Antiplatelet therapy and cardiac surgery: review of recent evidence and clinical implications.

Since the publication of the 2009 Canadian Cardiovascular Society position paper on antiplatelet therapy and cardiac surgery, new antiplatelet strategies with either double-dose clopidogrel or with new and more potent agents (prasugrel and ticagrelor) have become accepted practice. For the patient requiring coronary artery bypass surgery who has recently received either double-dose clopidogrel or one of the new P2Y12 platelet inhibitors, increased perioperative bleeding can be anticipated. For patients who are stable and can wait, surgery should be delayed for 5 days after the last dose of clopidogrel (standard or double-dose), and for 7 days after the last dose of prasugrel. Patients who have received ticagrelor should wait 5 days after the last dose before surgery, although it is likely that surgery can be safely performed 3 days after discontinuing ticagrelor. For patients who require emergency surgery despite recently receiving double-dose clopidogrel, prasugrel, or ticagrelor, the measures to limit perioperative bleeding discussed in the 2009 Canadian Cardiovascular Society position paper remain applicable, but have not yet been rigourously tested. Recent studies have suggested the value of preoperative in vitro platelet aggregometry to determine perioperative bleeding risk.