Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#228 The Journey of Drug-Eluting Stents and Anesthesia Patient Safety
What if the future of cardiac care meant shorter duration of dual antiplatelet therapy without compromising safety? Join us as we explore this possibility with Dr. Joseph Szokol, a leading expert in clinical anesthesiology at the Keck School of Medicine of USC. Dr. Szokol shares his insights into the revolutionary advancements in drug-eluting stent technology, which are reshaping how we approach perioperative care and patient safety. With over 600,000 cardiac stents placed each year, this episode is a must-listen for understanding the evolving landscape and its implications for anesthesia professionals.
Reflecting on past challenges, we transport you back to insights from the 2009 APSF newsletter that spotlighted the critical risks of stent thrombosis associated with older stent technologies. Discover how recommendations have dramatically shifted—from urging a 12-month delay for elective surgeries post-stent placement to adapting to breakthroughs in new generation stents. With a compelling narrative filled with historical context and cutting-edge research, this episode equips listeners with vital knowledge and updated guidelines that could significantly enhance perioperative patient management and safety.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/228-the-journey-of-drug-eluting-stents-and-anesthesia-patient-safety/
© 2024, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. Let's take a quick quiz Question. Let's take a quick quiz Question how long do patients need to continue dual antiplatelet therapy following placement of a drug-eluting stent? Before we dive into the episode today, we'd like to recognize Vertex Pharmaceuticals, a major corporate supporter of APSF. A major corporate supporter of APSF, vertex Pharmaceuticals has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, vertex Pharmaceuticals. We wouldn't be able to do all that we do without you. Don't worry.
Speaker 2:We will reveal the answer to our question on the show today as we discuss our featured article from the October 2024 APSF newsletter. It is New Drug Eluding Cardiac Stents and Dual Antiplatelet Therapy how Short is Too Short? By Janik Chandrasoma, abigail Song, joseph Skokul and Antres Hindoyan. This article has it all history, a literature review and guidelines. Plus, we have exclusive content from the authors. To follow along with us. Head over to apsforg and click on the newsletter heading First. One down is the current issue, october 2024. Then scroll down until you get to our featured article today. I will include a link in the show notes as well, to help kick off the show. Today we are going to be hearing from one of the authors. Let's take a listen now.
Speaker 3:I am Joseph Soule, a professor of clinical anesthesiology at the Keck School of Medicine of USC in Los Angeles, California.
Speaker 3:The reason we wrote this article was due to the significant knowledge gap on the subject of the duration of dual antiplatelet therapy after the placement of a drug-eluting cardiac stent. The outdated and probably prevalent view is that patients receive a drug-eluting stent would have to be on dual antiplatelet drugs for anywhere between 6 and 12 months. The obvious concern is the fear of early and late stent thrombosis. However, there has been a revolution in technology behind drug eluting stents. While most drug eluting stents are based on durable polymers such as cobalt, chromium, platinum, chromium and other metals, they're increasing use of biodegradable polymer-based drug eluting stents, which allows for an even shorter period of time of dual end-plate platelet therapy, which has a potential for decreasing inflammatory response and to prove drug elution kinetics and lower rates of early and late stent thrombosis. Additionally, there are a new generation of antiproliferative agents which have allowed the early discontinuation of dual antiplatelet therapy. With over 600,000 cardiac stents placed a year, it will not be unusual for an anesthesia professional to be faced with these newer generation stents.
Speaker 2:Thank you so much to Skokul for helping to introduce this important topic. Have you provided anesthesia care for a patient who had one of these newer generation cardiac stents placed? There is so much to learn and now it's time to get into the article. First, we are going to review some history, going back to the spring 2009 APSF newsletter and the article Perioperative Coronary Stent Thrombosis a Continuing Safety Concern by Greenberg and colleagues. This article from our archives highlighted the risk of late thrombosis after drug-eluting stent placement. When an in-stent thrombosis occurred, there was a 60% myocardial infarction rate, with a mortality rate of almost 50%. These events were rare but devastating when they occurred. Animal studies of bare metal stents revealed complete endothelialization in 28 days and for the first-generation drug-eluting stents there was incomplete healing at 180 days. The recommendation in 2008 from the American College of Chest Physicians included delaying elective surgery for 12 months after placement of a drug-eluting stent. As we know, many surgeries are not purely elective and the recommendations did not address patients requiring urgent surgery. The 2009 APSF article recognized this threat to anesthesia patient safety. There was a call to action for collaboration between the patient, internist surgeon, anesthesiologist and cardiologist to consider the type and timing of stent placed, the nature and urgency of the surgery, the management of perioperative antiplatelet therapy and the choice of facility to perform the surgery. Patients with recent stent placement who required urgent surgery would ideally have their surgery performed at a facility with 24-hour interventional cardiology available to perform emergent percutaneous coronary intervention if required to treat the dreaded instant thrombosis. I will include a link to the 2009 APSF newsletter article in the show notes as well.
Speaker 2:Over the past 15 years, there has been some technological advancements when it comes to cardiac stents. The first-generation stents were made of a standard bare metallic stent and a coated polymer mixed with an anti-restenotic drug such as sirolimus or paclitaxel. Newer-generation drug-eluting stents include biodegradable polymer stents or bioresorbable scaffolds. These have a lower rate of in-stent thrombosis and may need a shorter duration of dual antiplatelet therapy without compromising patient safety. An important consideration with every type of cardiac stent when deciding on the optimal duration of dual antiplatelet therapy is balancing the risks. On one hand, there is the risk of instant thrombosis and on the other, there is the risk of bleeding complications. Prolonged dual antiplatelet therapy is associated with an increased risk of bleeding complications, and elderly patients and those with multiple comorbidities are at higher risk as well. When bleeding complications occur, this increases the risk of morbidity and mortality.
