ABC | Volume 111, Nº4, Octuber 2018

Original Article Borges et al Inadequate management of antiplatelet agents Arq Bras Cardiol. 2018; 111(4):596-604 Table 2 – Results of noncompliance with the SBC recommendations for using aspirin and clopidogrel in preoperative periods of non-cardiac surgeries (n = 161) in high-complexity Hospital, Aracaju, Sergipe, Brazil, 2014-2016 Therapy* Frequency n(%) Compliance 31(19.3) Non compliance It was not suspend; it was supposed to be suspended 30(18.6) It was suspended; it was not supposed to be suspended 37(23.0) It was suspended; it was supposed to be suspended, but for a period longer than recommended 42(26.1) It was suspended; it was supposed to be suspended, but for a period lower than recommended 21(13.0) Total 161(100) ASPIRIN: acetylsalicylic acid; SBC: Brazilian Society of Cardiology; (*) Therapy according or noncomplying with the use recommended by the SBC for using aspirin or clopidogrel in preoperative periods according to the SBC. on this matter, and, as such, diverging conducts strengthen the need of defining internal conducts, more divulgation of the guidelines used as reference at that institution, and continued education. Double checking conducts according to internal protocols of an institution can also be an important choice to ensure patients’ safety. Other important datum in this study, and one that draws attention, is that a significant number of noncomplying therapies occurred resulting from having patients oriented to suspend antiplatelet agents when the Brazilian guidelines state the opposite for cases where patients use aspirin and clopidogrel for secondary prevention of cardiovascular diseases, 24,27 except for clopidogrel, which depends of the procedure’s bleeding risk; 28 but in this case, all 5 patients who had been using this drug were submitted to low bleeding-risk surgeries. According to some authors, an increased bleeding risk related to the effect of the antiplatelet action of those drugs is well known, 29,30 mainly in the ageing population, 31 which stands for the majority in this study. However, other studies, as much as the SBC orientations (2013), except for neurosurgeries and transurethral resection of the prostate, advocate that the benefits of secondary prevention substantially exceeds the bleeding risks those drugs may cause 13,24,27 once the AMI is the main cause of death in old patients after non-cardiac surgeries. 32 A successful surgery depends on the aptitude and technical skills of the surgeon, on the indication and previous preparation, on the perioperative period management and care dimensioning the risks, on preventing and treating complications. 33 In other words, a surgeon operates trying to avoid surgical complications during the procedure as much as possible, and among them one can be highlighted among general complications, whose universal example is hemorrhage. 34 Those statements can justify the results of this study because the medical expertise representing the majority of the results noncomplying with the guidelines was surgery. As to the association with patients’ characteristics, it was observed that patients with more schooling and those who at some moment had an AMI episode have more chance of using antiplatelet therapy in the preoperative period of non-cardiac surgeries according to the SBC (2013). No studies with this type of association were found in the literature. However, on this matter, in a research done in the United States, its findings strongly suggest that the level of schooling is able to affect the risk of an individual developing cardiovascular diseases, regardless of any cardiovascular risk factor defined, i.e., patients with less than 12-year schooling ran significantly higher risk of AMI than those with 12-year or more schooling. 35 As much as other authors, we understand that a higher schooling level enables patients to understand better the doctor’s orientations as to managing medicines and their health condition, as much as to have more access to information, 36 once nowadays patients would rather participate more and more in the decision-making process with their doctors. 37 As to patients who already had an AMI episode and are in the group where the antiplatelet therapy complies more with the guidelines in the perioperative period, one can understand that surgeons and doctors in charge of this medicine management look for avoiding reinfarction, and so they instruct their patients not to suspend aspirin or clopidogrel in the preoperative period of non-cardiac surgeries, thus abiding by the recommendations in the guidelines and advocated by other authors. 15,24,25,27,38 This study has some limitations once the information obtained about management of antiplatelet therapy was rendered by the very patients, or by their companions, who in some situations said that opinions diverged between surgeon and cardiologist, or between surgeon and anesthetist, for instance, which would lead the very patients, or their companions, to decide which orientations should be followed. Additionally, the answers were written down on the patients’ reports, and physicians did not have the opportunity of confirming them. In addition, the study is limited to assessing simultaneously the two types of revascularization procedures (angioplasty and coronary revascularization) referring to the management of the antiplatelet agents, and it just does not assess the clinical impact of the antiplatelet therapy after the preoperative period. Therefore, we suggest that future studies address this prospective approach in order to size up the occurrence of thrombotic or hemorrhagic events during and after surgery. Conclusion General surgeons stand for a group of physicians which follows the least the guidelines for managing antiplatelet agents in perioperative periods of non-cardiac surgeries. 600