What are the ESC guidelines on antiplatelet therapy for acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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The 2017 ESC focused update recommendations for antiplatelet therapy in coronary artery disease are outlined below. [114, 115]

Predicting perioperative bleeding

Preoperative fibrinogen levels may be considered to identify patients at high risk of bleeding.

Routine use of viscoelastic and platelet function testing is not recommended to predict bleeding in patients without antithrombotic treatment.

Platelet function testing may be considered to guide the decision on the timing of cardiac surgery in patients who have recently received P2Y12 inhibitors or who have ongoing dual antiplatelet therapy (DAPT).

Managing preoperative anticoagulants and antiplatelet drugs

In patients undergoing coronary artery bypass grafting (CABG), acetylsalicylic acid (ASA) should be continued throughout the preoperative period.

In patients at high risk of bleeding or refusing blood transfusions and undergoing non-coronary cardiac surgery, stopping ASA should be considered at least 5 days preoperatively.

It is recommended that ASA be re(started) as soon as there is no concern over bleeding (within 24 hr) after isolated CABG.

In patients taking DAPT who need to have non-emergent cardiac surgery, postponing surgery for at least 3 days after discontinuation of ticagrelor, 5 days after clopidogrel, and 7 days after prasugrel should be considered.

It is recommended that GPIIb/IIIa inhibitors be discontinued at least 4 hours before surgery.

It is recommended that prophylactic low-molecular-weight heparin (LMWH) be discontinued 12 hours before surgery and fondaparinux 24 hours before surgery. A longer interval may be necessary for patients with impaired renal function and/or therapeutic doses.

Elective cardiac surgery should be performed if the international normalized ratio (INR) is < 1.5 in patients taking vitamin K antagonists (VKAs). When surgery cannot be postponed, coagulation factors should be used to reverse the effect.

In patients having elective cardiac surgery, direct oral anticoagulants (DOACs) should be stopped at least 48 hours before surgery. A longer interval may be necessary for patients with impaired renal function.

Preoperative anemia

Oral or intravenous iron alone prior to cardiac surgery may be considered in mildly anemic patients (women, hemoglobin (Hb) 100–120 g/L; men, Hb 100–130 g/L) or in severely anemic patients (both genders, Hb ≤100 g/L) to improve erythropoiesis.

Erythropoietin with iron supplementation should be considered to reduce postoperative transfusions in patients with non-iron deficiency (eg, erythropoietin (EPO), vitamin D, or folate acid deficiency) undergoing elective surgery.

Intraoperative anticoagulation

Heparin-level-guided heparin management should be considered over activated clotting time (ACT)-guided heparin management to reduce bleeding.

Heparin-level-guided protamine dosing may be considered to reduce bleeding and transfusions.

Protamine should be administered in a protamine-to-heparin dosing ratio < 1:1 to reduce bleeding.

Antithrombin (AT) supplementation is indicated in patients with AT deficiency to improve heparin sensitivity.

In patients with heparin-induced thrombocytopenia (HIT) antibodies for whom surgery cannot be postponed, anticoagulation with bivalirudin should be considered when the bleeding risk is acceptable. The use of heparin in the pre- and postoperative periods should be avoided.

Transfusion strategies

Implementation of a patient blood management protocol for the bleeding patient is recommended.

The use of packed red blood cells (PRBCs) of all ages is recommended, because the storage time of the PRBCs does not affect the outcomes.

The use of leukocyte-depleted PRBCs is recommended to reduce infectious complications.

Pooled solvent detergent fresh-frozen plasma (FFP) may be preferred to standard FFP to reduce the risk of transfusion-related acute lung injury.

Perioperative treatment algorithms for the bleeding patient based on viscoelastic point-of-care tests should be considered to reduce the number of transfusions.

Platelet concentrate should be transfused in bleeding patients with a platelet count below 50 (109/L) or patients on antiplatelet therapy with bleeding complications.

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