Tirofiban 'bridging' therapy for patients with drug-eluting stents undergoing non-cardiac surgery.


Editor—We read with interest the report of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel, in the presence of drug-eluting stents (DES), for non-cardiac surgery and noted the similarity of this group’s regimen to that already described in this journal in 2007 by our group. The rationale for including unfractionated heparin in our bridging therapy is based on the findings of the PRISM-PLUS study in acute coronary syndrome (ACS), in which one arm was terminated early because the use of tirofiban without heparin was associated with an increased mortality at 7 days. These published data using tirofiban now apply to 33 reported patients successfully treated with tirofiban ‘bridging’ therapy. We have also treated a further 12 patients with a tirofiban ‘bridging’ protocol which includes the use of unfractionated heparin. None of our patients has suffered perioperative cardiac complications or excessive bleeding. This brings to 45 the number of patients successfully treated with tirofiban ‘bridging’ therapy and may add sufficient numbers to recommend this management to all anaesthetists. The Cardiac Society of Australia and New Zealand has published guidelines on antiplatelet management for patients with DES undergoing non-cardiac surgery. The guidelines attempt to stratify risks of bleeding vs in-stent thrombosis to tailor perioperative management. Bridging therapy with glycoprotein IIb/IIIa inhibitors is considered in this document for patients at high risk of stent thrombosis and surgical bleeding. The difficulty of relatively small numbers of patients being treated in each institution can be overcome by the use of Internet-based data collection as we have previously suggested. 6 We welcome Savonitto’s cases being reported to our database at DES Reporting.com. The clinical dilemma of thrombosis risk vs bleeding risk in each patient would be greatly helped by a better understanding of the bleeding risk for patients on clopidogrel at the time of surgery. Although a meta-analysis of cardiac surgery has demonstrated an increased risk of bleeding complications (albeit without worse outcome), in patients who remained on clopidogrel until cardiac surgery, there is little data from prospective studies of noncardiac surgery. In the published studies of non-cardiac surgery patients, in whom clopidogrel was continued, an increased bleeding risk has not been described. 8 9

DOI: 10.1093/bja/aeq101

Cite this paper

@article{Bolsin2010TirofibanT, title={Tirofiban 'bridging' therapy for patients with drug-eluting stents undergoing non-cardiac surgery.}, author={Stephen N C Bolsin and Myles M Conroy and Clay Osborne}, journal={British journal of anaesthesia}, year={2010}, volume={104 6}, pages={779; author reply 779-80} }