Central Line

Episode Number: 172

Episode Title: New DAPT-Related Guidelines

Recorded: September 2025

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome back to Central Line. I'm Dr. Adam Striker, your editor and host. Today, I have the good fortune of being joined by Dr. Natalie Bodmer, a member of the editorial board for Anesthesiology Continuing Education, or more familiarly, as ACE. We're going to discuss an item from the current issue: the recent guidelines from the American Heart Association and the American College of Cardiology regarding the perioperative cardiovascular management of patients undergoing noncardiac surgery.

Dr. Bodmer, welcome to the show.

DR. NATALIE BODMER:

Thanks so much for having me.

DR. STRIKER:

Absolutely. Well, like we do traditionally on the podcast, before we get to the specific topic, if you don't mind, tell our listeners just a little bit about yourself, your role with ACE or how you got involved in ACE.

DR. BODMER:

Of course. So I'm a cardiac anesthesiologist at Stanford. I work also on our perioperative service and in our preoperative clinic. I actually did a combined residency in internal medicine and anesthesia. And so that's really impacted my approach to patient care. And some of my interests are in the perioperative optimization for high-risk patients. And I am the associate program director for both our residency and cardiac fellowships. And I do a lot on our educational curriculum and assessment. And so kind of that segue right into my passion for lifelong learning, um, that's what I always tell all of our trainees that medicine, you've got to be a lifelong learner because things change fast. And that's really what ACE helps support. And so I was really happy to get involved and to help contribute writing questions to make sure that the broader community of anesthesiologists can stay on top of it and learn myself too from the really great discussions that we have on our editorial board.

DR. STRIKER:

Wonderful. Well, let's talk about the new guidelines. These came out last year in 2024, replacing the 2014 guidelines. And was this just a routine update or were there specific reasons as to why these new guidelines came out?

DR. BODMER:

Well, right. 2014 is ten years ago. And you know how fast the field of medicine changes. And so there was quite a lot to be updated. I would say for some of us, we were wondering kind of when these things would be updated. And so we were happy to see that they came out last year. There are some significant changes that I think we’ll probably highlight. Obviously in ten years, a lot of things--perioperative risk calculators have been updated, guidelines for perioperative cardiac diagnostic testing, perioperative considerations for other cardiovascular comorbidities, new medications. There's a whole bunch of medications that have come out. Um, guideline directed medical therapy has also changed in these ten years. All of this goes into affecting our anesthetic considerations for these types of patients. So I'll pause there, I guess, to see what specific questions we can talk about today.

DR. STRIKER:

Well, it's tough to pick one thing, but is there something specific that you found interesting that was updated that maybe you weren't expecting, or that you thought might be important to let our listeners know? I know it's all going to be important, but anything of particular interest that you noticed?

DR. BODMER:

Yeah, I think so. There's guidance in the importance of frailty assessment, which I think as as all of us who practice anesthesia, that's kind of sometimes that your gut telling you this patient just does not look like they will tolerate surgery the most. And, you know, the frailty assessment is something that can really predict outcomes and morbidity and mortality postoperatively and how they're going to do. And so that highlight was specifically interesting to me. And then, in addition, the dual antiplatelet therapy for coronary artery disease, they made some really important updates to that that I think are essential for us to know in terms of what the risk is when we stop those medications. Also, ten years ago, you know, the field of oral anticoagulation therapy was just starting. And so this one really highlighted: when does somebody need to be bridged with anticoagulation? And really that's just in the high-risk cases. But you know you want to pay attention to what those high-risk states are. Because obviously in surgery it's always a balance. We want to balance people who are on any kind of oral anticoagulation therapy, their risk of bleeding, versus their risk of clotting. And so again, a lot of those medications weren't even around or were just starting to be around. And so this incorporates some considerations for that.

DR. STRIKER:

Well let's stay on the dual antiplatelet therapy topic. Now is the acronym, D.A.P.T., is that one that is fairly commonly applied or is that…

DR. BODMER:

Yeah. Yes it is. And yes. Or even what a lot of us call DAPT for short.

DR. STRIKER:

Okay so walk us through the optimal timing of elective or time sensitive noncardiac surgery for prior PCI requiring management of dual antiplatelet therapy.

DR. BODMER:

Perfect. And I will highlight too, these guidelines have some beautiful, easy to interpret flow algorithms to follow. And so again, if any of our listeners want to go to the original guidelines to look at that. I think they spell it out really easily to follow.

