The art of delivering evidence-based dual antiplatelet therapy

For emergent surgery, when severe bleeding is not seen or expected, interruption of DAPT can be minimized. After cessation of DAPT components, normal platelet function will return in¹²:

• 7 to 10 days for ASA,
• 5 to 7 days for prasugrel,
• 5 days for clopidogrel, and
• 3 to 5 days for ticagrelor.

If significant bleeding occurs perioperatively, or is expected, platelet transfusion can be helpful, and might need to be repeated because each P2Y12inhibitor has a half-life of between 8 and 12 hours.

For urgent or time-sensitive surgery, discontinuing a P2Y12inhibitor can be considered—while continuing ASA, if possible. DAPT should be restarted as soon as safely possible. If enteral administration is not feasible, ASA can be administered rectally. In this setting, cardiology consultation is strongly encouraged.

Consider giving a proton-pump inhibitor to a patient receiving DAPT who has a history of gastrointestinal bleeding.

Last, elective surgery should be delayed until DAPT is completed, but without discontinuing ASA, if feasible. Spinal, intracranial, prostate, middle-ear, and ophthalmologic surgery while taking ASA can lead to catastrophic complications; consider discontinuing ASA. Cardiology consultation can provide an estimate of thrombosis risk to guide clinical decision-making.³⁰

Can DAPT prevent secondary stroke?

DAPT has brought improvements in the treatment of patients with cardiovascular disease; it has been hypothesized that similar benefits can be seen in patients with ischemic stroke. Knowing the cause of stroke is key to developing a secondary prevention plan; patients with stroke secondary to atherosclerotic disease are most likely to benefit from DAPT.³¹ Conversely, secondary prevention in patients with small-vessel disease and in studies of unselected stroke type has been shown to be harmful.^32,33

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