy is not feasible.
The incidence of perioperative cardiac events in patients undergoing noncardiac surgery after stent implantation is well-documented. For bare metal stents, the risk of cardiac events is highest within the first 30 days post-implantation (10.8%), decreasing to 3.8% between 31 and 90 days, and further to 2.8% after 91 days. For drug-eluting stents, the risk is 11.6% within the first 6 weeks, decreasing to 6.4% between 6 weeks and 6 months, and to 4.2% between 6 and 12 months. International guidelines recommend delaying noncardiac surgery for at least 6 weeks after stent implantation, and preferably 6 months, with elective surgery postponed until 1 year post-stenting for high-risk patients. However, these recommendations often conflict with the need for timely surgical intervention in orthopedic cases.
In the context of spinal surgery, patients on DAPT are at high risk of intraspinal hemorrhage, which can lead to catastrophic outcomes such as spinal cord or cauda equina compression. Similarly, hip fractures in elderly patients require prompt surgical treatment to reduce complications and mortality. The European Society of Cardiology (ESC) and European Society of Anaesthesiology (ESA) guidelines recommend discontinuing antiplatelet therapy 5 to 7 days before noncardiac surgery, but this is often impractical for urgent orthopedic cases.
The study’s findings align with previous research suggesting that the continuation of DAPT or single antiplatelet therapy during orthopedic surgery does not increase bleeding risk. However, the discontinuation of antiplatelet therapy significantly increases the risk of adverse cardiac events. This underscores the importance of carefully managing antiplatelet therapy in patients requiring orthopedic surgery, particularly in the early postoperative period when the risk of stent thrombosis is highest.
The study also highlights the limitations of using low-molecular-weight heparin as a replacement for DAPT. While heparin can reduce the risk of bleeding, it is not as effective as antiplatelet therapy in preventing stent thrombosis. This was evident in the case of a 58-year-old female patient who died from myocardial infarction after discontinuing DAPT and switching to low-molecular-weight heparin before orthopedic surgery. The study emphasizes that antiplatelet therapy should not be discontinued in high-risk patients, and that bridging therapy with heparin is not a suitable alternative.
In conclusion, the study demonstrates that continuing DAPT or single antiplatelet therapy during orthopedic surgery does not increase the risk of bleeding compared to switching to low-molecular-weight heparin. However, the discontinuation of antiplatelet therapy significantly increases the risk of serious cardiac complications. This highlights the need for a balanced approach to managing antiplatelet therapy in patients requiring orthopedic surgery, particularly in the context of urgent or emergency procedures. The findings suggest that antiplatelet therapy should be continued whenever possible, with careful monitoring for bleeding complications. Further multicenter studies with larger sample sizes are needed to confirm these findings and refine clinical guidelines for managing antiplatelet therapy in patients undergoing orthopedic surgery.
doi.org/10.1097/CM9.0000000000000186
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