Speaker 2:We can calculate the bleeding risk associated with dual antiplatelet therapy with the PRECISE DAPT score and the Academic Research Consortium for High-Risk Bleeding, the ARC-HBR criteria. To calculate the PRECISE DAPT score, you can head over to PreciseDAPTscorecom and use their web calculator. There you will need to input the hemoglobin level, age, white blood cell count, creatinine clearance and if there was a prior bleeding event. To get the patient's score and their calculated bleeding risk, check out the link in the show notes. The ARC-HBR includes 20 clinical criteria that were determined based on consensus and published evidence. The good news is that you don't have to calculate a score. Patients are high bleeding risk if they have at least one major criteria or two minor criteria present, or they are not high bleeding risk. Here are the major criteria Long-term oral anticoagulation.
Speaker 2:Severe or end-stage chronic kidney disease with an estimated GFR of less than 30 mLs per minute. Hemoglobin less than 11 grams per deciliter. Spontaneous bleeding requiring hospitalization and transfusion in the past six months. Moderate to severe baseline thrombocytopenia with a platelet count of less than 100, chronic bleeding diathesis. Liver cirrhosis with portal hypertension. Active cancer in the past 12 months. Previous spontaneous intracerebral hemorrhage at any time. Previous traumatic ICH within the past 12 months. Presence of a known brain arterial venous malformation. Moderate to severe ischemic stroke within the past six months. Non-deferable major surgery on dual antiplatelet therapy. And finally, recent major surgery or trauma within 30 days before the PCI. And now for the minor criteria Age greater than 75 years.
Speaker 2:Moderate chronic kidney disease with an estimated GFR between 30 and 59. Hemoglobin level between 11 and 12.9 grams per deciliter for men and 11 to 11.9 grams per deciliter for women and 11 to 11.9 grams per deciliter for women. Spontaneous bleeding requiring hospitalization or transfusion within the past 12 months not meeting the major criteria. Long-term use of oral non-steroidal anti-inflammatory drugs or steroids. And, finally, any ischemic stroke at any time not meeting the major criteria. Check out Table 1 in the article for a list of the high bleeding risk criteria. Remember high bleeding risk is defined as the presence of at least one from the list of high bleeding risk criteria bleeding risk criteria.
Speaker 2:Let's continue our literature review with some of the evidence that supports a shorter duration for dual antiplatelet therapy. There are two early studies that evaluated high-risk patients who underwent PCI and then completed a short duration of dual antiplatelet therapy with either ticagrelor monotherapy or ticagrelor with aspirin. Ticagrelor is a reversible and direct-acting oral P2Y12 receptor antagonist that provides faster, greater and more consistent platelet inhibition when compared to clopidogrel. When compared to clopidogrel, the first study published in the Lancet in 2018, reported improved outcomes after PCI for patients who received ticagrelor and aspirin for one month, followed by ticagrelor alone for 23 months, compared to standard antiplatelet therapies with clopidogrel or ticagrelor with aspirin for 12 months, followed by aspirin alone for 12 additional months. The second study, published in the New England Journal of Medicine in 2019, evaluated high-risk patients who underwent PCI and completed three months of dual antiplatelet therapy. The results revealed that ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding compared to ticagrelor and aspirin therapy. There was no higher risk of death, mi or stroke with ticagrelor monotherapy.
Speaker 2:If you want to continue the literature review, check out Table 2 in the article for a list of recent studies that looked at shorter-duration dual antiplatelet therapy regimens. Overall, these studies highlight the safety and efficacy of shorter-duration dual antiplatelet therapy. Another important consideration is that the newer coronary stents may be a good choice for patients at higher risk for bleeding. The results from these studies reveal lower rates of ischemia, which means shorter duration dual antiplatelet therapy, which means lower bleeding risk and less complications from bleeding. Multiple studies have shown that the newer stents are comparable to bare metal stents in terms of all-cause mortality, myocardial infarction stroke and ischemia-driven target lesion revascularization.
Speaker 2:We will be back next week to continue the literature review and discuss the societal recommendations in more detail, but before we wrap up for today, we are going to turn our attention to Table 3 in the article. There are three societies that have provided updated recommendations. Let's go through them now. First, the ACC AHA guidelines are Level of Recommendation 2A with Level of Evidence A, and the recommendation is that a shortened dual antiplatelet therapy of 1-3 months is reasonable. Next, the European Society of Cardiology guidelines have Level 2A recommendations with level of evidence B. Their recommendation is that in patients with high risk of bleeding, discontinuation of P2Y12 receptor inhibitor therapy after three months should be considered. Finally, the American College of Chest Physicians provides a conditional recommendation with very low-level certainty of evidence for the following In patients receiving aspirin and a P2Y12 inhibitor who had coronary stents placed within the last 3 to 12 months and are undergoing elective surgery or a procedure, we suggest stopping the P2Y12 inhibitor prior to surgery. Over continuation of the P2Y12 inhibitor, don't worry, we will be back next week to talk about the evidence and the recommendations in more detail. Plus, we have more exclusive content from one of the authors.
Speaker 2:If you have any questions or comments from today's show, please email us at podcast at apsforg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today. Thank you so much to all of our listeners. If you get a chance, we would love for you to give us a five-star rating and leave us a review. This helps other people interested in anesthesia patient safety to find our show and become listeners too. You can share this podcast with your anesthesia colleagues, members of your perioperative team, the surgeons that you work with, trainees, students and more. We are looking forward to continuing to bring you the latest in anesthesia patient safety. Until next time, stay vigilant so that no one shall be harmed by anesthesia care. Thank you.