Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA.
National Clinician Scholars Program, University of California, Los Angeles, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA.
Syst Rev. 2023 Oct 14;12(1):197. doi: 10.1186/s13643-023-02360-9.
Antiplatelet 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.
A 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.
Eighteen 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.
The 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.
A 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).
抗血小板药物是血管疾病管理的核心。在围手术期，必须权衡使用双联抗血小板治疗（DAPT）治疗血栓栓塞并发症的益处与出血风险。在接受心脏或非心脏手术的患者中，这种平衡至关重要。对于任何适应症（包括支架）接受 DAPT 治疗的患者的管理尚不清楚，并且指导决策的证据有限。本综述总结了 2015 年以来与继续、暂停或改变围手术期 DAPT 相关的主要不良事件发生相关的现有证据。
研究图书管理员于 2015 年 11 月 30 日至 2022 年 5 月 17 日在 PubMed 和 Cochrane 中使用相关术语搜索了接受任何原因手术的接受 DAPT 治疗的成年患者的相关文献，手术期间 DAPT 策略发生了变化。感兴趣的结局包括主要不良心脏事件、主要不良肢体事件、全因死亡、大出血和再次手术。我们认为停止 DAPT 治疗是指停止使用阿司匹林或 P2Y12 抑制剂或两者同时停用；继续 DAPT 治疗是指在规定的时间内使用两种药物。
符合纳入标准的有 18 项观察性研究。未发现 RCT，也没有研究被认为有低偏倚风险。12 项研究报告了 CABG 手术。DAPT 治疗超过 2 天的停药与出血量减少和输血及手术再次探查减少有轻微趋势。在五项关于 CABG 的观察性研究中，不同 DAPT 管理策略之间的患者死亡率没有统计学差异。很少有研究报告心脏结局。其余关于除 CABG 之外的其他手术的研究，关于 DAPT 策略、出血和缺血性结局的结果不一。
关于支架置入患者不同围手术期 DAPT 策略的获益和风险的证据基础极为有限。最强的信号（尽管仍被判定为低确定性证据）是，CABG 术前 DAPT 治疗暂停超过 2 天与出血、输血和再次探查减少相关。不同 DAPT 策略与其他感兴趣的结局（如 MACE）的相关性尚不确定。
本综述的预注册方案可在 PROSPERO 国际前瞻性系统评价注册库（http://www.crd.york.ac.uk/PROSPERO/；注册编号：CRD42022371032）中找到。
