# Perioperative Statin, Antiplatelet, and Other Medication Management — ACC/AHA 2014

## Perioperative Statin Therapy

### Continuation of Statins (Class I)

- **Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery.** (Class I, Level of Evidence: B)
- Perioperative statin discontinuation has been associated with increased cardiac morbidity and mortality in observational studies.

### Initiation of Statins in Vascular Surgery (Class IIa)

- **Perioperative initiation of statin therapy is reasonable in patients undergoing vascular surgery.** (Class IIa, Level of Evidence: B)
- Multiple observational studies and a randomized trial (the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography [DECREASE] III trial) have demonstrated reduced perioperative cardiovascular events with perioperative statin use in vascular surgery patients, though the DECREASE trials have been subject to integrity concerns.

### Initiation of Statins in Elevated-Risk Procedures (Class IIb)

- **Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures.** (Class IIb, Level of Evidence: C)
- This applies to patients who have an indication for statin therapy per the ACC/AHA cholesterol guidelines but are not currently on one.

### Practical Considerations

- If a statin is to be initiated perioperatively, it should be started sufficiently in advance to achieve pleiotropic effects (anti-inflammatory, plaque stabilization).
- Continue at the current dose throughout the perioperative period; there is no evidence supporting dose adjustment.
- For patients who cannot take oral medications postoperatively, statin therapy should be resumed as soon as the patient can tolerate oral intake.

## Perioperative Antiplatelet Therapy

### Patients with Coronary Stents

Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery is one of the most complex clinical scenarios. The guideline provides the following recommendations:

#### Timing of Elective Surgery After Stent Implantation

| Intervention | Minimum Delay Before Elective Noncardiac Surgery | COR / LOE |
|---|---|---|
| **Balloon angioplasty (no stent)** | 14 days | Class I, LOE: C |
| **Bare-metal stent (BMS)** | 30 days | Class I, LOE: B |
| **Drug-eluting stent (DES)** | Optimally 365 days | Class I, LOE: B |
| **DES (abbreviated DAPT)** | May be considered after 180 days if risk of delay > risk of stent thrombosis | Class IIb, LOE: B |

- Elective noncardiac surgery should **not** be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom dual antiplatelet therapy (DAPT) will need to be discontinued perioperatively. (Class III: Harm, Level of Evidence: B)

#### Aspirin Management in Patients with Stents

- In patients with coronary stents who must undergo surgical procedures that mandate discontinuation of P2Y12 platelet receptor-inhibitor therapy, **aspirin should be continued if possible** and the P2Y12 inhibitor restarted as soon as possible after surgery. (Class I, Level of Evidence: C)

#### Urgent and Emergency Surgery in Patients with Stents

- In patients undergoing **urgent noncardiac surgery** during the first 4 to 6 weeks after BMS or DES implantation, DAPT should be continued unless the relative risk of bleeding outweighs the benefit of preventing stent thrombosis. (Class I, Level of Evidence: C)

#### Multidisciplinary Decision Making

- Management of perioperative antiplatelet therapy should be determined by a **consensus of the surgeon, anesthesiologist, cardiologist, and patient**, who should weigh the relative risk of bleeding versus the risk of stent thrombosis. (Class I, Level of Evidence: C)

### Aspirin in Patients Without Coronary Stents

- In patients undergoing noncardiac surgery who have not had previous coronary stenting, the management of aspirin should be guided by the clinical context:
  - Continuation of aspirin may be considered in patients at elevated cardiac risk undergoing noncardiac surgery, unless the risk of bleeding outweighs the cardiac benefit.
  - Aspirin should generally be discontinued in patients undergoing procedures with a very high bleeding risk (e.g., intracranial surgery, spinal canal surgery, surgery in a closed compartment) where even minor bleeding can have severe consequences.

## ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)

### Continuation (Class IIa)

- **Continuation of ACE inhibitors or ARBs perioperatively is reasonable.** (Class IIa, Level of Evidence: B)
- If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart them as soon as clinically feasible postoperatively.

### Clinical Considerations

- ACE inhibitors and ARBs have been associated with intraoperative hypotension, particularly after induction of anesthesia.
- Some clinicians choose to hold ACE inhibitors and ARBs on the morning of surgery to reduce hypotension risk; this practice is not addressed with a specific recommendation in the 2014 guideline, and the decision should be individualized.
- Patients taking ACE inhibitors or ARBs for heart failure or LV dysfunction should generally continue therapy given the mortality benefit in these populations.

## Alpha-2 Agonists

- **Alpha-2 agonists (e.g., clonidine) are NOT recommended for prevention of cardiac events** in patients who are undergoing noncardiac surgery. (Class III: No Benefit, Level of Evidence: B)
- The POISE-2 trial (2014) demonstrated no reduction in death or nonfatal MI with perioperative clonidine but increased clinically significant hypotension and nonfatal cardiac arrest.

## Calcium Channel Blockers

- The guideline does not specifically recommend perioperative initiation of calcium channel blockers for cardiac risk reduction.
- Calcium channel blockers that are part of the patient's chronic medication regimen (e.g., for hypertension, angina, or rate control) should generally be continued perioperatively.

## Perioperative Anticoagulation

- Decisions about perioperative anticoagulation management (bridging therapy for patients on warfarin, management of DOACs) are generally guided by the indication for anticoagulation and the bleeding risk of surgery.
- The 2014 guideline does not provide detailed perioperative anticoagulation protocols, deferring to anticoagulation-specific guidelines.

## Summary of Perioperative Medication Recommendations

| Medication | Already Taking | Initiation Perioperatively |
|---|---|---|
| **Beta-blockers** | Continue (Class I, LOE: B) | May be reasonable if >= 3 RCRI factors (Class IIb, LOE: B); do NOT start day of surgery (Class III) |
| **Statins** | Continue (Class I, LOE: B) | Reasonable for vascular surgery (Class IIa, LOE: B); consider for elevated-risk procedures (Class IIb, LOE: C) |
| **ACE inhibitors/ARBs** | Continuation reasonable (Class IIa, LOE: B) | Not specifically addressed for perioperative initiation |
| **Aspirin (with stent)** | Continue through surgery if possible (Class I, LOE: C) | Not applicable |
| **P2Y12 inhibitors (with stent)** | Continue if within 4-6 weeks of stent and urgent surgery (Class I, LOE: C) | Not applicable |
| **Alpha-2 agonists** | -- | NOT recommended (Class III, LOE: B) |

## Special Considerations

### Insulin-Treated Diabetes

- The guideline acknowledges insulin-treated diabetes as an independent RCRI risk factor but does not provide specific perioperative insulin management protocols. Perioperative glycemic control should follow institutional protocols.

### Patients with Implantable Cardioverter-Defibrillators (ICDs) and Pacemakers

- Management of cardiac implantable electronic devices perioperatively should follow the applicable HRS/ASA Expert Consensus Statement.
- Electromagnetic interference from electrocautery can affect device function; appropriate reprogramming before surgery may be necessary.

## Limitations

- The statin initiation recommendations are based largely on observational data and the DECREASE trial family, which has been subject to integrity concerns.
- ACE inhibitor/ARB management lacks definitive randomized trial data to guide whether to hold or continue on the morning of surgery; the 2014 guideline provides a Class IIa recommendation for continuation but acknowledges the practice of holding on the morning of surgery.
- Antiplatelet therapy recommendations in the context of coronary stents must be individualized, as the risk of stent thrombosis (potentially fatal) must be balanced against the risk of surgical bleeding.
- The guideline was published before several important trials (e.g., MANAGE trial for perioperative DOAC use) and before the 2016 ACC/AHA Focused Update on DAPT duration.
