Antiplatelet agents

We recommend that aspirin therapy should continue perioperatively in most surgical settings, especially cardiac surgery. 1C

Where aspirin withdrawal before surgery is considered, we recommend a time interval of 3 days. 1C

In patients with risk factors for vascular complications naı¨ve of any antiplatelet treatment, it is not recommended that treatment with aspirin be initiated preoperatively. 1B

In patients treated chronically with aspirin for the secondary prevention of cardiovascular events, except those patients with coronary stents, we recommend aspirin interruption for procedures where there is a very high bleeding risk. 1B

In patients chronically treated with aspirin for secondary prevention of cardiovascular events, we recommend aspirin be maintained during and after low and medium bleeding risk procedures. 1B

We suggest careful consideration of postoperative bleeding complications when timing the first postoperative administration and dose of anticoagulants along with resumption of aspirin. 2C

For intraoperative or postoperative bleeding clearly related to aspirin, we suggest that platelet transfusion be considered (dose: 0.7x1011 per 10 kg body weight in adults). 2C

We recommend that aspirin be continued for at least 4 weeks after bare metal stent (BMS) implantation and 3 to 12 months after drug-eluting stent (DES) implantation, unless the risk of life-threatening surgical bleeding on aspirin is unacceptably high. 1A

We suggest that P2Y12 inhibitor treatment be considered for at least 4 weeks after BMS implantation and 3 to 12 months after DES implantation, unless the risk of lifethreatening surgical bleeding on this agent is unacceptably high. 2A

If clinically feasible, we suggest postponing (semiurgent) surgery for at least 5 days after cessation of ticagrelor and clopidogrel, and for 7 days in the case of prasugrel, unless the patient is at high risk of an ischaemic event. 2B

We recommend that antiplatelet agent (APA) therapy should resume as soon as possible postoperatively to prevent platelet activation. 1C

We suggest that the first postoperative dose of clopidogrel or prasugrel should be given no later than 24 h after skin closure. We also suggest that this first dose should not be a loading dose. 2C

We recommend that a multidisciplinary team meeting should decide on the perioperative use of APAs in urgent and semi-urgent surgery. 1C

We suggest that urgent or semi-urgent surgery should be performed under aspirin/clopidogrel or aspirin/prasugrel combination therapy if possible, or at least under aspirin alone. 2C

We suggest that platelet transfusion be considered (dose: 0.7x1011 per 10 kg body weight in adults) in cases of intraoperative or postoperative bleeding clearly related to clopidogrel or prasugrel. 2C

According to pharmacological characteristics, we suggest that the management of ticagrelor may be comparable to clopidogrel (i.e. withdrawal interval of 5 days). 2C

Platelet transfusions may be ineffective for treating bleeding related to ticagrelor if given within 12 h of the drug’s administration. C