Dataset Information

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

ABSTRACT:

Objective

To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.

Methods

This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible.

Results

In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE).

Conclusion

This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.

SUBMITTER: Shah S

PROVIDER: S-EPMC9594114 | biostudies-literature | 2022 Dec

REPOSITORIES: biostudies-literature

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Publications

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

Shah Sahrish S Urtecho Meritxell M Firwana Mohammed M Nayfeh Tarek T Hasan Bashar B Nanaa Ahmad A Saadi Samer S Flynn David N DN Abd-Rabu Rami R Seisa Mohamed O MO Rajjoub Noora S NS Hassett Leslie C LC Spyropoulos Alex C AC Douketis James D JD Murad M Hassan MH

Mayo Clinic proceedings. Innovations, quality & outcomes 20221021 6

<h4>Objective</h4>To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.<h4>Methods</h4>This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Me ...[more]

PMID: 36304523

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Project description:BackgroundAntiplatelet agents are central in the management of vascular disease. The use of dual antiplatelet therapy (DAPT) for the management of thromboembolic complications must be weighed against bleeding risk in the perioperative setting. This balance is critical in patients undergoing cardiac or non-cardiac surgery. The management of patients on DAPT for any indication (including stents) is not clear and there is limited evidence to guide decision-making. This review summarizes current evidence since 2015 regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period.MethodsA research librarian searched PubMed and Cochrane from November 30, 2015 to May 17, 2022, for relevant terms regarding adult patients on DAPT for any reason undergoing surgery, with a perioperative variation in DAPT strategy. Outcomes of interest included the occurrence of major adverse cardiac events, major adverse limb events, all-cause death, major bleeding, and reoperation. We considered withdrawal or discontinuation of DAPT as stopping either aspirin or a P2Y12 inhibitor or both agents; continuation of DAPT indicates that both drugs were given in the specified timeframe.ResultsEighteen observational studies met the inclusion criteria. No RCTs were identified, and no studies were judged to be at low risk of bias. Twelve studies reported on CABG. Withholding DAPT therapy for more than 2 days was associated with less blood loss and a slight trend favoring less transfusion and surgical re-exploration. Among five observational CABG studies, there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively CABG, demonstrated mixed findings with respect to DAPT strategy, bleeding, and ischemic outcomes.ConclusionThe evidence base on the benefits and risks of different perioperative DAPT strategies for patients with stents is extremely limited. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for greater than 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Different DAPT strategies' association with other outcomes of interest, such as MACE, remains uncertain.Systematic review registrationA preregistered protocol for this review can be found on the PROSPERO International Prospective Register of systematic reviews ( http://www.crd.york.ac.uk/PROSPERO/ ; registration number: CRD42022371032).

Project description:BACKGROUND:The correct perioperative management of antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) is often debated by clinicians. American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend postponing elective NCS at least 3 months after stent implantation. Regardless of the timing of surgery, ACC/AHA guidelines recommend continuing at least ASA throughout the perioperative period and ideally continuing dual APT (DAPT) therapy "unless surgery demands discontinuation." The objective of this review was to ascertain the risks and benefits of APT in the perioperative period, to assess how these risks and benefits vary by APT management, and the significance of length of time since stent implantation before operative intervention. METHODS:PubMed, Web of Science, and Scopus were searched from inception through October 2017. Articles were included if patients were post PCI with stent placement (bare metal [BMS] or drug eluting [DES]), underwent elective NCS, and had rates of major adverse cardiac events (MACE) or bleeding events associated with pre and perioperative APT therapy. RESULTS:Of 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small (< 50: n = 5, 51-150: n = 5, >150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (< 6 months: n = 3, 6-12 months: n = 1, > 12 months: n = 6). At least six different APT strategies were described. Six studies further utilized bridging protocols using three different pharmacologic agents. Studies typically included multiple surgical fields with varying degrees of invasiveness. Across all APT strategies, rates of MACE/bleeding ranged from 0 to 21% and 0 to 22%. There was no visible trend in MACE/bleeding rates within a given APT strategy. Stratifying the articles by type of surgery, timing of discontinuation of APT therapy, bridging vs. no bridging, and time since stent placement did not help explain the heterogeneity. CONCLUSIONS:Evidence regarding perioperative APT management in patients with cardiac stents undergoing NCS is insufficient to guide practice. Other clinical factors may have a greater impact than perioperative APT management on MACE and bleeding events. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42016036607.

