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Introduction

Antiplatelet therapy is critical in the management of patients who have undergone placement of coronary stents. Current guidelines recommend at least 1 month and ideally 1 year of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel following bare-metal stent (BMS) placement and at least 1 year of DAPT for drug-eluting stent (DES) placement in order to reduce the risk of stent thrombosis that may lead to myocardial infarction or death (class I recommendation) . In the 2011 focused update released by the American College of Cardiology Foundation/American Heart Association, continuation of DAPT beyond 15 months following DES is now a class IIb recommendation, suggesting that use beyond one year may be beneficial (level of evidence: C) . When patients receive DAPT, their 30-day risk of cardiovascular morbidity or mortality (including cardiac death, acute myocardial infarction or repeat revascularization) is reduced from 3.6%–3.9% in patients who receive only aspirin therapy to 0.5%–0.8% with DAPT . Although the risk of stent thrombosis in both DES and BMS is highest in the first 30 days after stent placement, the overall incidence ranges from 0.5% to 1% per year .

In patients undergoing noncardiac surgery within 1 year of coronary artery stenting, major adverse cardiac event rates including cardiac death, myocardial infarction, revascularization or bleeding ranging from 4% to 45% have been reported. The rates reviewed depended on the timing of surgery, whether or not antiplatelet therapy was continued and type of stent . Interruption of antiplatelet therapy prematurely places patients at increased risk for stent thrombosis depending on the exact timing of discontinuation and the type of stent . In a retrospective cohort study, among percutaneous coronary intervention-treated patients with acute coronary syndrome (ACS), the first 90-day interval after stopping clopidogrel treatment was associated with a significantly higher risk of adverse events (incidence rate ratio 1.82; 95% confidence interval 1.17–2.83) . However, continued use in the perioperative period places patients at an increased risk of bleeding. Thus, for patients requiring surgery within their first year following coronary stent placement (especially DESs), maximizing the prevention of stent thrombosis with antiplatelet therapy while minimizing the risk of intraoperative bleeding has become a management challenge for cardiologists, surgeons and anesthesiologists.

In this manuscript, we describe a case of a patient who received three stents (two of which were drug-eluting) and 7 months later was bridged with intravenous (iv) eptifibatide, a short-acting glycoprotein (GP) IIb/IIIa inhibitor, for 3 days prior to bronchoscopy and cervical mediastinoscopy for a suspected lung cancer. We then review the current literature for data describing the use of short-acting GP IIb/IIIa inhibitors as bridge therapy. Finally, we provide recommendations, based on our experience combined with this review, for bridge therapy in the perioperative period for patients with recent coronary stents undergoing surgery.