Zusammenfassung
Hintergrund
Die häufig geübte Praxis, die Therapie mit Acetylsalicylsäure (ASS) und/oder Clopidogrel perioperativ zu pausieren, wird in der Literatur kritisch hinterfragt. Allgemein gültige Leitlinien für die Handhabung dieses Problems gibt es nicht. In dieser Untersuchung wurde die gegenwärtige Strategie der perioperativen antithrombozytären Therapie bei thoraxchirurgischen Eingriffen an deutschen Kliniken analysiert.
Methodik
An alle bei der Deutschen Gesellschaft für Thoraxchirurgie gelisteten Leiter von Einrichtungen, die thoraxchirurgische Eingriffe durchführen (n = 133), wurden Fragebögen verschickt. Gefragt wurde nach dem abteilungsinternen Umgang mit ASS und Clopidogrel bei elektiven thoraxchirurgischen Interventionen. Die Rücklaufquote betrug 59% (n = 78).
Ergebnisse
Es zeigt sich ein heterogenes Vorgehen: So gaben 51–53% der Befragten an, bei Patienten mit „bare metal stent“ (Implantation 3 Monate zuvor) die ASS-Therapie präoperativ zu pausieren. Eine noch größere Anzahl, nämlich 59–63% bzw. 59–65% der Befragten, pausieren bei Zustand nach ischämischem Insult bzw. bei arterieller Verschlusskrankheit mit Zustand nach infrainguinaler Stenteinlage die ASS-Therapie präoperativ. Im Falle eines „drug-eluting stent“ (Implantation 3 Monate zuvor) gaben 35–41% der Befragten an, die duale Plättchenhemmung präoperativ vollständig abzusetzen und nur 6–8% der Chirurgen gaben an, unter Fortführung der dualen Plättchenhemmung zu operieren. Die aktuelle Datenlage zur Handhabung des Problems wird nur von 28% der Befragten als ausreichend erachtet. Bei denen, die die Datenlage zur Handhabung der perioperativen Plättchenhemmung für ausreichend erachteten, zeigte sich für alle Interventionen eine stärkere Tendenz, die antithrombozytäre Therapie fortzuführen. Die ASS- und Clopidogrel-Therapie wird meist 5 bis 7 Tage präoperativ pausiert.
Schlussfolgerung
Die Umfrage ergibt, dass in Deutschland bei der Mehrzahl der thoraxchirurgischen Operationen eine zur Sekundärprophylaxe gegebene antithrombozytäre Therapie pausiert oder reduziert wird. Die Patienten werden dadurch vermutlich einem erhöhten kardiovaskulären Morbiditäts- und Mortalitätsrisiko ausgesetzt.
Abstract
Background
The common practice to stop therapy with acetylsalicylic acid (aspirin) and/or clopidogrel perioperatively is critically discussed in the literature. There are no generally accepted guidelines for the handling of this problem. In this article the present strategy of perioperative antiplatelet therapy applied in German thoracic surgery departments was investigated.
Methods
Questionnaires were sent to the heads of thoracic surgery departments registered in the German Society of Thoracic Surgery (n = 133) inquiring about the handling of aspirin and clopidogrel before elective thoracic surgical procedures. The return ratio was 59% (n = 78).
Results
The analysis of the survey results showed a heterogeneous approach. Of the respondents 51–53% reported stopping aspirin therapy before surgery if the patient was taking aspirin due to a bare metal stent (implantation 3 months before). An even larger number of respondents stopped aspirin therapy before surgery if the patient was taking aspirin due to an ischemic insult or due to peripheral arterial disease with infrainguinal stenting (59–63% and 59–65%, respectively). In the case of drug-eluting stent implantation (implantation 3 months before) 34–41% of the respondents completely stopped the dual antiplatelet therapy before surgery and only 6–8% of the surgeons proceeded with surgery under dual platelet inhibition. Of the thoracic surgeons questioned 28% considered the existing data sufficient to manage this problem. Those surgeons who considered the existing data concerning the management of perioperative antiplatelet therapy as adequate had a stronger tendency to continue the antiplatelet therapy perioperatively. The aspirin and clopidogrel therapy was usually stopped 5–7 days preoperatively.
Conclusions
The survey showed that in Germany the majority of thoracic surgeons reduce or stop antiplatelet therapy (given as secondary prophylaxis) before surgical procedures. It can be assumed that patients are therefore exposed to an increased risk of cardiovascular morbidity and mortality.
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Wiesemann, S., Passlick, B. Perioperative Thrombozytenaggregationshemmmung in der Thoraxchirurgie. Chirurg 83, 576–582 (2012). https://doi.org/10.1007/s00104-011-2252-z
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DOI: https://doi.org/10.1007/s00104-011-2252-z