Project description:BackgroundTreatment with aspirin and a P2Y12 inhibitor is commonly used in patients with cardiovascular disorders. The overall effect of such treatment on all-cause mortality is unknown. In the Dual Antiplatelet Therapy (DAPT) Study, continuation of dual antiplatelet therapy beyond 12 months after coronary stenting was associated with an unexpected increase in non-cardiovascular death. In view of the potential public health importance of these findings, we aimed to assess the effect of extended duration dual antiplatelet therapy on mortality by doing a meta-analysis of all randomised, controlled trials of treatment duration in various cardiovascular disorders.MethodsWe searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomised controlled trials assessing the effect of extended duration versus no or short duration dual antiplatelet therapy, published before Oct 1, 2014. We did a meta-analysis to pool results with a hierarchical Bayesian random-effects model. The primary outcomes were hazard ratios comparing rates of all-cause, cardiovascular, and non-cardiovascular death.FindingsIncluding the DAPT Study, we identified 14 eligible trials that randomly assigned 69,644 participants to different durations of dual antiplatelet therapy. Compared with aspirin alone or short duration dual antiplatelet therapy (≤6 months), continued treatment was not associated with a difference in all-cause mortality (hazard ratio [HR] 1·05, 95% credible interval [CrI] 0·96-1·19; p=0·33). Similarly, cardiovascular (1·01, 0·93-1·12; p=0·81) and non-cardiovascular mortality (1·04, 0·90-1·26; p=0·66) were no different with extended duration versus short duration dual antiplatelet therapy or aspirin alone.InterpretationExtended duration dual antiplatelet therapy was not associated with a difference in the risk of all-cause, cardiovascular, or non-cardiovascular death compared with aspirin alone or short duration dual antiplatelet therapy.FundingNone.

Project description:BackgroundIntegration of artificial intelligence (AI) into medical practice has increased recently. Numerous AI models have been developed in the field of anesthesiology; however, their use in clinical settings remains limited. This study aimed to identify the gap between AI research and its implementation in anesthesiology via a systematic review of randomized controlled trials with meta-analysis (CRD42022353727).MethodsWe searched the databases of Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (Embase), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), Institute of Electrical and Electronics Engineers Xplore (IEEE), and Google Scholar and retrieved randomized controlled trials comparing conventional and AI-assisted anesthetic management published between the date of inception of the database and August 31, 2023.ResultsEight randomized controlled trials were included in this systematic review (n = 568 patients), including 286 and 282 patients who underwent anesthetic management with and without AI-assisted interventions, respectively. AI-assisted interventions used in the studies included fuzzy logic control for gas concentrations (one study) and the Hypotension Prediction Index (seven studies; adding only one indicator). Seven studies had small sample sizes (n = 30 to 68, except for the largest), and meta-analysis including the study with the largest sample size (n = 213) showed no difference in a hypotension-related outcome (mean difference of the time-weighted average of the area under the threshold 0.22, 95% confidence interval -0.03 to 0.48, P = 0.215, I2 93.8%).ConclusionsThis systematic review and meta-analysis revealed that randomized controlled trials on AI-assisted interventions in anesthesiology are in their infancy, and approaches that take into account complex clinical practice should be investigated in the future.Trial registrationThis study was registered with the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022353727).

Project description:Background: The benefit-risk profile of perioperative corticosteroids in pediatric patients undergoing cardiac surgery remains controversial. Objective: To investigate the influence of perioperative corticosteroids on the postoperative mortality and clinical outcomes in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We conducted a systematic search using MEDLINE, EMBASE, and Cochrane Database through August 31, 2019. We included randomized controlled trials comparing perioperative corticosteroids with other clinical interventions, placebo, or no treatment in children between 0 and 18 years of age undergoing cardiac surgery. The primary outcome of interest was all-cause in-hospital mortality. The secondary outcomes were length of intensive care unit stay (LOIS), duration of mechanical ventilation (DMV), postoperative insulin therapy, postoperative low cardiac output syndrome (LCOS), postoperative infection, maximal temperature (T max) in the first 24 h postoperatively, urine output (UO) in the first 24 h postoperatively, serum lactate at postoperative day (POD) 1, blood glucose at POD 1, vasoactive inotrope score (VIS) at POD 1, and postoperative acute kidney injury (AKI). Study quality was assessed using the Cochrane Risk of Bias Assessment Tool. Results: Our analysis included 17 studies and 848 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant difference on the all-cause in-hospital mortality with a fixed-effect model (RR = 0.59, 95% CI = 0.28-1.25, P = 0.55) compared with controls. For the secondary outcomes, corticosteroids had a statistically significant reduction on the VIS at POD1 (MD = -2.04, 95% CI = -3.96 -0.12, P = 0.04), while it might be significantly associated with an increased blood glucose at POD1 (MD = 1.38, 95% CI = 0.68-2.09, P = 0.0001) and a 2.69-fold higher risk of postoperative insulin therapy (RR = 2.69, 95% CI = 1.37-5.27, P = 0.004). No statistical significance was shown in other secondary outcomes. Conclusion: Perioperative corticosteroids might not significantly improve clinical outcomes identified as mortality, LOIS, DMV, AKI, and LCOS other than VIS at POD1. However, it might increase the blood glucose and episodes of insulin therapy. Perioperative corticosteroids to attenuate the inflammatory response are not supported by available evidence from our study. Further results from ongoing randomized controlled trials with a larger sample size are required.

Dataset Information

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

Objective

Methods

Results

Conclusion

Publications

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

Similar Datasets

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