Abstract P79: Drug-Eluting Stents and Noncardiac Surgery: VA Provider Perceptions and Management Practices
Authors: Maddox Thomas M , Graham Laura A , Hawn Mary T 
Published: July 2021

Background
The optimal management of anti-platelet therapy in patients undergoing non-cardiac surgery in the year following drug-eluting stent (DES) placement is unknown. The most recent AHA guidelines recommend consideration of continuing dual anti-platelet therapy among these patients, but consensus on the best approach does not exist. We assessed VA provider perceptions and practices of anti-platelet use in DES patients with cardiac stents needing surgery in the subsequent year.

Methods
A national web-based survey was administered to VA cardiologists, surgeons, and anesthesiologists. The survey was distributed by the national directors of each specialty via email. Responses were collected on a 5-level Likert scale and compared with chi-square tests.

Results
319 providers from 80 medical centers responded to the survey. Of these, 110 (34.9%) were cardiologists, 91 (28.9%) surgeons, and 94 (29.8%) anesthesiologists. Most respondents were aware of the AHA guidelines, reported implementation at their facilities, and agreed with the guidelines, but surgeons were less likely to report this than other providers (Table). Cardiologists were more likely than surgeons to view peri-operative stent thrombosis as difficult, while surgeons were more likely than cardiologists to view bleeding complications as difficult. Similarly, cardiologists were more likely than surgeons to report that the risk of stent thrombosis outweighs the risk of bleeding complications in their decision to use clopidogrel, while surgeons reported the converse. Cardiologists were more likely than surgeons to continue dual anti-platelet therapy in the peri-operative period or utilize bridging therapies (such as 2b/3a inhibitors).

Conclusions
Despite a broad awareness and agreement with the guidelines, significant variation by provider in anti-platelet management among DES patients exists. This variation points to the need for further clarity and consensus in optimal treatment.

VA Provider Perceptions and Management of Anti-Platelet Therapies in DES Surgical Patients

Overall (n=319)
Cardiologists (n=110)
Surgeons (n=91)
Anesthesiologists (n=94)
Other (n=24)
P-value

Aware of guidelines
285 (91.9%)
109 (99.1%)
71 (78%)
94 (100%)
11 (61.1%)
<0.0001

Implemented at medical center
187 (65.2%)
81 (73.6%)
34 (45.3%)
64 (68.1%)
8 (80.0%)
0.002

Agree with guidelines
251 (78.7%)
99 (90.0%)
58 (63.7%)
82 (87.2%)
12 (50.0%)
<0.0001

Stent thrombosis is difficult to manage
255 (79.9%)
101 (91.8%)
61 (67.0%)
81 (86.2%)
12 (50.0%)
0.0001

Bleeding is difficult to manage
219 (68.7%)
70 (63.6%)
65 (71.4%)
75 (79.8%)
9 (37.5%)
0.04

Stent thrombosis is a more important risk than major bleeding in the decision to use clopidogrel
175 (54.9%)
69 (62.7%)
43 (47.3%)
55 (58.5%)
8 (33.3%)
0.46

Would continue both aspirin and clopidogrel in the peri-operative period
214 (72.1%)
81 (73.6%)
53 (60.2%)
73 (79.4%)
7 (70.0%)
0.001

Would use bridging therapies (e.g. 2b/3a inhibitors) if clopidogrel was discontinued
206 (64.6%)
71 (64.5%)
50 (54.9%)
64 (68.1%)
21 (87.5%)
0.002