So one thing to consider in your patients. So let's just say we've got a patient who is on DAPT because they've had a past PCI or percutaneous intervention. So you know a stent placed for coronary artery disease. And so if they're on DAPT because of PCI, then the first thing you want to do is find out or understand why they had a PCI. And so this will usually group them into two categories. One if it was a four ACS. So if they presented for an acute MI into the ER and got a PCI after that, then elective noncardiac surgery should be delayed for 12 months. And that's the strongest recommendation, class one recommendation. Now if it was caught on routine testing. So let's say that, you know they got caught on a CT scan or something else, and there was some concern. They went for an angio and they just had chronic coronary artery disease. Then that would be a six-month delay if for just elective noncardiac surgery. As you know, things are always gray. And so what this guideline tried to take into consideration as well is for those time sensitive surgeries, which are a huge group of surgeries that our patients have, and these time sensitive surgeries, for example, the most common one that we think of is for a malignancy. If there's some resection or an oncologic process that deferring the surgery for 6 to 12 months if somebody had a recent PCI, would really impact the other disease process going on, then the guidelines state that noncardiac surgery can be performed three months after a PCI. And this is the change from the previous recommendation of waiting six months.

DR. STRIKER:

Well, are there any new recommendations regarding cardiac caths and how do these new anticoagulation guidelines play into that?

DR. BODMER:

Excellent question. So right, this is, I think, the age-old question of, you know, if somebody is having chest pain and abnormal stress test, what do you do with that before they have surgery. And I think the really big key takeaway from the evidence that has come out as of now. And again, one thing I do want to recognize too, with these guidelines, as well as anything that we talk about, is this was from as current as we can be. But again, at the time of these guidelines, even the GLP one agonists, some other medication recommendations are, you know, in flux and changing as we find out more. So given all of that, that I can say that the evidence that is out there now shows that it's based on an individual and also if it's not going to change the management. So if somebody has an abnormal stress test, if there are definitely high risk features. So if you're concerned about left main disease then sure they should be capped. And that should prompt a PCI. However, if they are not high-risk features and it is not going to change the patient's decision or the surgeon's decision about doing the surgery, then the patient should not go for coronary calf because that could significantly delay their surgery. So, for instance, if somebody had abnormal stress tests, went for a CAPT, got a PCI, then again that would put them on DAPT. And as we stated before, that would put them out for about six months for their surgery. Again, in these recommendations, if the six months and 12 months is specifically related to the risk of stent Stenosis. And so again, the reason that there is those different categories between chronic coronary artery disease and ACS is because in that acute setting for an acute MI, they have much higher risks of having stent thrombosis in that first year. Whereas with just chronic coronary disease their risk drops significantly after six months. And so that's why there is that difference in time recommendations for when to delay the elective non-coronary or noncardiac surgery. And again, there is some drop in risk. And the highest risk after a PCI is that three-month period. And so that's why even for time sensitive surgeries, they recommend waiting three months after someone has gotten a PCI. So, you know, as these perioperative physicians that are partnering with our multidisciplinary teams to decide what is appropriate and how we can best optimize our patients. When we are recommending more diagnostic testing, such as coronary caths, then we need to weigh that with the timing and appropriateness for surgery. If that's within the patient's goals and having that shared decision making as well.

DR. STRIKER:

Okay. Gotcha. Well, circle back and let's talk about how these guidelines are developed. What are the methods the organizations use to explore the topic and actually come up with the final product?

DR. BODMER:

Of course. So these guidelines are put out by by obviously two big societies, the American Heart Association as well as the American College of Cardiology. And so what they did is they took their 2014 guidelines and then basically did an extensive literature review on all the evidence. And so these are randomized controlled trials. These are registry data. Everything that they can find--cohort studies, case controls--that is very reputable. And so they took that from August 2022 to March 2023. And then they had committees. And also they included several subspecialty societies as well. So these are the experts in all of their respective fields who know the literature know the evidence. And then put this together to make these guidelines. They also use an extensive peer review committee go then review the document to make sure that again, it's vetted and makes sense by all of these experts in the field, including anesthesiology, including obviously, the cardiology fields. And so then they put all of this together to make sure everybody agrees that this is reasonable. And this is all, again, evidence based.

DR. STRIKER:

And how can we as anesthesiologists stay on top of all of this, whether it relates to the anticoagulation therapy or any of the guidelines that that are being addressed here. What resources should we know about?

DR. BODMER:

That's a great question. And so, um, I think this is where however, anesthesiologists try to stay up to date, whether that is, you know, doing their ACE questions. And then you get this question and see, oh, new 2024 guidelines came out. Oh, let me take a look at this. Whether that is going to conferences. Again, this is a pretty hot topic over the past year because it does impact so much of our perioperative care. And so I know a lot of conferences have had updates on this. A lot of other journals have put out different highlights of what these guidelines recommended. Again, I think however people hear about it is important and then they can always go to the primary guidelines themselves. But I think there's a lot of different ways that anesthesiologists stay up to date. And so obviously, that's why I think this made a good ACE question, not just because, you know, you need to know when to stop DAPT for your patient, but to highlight, oh, yeah, these new guidelines did come out. And I should take a look at them to just help get that word out there.

