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
#229 Revolutionizing Anesthesia Care for Cardiac Patients: Shorter and Safer Dual Antiplatelet Therapy with Next-Gen Stents
What if the future of dual antiplatelet therapy (DAPT) could be shorter, safer, and more effective? Uncover the latest insights into drug-eluting stents and how they are transforming how we think about dual-antiplatelet therapy. Join us as we examine the game-changing recommendations from top cardiology societies, which suggest that newer-generation stents can significantly reduce the duration of DAPT, particularly for patients with a high bleeding risk. Listen in as we dissect the innovative tools like the PRECISE-DAPT score and ARC-HBR criteria used to determine bleeding risk, ensuring patient safety without compromising on the efficacy of treatment. We delve into pivotal studies, including the Global Leader Study and the STOP-DAPT trial, that back these groundbreaking changes.
Our conversation takes an intriguing turn as we explore the intersection of cardiology advancements with anesthesia practices. Discover how these developments are influencing preoperative settings, potentially altering surgical timing and decision-making in anesthesia care. We bring you exclusive insights from contributor, Janak Chandrasoma, featured in the October 2024 APSF newsletter. We urge you to explore further resources, share the knowledge with your peers, and join us in promoting patient safety in perioperative environments. Don't forget to rate, review, and share the episode with colleagues keen on staying at the forefront of anesthesia patient safety advancements.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/229-revolutionizing-anesthesia-care-for-cardiac-patients/
© 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. Last week we asked the question joining us for another show. Last week we asked the question how long do patients need to continue dual antiplatelet therapy following placement of a drug-eluting stent? We will go into more detail today, but the short answer is that newer generation drug-eluting stents have decreased rates of instant thrombosis, permitting shorter duration of dual antiplatelet therapy. According to the American College of Cardiology and the American Heart Association, a shortened duration of dual antiplatelet therapy of one to three months is reasonable. According to the European Society of Cardiology, in patients with high risk of bleeding, you may consider discontinuation of P2Y12 receptor inhibitor therapy after three months. Don't turn that dial, because we have more to discuss when it comes to keeping patients with drug-eluting stents safe during anesthesia care. Before we dive into the episode today, we'd like to recognize BD, a major corporate supporter of APSF. Bd has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, bd. We wouldn't be able to do all that we do without you.
Speaker 2:Our featured article again today is 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 Andres Hindoyen. 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. Let's do a quick review from last week and then return to the article Plus. We have exclusive content from one of the authors later in the show.
Speaker 2:Remember, the first generation stents were made of a standard bare metallic stent and a coated polymer mixed with an anti-resinotic drug such as sirolimus or paxlitaxel. 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. Last week we talked about how to determine which patients are high risk using the PRECISE DAPT score or the ARC-HBR criteria, which includes major and minor criteria. To calculate the PRECISE DAPT score, you can head over to precise-dDaptScorecom and use their 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.
Speaker 2:The authors highlight criteria for high bleeding risk in table one in the article. We are going to go through it now. High bleeding risk is defined as the presence of at least one of the following Age greater than or equal to, 75 years old. Oral anticoagulation planned to continue after PCI. Anemia with a hemoglobin level of less than 11 grams per deciliter Transfusion within the past four weeks. Platelet count less than 100,000. Hospital admission for bleeding within the past 12 months. Stroke within the previous 12 months. History of intracerebral hemorrhage. Severe chronic liver disease. Chronic kidney disease defined as creatinine clearance less than 40 mLs per minute. Cancer within the previous three years. Planned major non-cardiac surgery in the next 12 months. Glucocorticoids or NSAIDs planned for more than 30 days after PCI and expected non-adherence to greater than 30 days of dual antiplatelet therapy.
Speaker 2:And now it's time to get back into the article right where we left off. These are evidence-based recommendations that we are talking about, and there is a lot of newer evidence to support the safety and efficacy of shorter duration of dual antiplatelet therapy. Patients who are at high bleeding risk are good candidates for these newer stents. The data to support the newer stents reveals the following Lower rates of ischemia. Shorter duration of dual antiplatelet therapy, which decreases the bleeding risk, and comparable to bare metal stents in terms of all-cause mortality, myocardial infarction, stroke and ischemia-driven target lesion revascularization.
Speaker 2:Let's take a closer look at Table 2 and some of the evidence. This is going to be a fast and furious literature review. First, the Global Leader Study evaluated various stent types with one-month dual antiplatelet therapy. The primary findings were that one month of dual antiplatelet therapy followed by ticagrelor alone improved outcomes versus standard regimens. The 2019 study by Marin evaluated various stents with 3-months dual antiplatelet therapy and found that 3-months dual antiplatelet therapy followed by ticagrelor monotherapy is associated with lower bleeding incidence compared to continued dual antiplatelet therapy, with no higher risk of death, mi or stroke.
