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Risk balance during surgery: should antiplatelet therapy be discontinued?
With advances in surgical techniques, patient survival rates have improved significantly; however, necessary risk assessment remains, especially in patients receiving antiplatelet therapy. Antiplatelet drugs, such as aspirin and ADP/P2Y inhibitors, are effective in reducing platelet aggregation and thrombosis, but these drugs may increase the risk of bleeding during surgery. This contradictory situation poses a challenge to clinicians. Whether antiplatelet therapy should be discontinued or continued before surgery becomes an important clinical decision-making issue.
The use of antiplatelet drugs is crucial in preventing blood clots such as heart attacks and strokes, but balancing the risk of bleeding with the risk of blood clots during surgery still requires careful consideration.
The role and indications of antiplatelet therapy
Antiplatelet drugs reduce platelet activation and reduce thrombus formation through several different mechanisms. These drugs are critical to improving existing cardiovascular disease outcomes and preventing unexpected events, especially in patients with stable and unstable angina. Antiplatelet therapy usually needs to be tailored to the patient's specific circumstances and is not recommended in low-risk patients to avoid the reported risk of significant bleeding.
Management of antiplatelet therapy before surgery
The trade-off between continuing antiplatelet therapy and discontinuing it during noncardiac surgery is tricky. According to a 2018 Cochrane Review, there was no significant difference in the impact of continuing versus discontinuing antiplatelet therapy on mortality, major bleeding, and ischemic events in patients undergoing noncardiac surgery. This result requires clinicians to conduct risk assessments on a case-by-case basis for each patient.
In some cases, such as patients who have received a stent or have just had an angioplasty, doctors recommend temporarily stopping antiplatelet therapy before surgery.
Risks of combined antiplatelet therapy
Although concomitant use of antiplatelet drugs can improve the antithrombotic effect, however, the issue of increased bleeding risk, as shown with dual antiplatelet therapy (DAPT), makes this treatment unsuitable for all patients. DAPT refers to the use of aspirin plus an ADP inhibitor. For those patients with high-risk cardiovascular disease, such as patients with unstable angina and NSTEMI, DAPT is the recommended second-line treatment. However, doctors typically do not prescribe this therapy for low-risk patients.
Surgery type and antiplatelet drug management
Different types of surgery have different requirements for antiplatelet therapy. For example, in cardiac surgery, patients are advised to resume antiplatelet therapy immediately after surgery; in some orthopedic surgeries, this can be flexibly arranged based on the patient's condition. When formulating surgical plans, doctors need to consider each patient's special requirements and the urgency of the surgery to better adjust the antiplatelet treatment plan.
Dental Treatment and Antiplatelet Therapy
For patients receiving antiplatelet therapy, dental practitioners need to be particularly aware of the risk of bleeding when planning any treatment that may cause bleeding. Physicians need to assess a patient's bleeding risk and take necessary steps to reduce potential complications, which may influence the choice and type of treatment.
Conclusion
In summary, antiplatelet therapy does carry multiple risks during surgery. Doctors need to comprehensively consider the risk of bleeding and thrombosis, and conduct necessary risk management when formulating clinical strategies. Patient safety should always come first. Is the use of antiplatelets really worth the risk and will it allow patients to achieve the best outcome after surgery? Careful consideration still needs to be given.
