The Cardiologist ideally would determine when/if anti-platelet needs to be withheld. More recently the need for stopping low dose aspirin has been questioned.

We usually discuss together the perioperative management and decide as a group on what the risk/benefit ratio is.

The antiplatelate therapy is cardiologist domain.

Chakrapani Seshachar

Not exclusively......in the perioperative domain you need to consider the risk/benefit ratio between your domain,and that of the surgeon and anaesthesiologist who are also involved in the patient's care.

You must be able to have your input to the balance of risks of thrombosis vs bleeding,and I can assure you that in the field of vascular surgery,this is very important.

It is not for one part of the equation to assume ownership of the entire problem,but for each to work TOGETHER to ensure the best overall outcome.

Of course the Cardiologist! DAPT / SAPT / High dose / Low dose! It’s cardiologist’s domain. Surgeon may request and alter the procedure with respect to type / time / need etc. after consulting the Cardiologist. Except in emergency / extraordinary situations...it’s a different matter!

Satej Janorkar

And in an emergency/urgent situation,what would you do then?

Would you then be prepared to discuss/modify and even alter therapy to achieve the best outcome and balance of risks for your patient?

Emergency warrants urgent attention!

No choice but to go ahead with the procedure!

SAPT should be started at the earliest weighing the risk of bleeding depending upon the post-intervention duration. It is a fundamental trade off between the thrombus and bleeding at the end of the day.

We all should follow Guidelines. The question is what paper is best.

Anesthesiologists (because, adopted procedures are related) and concerned Surgeons (because types and sequelae of surigcal trauma may be considered) [not a Cardiologist] is primarily responsible for the Pre and postoperative antiplatelet therapy protocols. Consultations with Cardiologists is sought in special scenario with multifaceted complications. Regards- Rabiul

Clinical hematologist or pediatric hematologist can provide valuable help in management. So their advice must always be included.

Regards

cardiologist and hematologist

but surgeons have their own stand

Dear Sikandar Hayat Khan & Zahra DAUD Khan Sir/Madams, are you recommending to consult every perioperative antiplatelet issue with cardiologist, hematologist... and so on?! Regards- Rabiul.

Sir Md Rabiul Alam

Grateful for your comments and very valid ones.

Not everyone, but whenever in doubt and the clinical hematologist is available, it can be helpful

As for as the cardiologist part is concerned, I am also not sure .

Regards

Anaesthesiologists, this issue has been discussed and guidelines have there for quite some times, todays Anaesthesiologists, have gained a wide experience in the Antiplatelet, different types of procedures have deferent protocol and rational, elective Vs urgent etc. add to that there knowledge of the surgeons.

This is an excellent question. I work in a cardiovascular ICU. We have a couple surgeons who will wait the 5 days, with IABP support as needed to let the antiplatelet drugs wear off. Sometimes you can't wait, we sometimes do bare metal stents to bridge to surgery. If we can't wait, we know there is going to be a bleeding mess. Day one or two post surgery the antiplatelet is restarted usually without issues. So, I have to say that the cardiologist and surgeon need to work together for the best patient outcome.

brigid

Thanks Prof Muaweih Ababneh and Prof Brigid Conroy for your valuable comments with guidelines.

Dear Respected Colleagues ,

Cardiologists, Surgeons and Anesthesiologist All are concerned with this management whether this operation is elective or emergency .... but the main controller for the Pre-operative antiplatelet therapy management is the anesthesiologist with help of the cardiologist ... because the indication for using this antiplatelet theray is mainly for a cardiac problem and rarely for neurological problem ....

Best Regards and Respect

These three specialists all have parts to play in the management of this patient who is on antiplatelet therapy, and now has indication for surgical operation to be done under anaesthesia.

Additionally, the haematologist would need to be consulted because he monitors the blood clotting profile of the patient.

I work on a Cardiovascular ICU and the cardiologist and CV surgeons work together. If surgery is likely, then no antiplatelets are used. If a stent is needed as a bridge to surgery, then a bare metal stent is used.

Cardiologist

Cardiologists --> Anaesthesiologist. In that order of priority. An anaesthesiologist has extensive knowledge about how the anti-platelets affect case specific decisions, whereas a cardiologist has a greater understanding of the heart, for which these drugs are most commonly prescribed. I honestly think Surgeons have no clue about any of this. This however is my own personal experience with the surgeons. :)

In my opinion multidisciplinary approach should be followed, depending upon pathology of heart disease for which aspirin is given to the patient, type & duration of anaesthesia given to the patient & type & duration of Surgery. Order should be like...

Cardiologist--> Anaesthesiologist--> Surgeon.

Multidisciplinary approach should be followed

I agree with multidisciplinary approach. In our institution we don't stop with ASA antipletelet therapy prior to vascular procedures. Patients on DPT are managed multidisciplinary with cardiologists and anaesthesiologists.