Speaker 2:The STOP-DAP trial evaluated the cobalt chromium everolimus eluting stent with three months of dual antiplatelet therapy. The results were that three months dual antiplatelet therapy followed by aspirin alone in selected patients was non-inferior to prolonged dual antiplatelet therapy followed by aspirin alone in selected patients was non-inferior to prolonged dual antiplatelet therapy. The POEM trial evaluated the Synergy drug-eluting stent, a bioresorbable polymer-coated everolimus-eluting stent, with one-month dual antiplatelet therapy, and found that one-month dual antiplatelet therapy followed by aspirin alone was safe, with low rates of bleeding and ischemic events. The senior trial compared bare metal stents and drug-eluting stents with one month of dual antiplatelet therapy in stable or silent cases, compared to six months dual antiplatelet therapy in unstable cases followed by aspirin monotherapy. The results were that drug-eluting stents with short dual antiplatelet therapy duration is associated with lower rates of all-cause mortality, mi stroke and ischemia-driven target lesion revascularization compared to bare metal stents with similar dual antiplatelet therapy duration. The EVOLVE short DAP study looked at the synergy drug-eluting stent with three months of dual antiplatelet therapy followed by aspirin monotherapy in high bleeding risk patients and found favorable rates of ischemic outcomes supporting the safety of shortened dual antiplatelet therapy.
Speaker 2:We have two more studies to go. The Zions Short DAPT program studied the Zions drug-eluting stent with one or three months dual antiplatelet therapy followed by aspirin alone was inferior to 6 to 12 months of dual antiplatelet therapy for ischemic outcomes potentially associated with fewer major bleeding events and low stent thrombosis incidence incidence. Finally, the STOP-DAP2-ACS trial studied the cobalt chromium everolimus eluting stent and found that 1-2 months dual antiplatelet therapy followed by aspirin alone did not establish non-inferiority compared to 12 months dual antiplatelet therapy. There was a reduction in major bleeding events but also a numerical increase in cardiovascular events in the 1-2-month dual antiplatelet group. Phew, what an exciting review of all these new studies.
Speaker 2:The studies highlighted in Table 2 include updated evidence that several societies have used to update their guidelines. First, the American College of Cardiology and the American Heart Association give a Class 2a or moderate recommendation for a shorter duration of dual antiplatelet therapy therapy. Select patients undergoing PCI may safely transition to P2Y12 inhibitor monotherapy and discontinue aspirin after 1-3 months of dual antiplatelet therapy where the benefits outweigh the risks. The European Society of Cardiology guidelines are different. These guidelines highlight that, following PCI for non-ST segment elevation acute coronary syndrome, dual antiplatelet therapy with a potent P2Y12 receptor inhibitor and aspirin is generally recommended for 12 months, regardless of stent type, unless contraindicated.
Speaker 2:There are specific clinical cases, including high bleeding risk with a precise DAP score greater than 25 or meeting the ARC-HBR criteria, in which clinicians may consider a shorter duration of dual antiplatelet therapy of less than 12 months. Clinicians may consider modifying the regimen depending on ischemic and bleeding risks, adverse events, comorbidities, concomitant medications and drug availability. An important consideration is that for non-ST segment elevation acute coronary syndrome patients with stent implantation who are at high bleeding risk, discontinuation of P2Y12 receptor inhibitor therapy after three to six months should be considered. In addition, in patients who are at very high bleeding risk, such as a bleeding event within the past 30 days or with an imminent non-deferable surgery, a one-month duration of therapy with aspirin and clopidogrel may be considered. Finally, the American College of Chest Physicians updated its recommendations in 2022 for duration of dual antiplatelet therapy after drug-eluting stent placement. This is a conditional recommendation for patients scheduled for elective surgery who have had stent placement within the last 3-12 months and are on dual antiplatelet therapy. If you work in a preoperative anesthesia clinic, then it is very likely that you have seen patients who fit this scenario. The updated recommendation is for the discontinuation of the P2Y12 inhibitor prior to surgery, based on indirect evidence and expert opinion suggesting the safety of stopping the P2Y12 inhibitors in patients with stents implanted more than three months prior. Check out table 3 in the article for a quick reference guide for these updated guidelines.
Speaker 2:We made it to the end of the article. The authors highlight that newer generation stent technology has led to less stent thrombosis. This has led cardiology experts to update the recommendations for the duration of dual antiplatelet therapy on these new drug-eluting stents to one to three-month courses of anticoagulation in patients with stable coronary artery disease. Bare metal stents have largely been replaced by these newer stents with their enhanced performance. A multidisciplinary approach with the cardiologist, surgeon and anesthesiologist is required to make clinical decisions regarding the duration of dual antiplatelet therapy and urgent surgery, and this may lead to a very short course of dual antiplatelet therapy. There is a call to action for anesthesia professionals to be mindful of the shorter duration of dual antiplatelet therapy regimens and be aware that the duration for anticoagulation of as little as one month may be recommended for patients with recent stent placement, based on the evidence of enhanced safety profile of these newer generation stents. Before we wrap up for today, we are going to hear from another APSF author. Here he is now.
Speaker 3:Hi, my name is Janak Chandrasoma and I'm with the Department of Anesthesiology at the Keck Medical Center of USC.
Speaker 2:I asked Chandrasoma what he hopes to see going forward. Let's take a listen to what he had to say take a listen to what he had to say.
Speaker 3:I work at the preoperative clinic at USC and I'm really excited for this data to come out because for a long time, anesthesiologists have just been in the dark with regards to how long you need to wait for dual antiplatelet therapy and I constantly have conversations with our anesthesiologists where I tell them you know the six month thing. It's totally out of date. So I'm hoping really that this changes practice for a lot of people. I'm really excited about it.
Speaker 2:Thank you so much to Chandrasoma for contributing to the show today. We are really excited to hear about this shortened duration of dual antiplatelet therapy. It will help us in our preoperative anesthesia clinics for timing of surgery and decisions about dual antiplatelet therapy. 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.
Speaker 2: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 also 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.