Management of Perioperative Anticoagulation

Readers were asked to respond to questions regarding a clinical scenario in which a patient for major lung resection had coronary stents placed prior to surgery. The results were interesting, demonstrating a fair amount of variability in the management of this situation and a surprisingly liberal attitude towards the use of anti-platelet agents in the immediate perioperative period.

Most surgeons were more concerned about the effects of Plavix than of aspirin in patients with coronary artery stents. In patients with stents that were not recent, almost 87% recommended discontinuation of Plavix 5 days or longer prior to surgery, whereas over 35% would continue aspirin until the day prior to surgery.

The results were different for patients with fresh coronary artery stents, although there remained greater concern for Plavix than for aspirin. Almost 75% of surgeons would continue aspirin until the day prior to surgery, and almost 35% would continue Plavix until the day prior to surgery.

Most surgeons preferred operating soon after coronary stent placement rather than waiting 4 months so that anti-platelet agents could be discontinued. Almost 75% of surgeons recommended re-starting anti-platelet agents within 1 or 2 days after major lung resection.

The results are generally in keeping with recent recommendations, which indicate that, in patients with recent coronary artery stents who require an operation such as lobectomy, continuation of aspirin and Plavix until the day prior to surgery is not associated with a significant risk of perioperative bleeding problems.

1. In a patient without fresh coronary artery stents who is on aspirin, for how long do you discontinue aspirin preoperatively?
	answered question		101
	skipped question		0
		Response Percent	Response Count
1 month		0.0%	0
2 weeks		6.9%	7
5 days		57.4%	58
The day prior to surgery		35.6%	36

2. In a patient without fresh coronary artery stents who is on Plavix, for how long do you discontinue Plavix preoperatively?
	answered question		100
	skipped question		1
		Response Percent	Response Count
1 month		2.0%	2
2 weeks		35.0%	35
5 days		58.0%	58
The day prior to surgery		5.0%	5

3. In a patient with fresh coronary artery stents who is on aspirin, for how long do you discontinue aspirin preoperatively?
	answered question		98
	skipped question		3
		Response Percent	Response Count
1 month		0.0%	0
2 weeks		4.1%	4
5 days		22.4%	22
The day prior to surgery		73.5%	72

4. In a patient with fresh coronary artery stents who is on Plavix, for how long do you discontinue Plavix preoperatively?
	answered question		98
	skipped question		3
		Response Percent	Response Count
1 month		2.0%	2
2 weeks		17.3%	17
5 days		55.1%	54
The day prior to surgery		25.5%	25

5. Would you recommend that this patient wait 4 months prior to having his operation?
	answered question		99
	skipped question		2
		Response Percent	Response Count
Yes		27.3%	27
No		72.7%	72

6. How soon after lung resection would you restart Plavix or aspirin?
	answered question		100
	skipped question		1
		Response Percent	Response Count
The following day		46.0%	46
Two days postoperatively		25.0%	25
At the time of hospital discharge		21.0%	21
Not until the first postoperative visit		8.0%	8

7. In what region do you work?
	answered question		95
	skipped question		6
		Response Percent	Response Count
North America		53.7%	51
Europe		36.8%	35
South America		4.2%	4
Asia		5.3%	5
Africa		0.0%	0
Other (please specify)			10