ABC | Volume 111, Nº4, Octuber 2018

Original Article Borges et al Inadequate management of antiplatelet agents Arq Bras Cardiol. 2018; 111(4):596-604 in compliance with the norms for scientific research involving human beings in Brazil. All individuals included in the study agreed to participate in the research by signing a free and informed consent (FIC). Results Out of the total number of patients interviewed (n = 1,200), 161 were included in this study because they reported using at least one antiplatelet agent: Aspirin (156) and clopidogrel (5). Among those, 48 used antiplatelet agent for primary prevention (29.8%) and 113 for secondary prevention (70.2%). The patients were 69.5 years old on average (minimum=42;maximum=99; SD = ±10.5) and the majority was female (54.7%), in addition to having an average AMI of 27.8 kg/m 2 (minimum = 17.3; maximum = 46.3; SD = ±5.5) and number of diseases 1.8 on average (minimum = 0; maximum = 4; SD = ±0.9). The majority had schooling up to high-school (40.4%) and the mean time of daily use of aspirin and/or Clopidogrel was 6.3 years (minimum = 1; maximum = 40; SD = ±6.8). Table 1 shows the characteristics of the sample in detail: Out of the whole sample, 80.7% of the sample failed to comply with the SBC cardiology guidelines. As to types of noncomplying therapies, most of them occurred in cases where platelet agents was suspended as recommended, but within a longer period of time to that recommended in the guidelines, as detailed in Table 2. As to the people in charge of rendering orientation for the management of antiplatelet agents, 85.1 % of the surgeons who rendered instructions to patients, in addition to 63.2% of the cardiologists, did it in disagreement with the recommendations in the SBC guidelines as to the use of aspirin or clopidogrel in the preoperative period of non‑cardiac surgeries. As to the cardiac risks in surgical procedures to which the patients were submitted, according to the SBC 20 guidelines for perioperative cardiovascular assessment, the majority (58%) of the procedures was classified as low cardiac risk (<1%), and none was classified high risk in this study. Table 3 presents the results of multivariate analyses of the characteristics associated to the therapy lacking compliance with the recommendations for using aspirin or clopidogrel in preoperative period according to the SBC. After multiple adjustments, schooling up to university, complete or incomplete (OR 0.24; CI95% 0.7-0.78), and previous history of AMI (OR 0.18: CI95% 0.04-0.95) remained independently associated with the therapy lacking compliance with the SBC. . Discussion The rather expressive frequency of therapies with aspirin and clopidogrel lacking compliance with the SBC guidelines’ recommendations (2013) in the perioperative period of non‑cardiac surgeries was not observed in other studies once, as far as we are aware, this is the first one conducted in Brazil on this subject. However, the lack of organization of standardization of medical conducts in the management of antiplatelet agents is well known, i.e., there are groups of physicians who advocate the suspension of those medicines before surgeries in order to avoid bleedings, while others advocate their maintenance in order to avoid thrombotic events. 11-13,21-24 The Brazilian guidelines say that in cases where aspirin or clopidogrel is used for primary prevention of cardiovascular diseases, they should be suspended, respectively seven and five days before a non-cardiac surgical procedure. However, in this study, the majority of the noncompliance with the Brazilian guidelines happened due to their suspension for periods longer than those disposed for aspirin and clopidogrel. This conduct can potentially expose patients to cardiac complications in the perioperative period once the literature evidences that those medicines, after being suspended for 8-10 days, lose their antiplatelet agent’s effect. 25,26 Cases where the conduct of suspending the drug was correct were also observed, but for a period shorter than that recommended in the guidelines and, so, the goal of losing the pharmacological effect of the antiplatelet agent is never reached once that effect at platelet level is irreversible, and the time they remain active is approximately 10 days. 26 Therefore, although the conduct of suspending the antiplatelet agent was correct, it is possible to infer that the suspension of the antiplatelet agent for longer or shorter periods than those recommended by the guidelines occurred because the hospital does not have its own assistance protocols focused Continuation Time using aspirin or clopidogrel 1-4 years 72(44.7) 19.4 80.6 0.956 5 years or more 89(55.3) 19.1 80.9 Surgeon expertise General or digestive system 67(41.6) 80.6 19.4 0.770 Urologist 11(6.8) 16.1 83.2 Orthopedist 24(14.9) 83.3 16.7 Other 59(36.7) 78.0 22.0 ASPIRIN: acetylsalicylic acid; SBC: Brazilian Society of Cardiology; (*) Therapy according or noncomplying with the use of aspirin or clopidogrel therapy in the preoperative period, according to the SBC; (†) Body Mass Index = (weight in Kg) : (height in meters 2 ); (‡) Number of diseases documented in the medical records and confirmed by patients on the date they were admitted for surgery; (#) history of percutaneous coronary intervention or surgical revascularization; (§) Obtained with Pearson chi-square test, significant when < 0.05. 599