DR. STRIKER:

Your interest in optimizing patients for anesthesia, medical management, preoperatively or perioperative, but particularly getting patients ready as optimally as possible for anesthesia. As someone who is involved in that aspect of care a little more than than perhaps your average anesthesiologist, is there anything you find that our listeners or the average practicing anesthesiologist should be aware of, or may not be aware of, or could be doing a better job at? It's kind of an all-encompassing question, but any insights from your particular expertise that you could share with us?

DR. BODMER:

Yeah. Oh, what a great question. Um, you know, I think in in my world, again, a lot of my patients actually are going in a more urgent sense. And so we don't have as much lead time to get them optimized. However, I will say I think that specifically and again, this is just one of the reasons why I'm so passionate about these guidelines and think they're so important is because almost half of our patients are over the age of 45 years old now, and they have multiple cardiovascular risk factors. And so taking that into consideration, you know, the amount of patients that you're going to encounter, who these guidelines impact is going to be almost half. As far as what you can do, I think that, you know, it depends on the timing of the surgery. Is this urgent? Is this elective?

And then really knowing and taking individual patient considerations into perspective again. One thing that I feel passionately for in these guidelines recommend to you is this is going to be an individual decision for some patients, and you need a shared decision making process. Some patients are going to want to have their surgery, and if they want to have their surgery, it's knowing what risk they're taking on. And then also the anesthesiologist being aware of how to manage those comorbidities. So intraoperatively and postoperatively, we can be watching out for certain complications and making sure they're getting through that whole perioperative period as safely as possible.

I will say low hanging fruit, things that we can do is making sure that all their comorbidities are managed appropriately. So whether that's diabetes, whether that's taking their inhalers ahead of time. You know, one of the key things that we see a lot in our patients who have heart failure with reduced ejection fraction is, you know, making sure that they're on their medications and making sure that they're coming in as optimized as possible. So if they're on a diuretic, making sure they're continuing that diuretic so that they're not showing up, volume overloaded for us, making sure that they're on all of those GDMT optimal medical therapies ahead of time.

Again, prehab is not done as widely, you know, here as, as in some other countries. But I think as much as you can encourage your patients to exercise beforehand to get ready. And part of this is also expectation setting: walking your patient through what the perioperative course is going to look like, what to expect when they get into the hospital, what the recovery time is going to look like. All of that is really expectation setting. And as much as we can match that, I think patients overall then have a stronger trajectory to their recovery.

DR. STRIKER:

You know everything you say. It certainly highlights, I think, the fact that anesthesiologists are truly a perioperative physician, and the value that I think any anesthesiologist can add to the entire course during that phase by by being a, shall we say, a resource for, for optimization beforehand, as opposed to perhaps falling into the role of, uh, more of technician and, and just getting them through the immediate operative phase. So I think what you've described articulates nicely, you know, the true value that, that anesthesiologists can bring to the entire perioperative experience.

DR. BODMER:

Definitely. Yeah.

DR. STRIKER:

Well, before I let you go, can you talk a little bit about your experience with ACE? What do you get out of the role and what advice do you have for others who might want to get involved in something similar?

DR. BODMER:

Yeah. So, um, I have been with ACE for about a year. And again, I will say it's been just an amazing experience. We, you know, meet quarterly. So four times a year we meet out near Chicago in the ASA headquarters. And with that, we just have such, such a diverse group of faculty from all different areas of the country, all different specialties, who are bringing in their perspectives and representing their regions, their patients, their specialties, and bringing that in to create this content that just highlights what I think we're all passionate about is continuing this medical education as a resource and making it really high value. We know that in today's world, no one has has a lot of time for anything. And so again, there's a lot of discussions that go into like what is the most relevant, what are the really key points that we want to have people take home, and we want to make it worth their time. If they're going to be using this resource, we want to make sure that they're getting something out of it. And I love thinking at that high level of how can people stay up to date? How can they integrate all of this knowledge to really take back to care for their patients? And again, I think that's one thing that I love about ACE is we're not thinking about just the content and writing the questions. We're thinking about how this is impacting the education of all the providers in the country who then will take this and go on and care for their patients? And so having that kind of level of impact is maybe a little bit bigger. Um, but I, I definitely get a ton and learn a ton from all of the rest of the editorial board there and, and just enjoy the ripe discussion that we have.

DR. STRIKER:

Yeah, we've talked about this before on the podcast. It's a it's a wonderful program and I appreciate all the work that you and the rest of the board put into making it such a wonderful product. And I really appreciate your time and this really interesting conversation. And thank you for dropping by to share all your knowledge with us.

DR. BODMER:

Of course. Thanks so much for having me. I was happy to join.

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DR. STRIKER:

And for our listeners that are interested in this topic or just in general, you can find more at asahq.org/ace, or ace. And please join us again next time for more Central Line. Take care.

VOICE OVER:

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