Checklist for Older Adults Undergoing Diagnostic and Therapeutic Procedures — Periprocedural Medical Issues (including Antiplatelet Management)

A periprocedural checklist for an older adult has five headings — appropriateness, antithrombotic management, organ-system optimisation, geriatric syndromes, and post-procedure care.

Appropriateness first: confirm the indication, the risk–benefit balance, life expectancy and lag time to benefit, capacity and informed consent, and advance directives. Ask whether the result will change management.

Anticoagulants should be stopped before most invasive procedures, but they may be continued for low-risk procedures where bleeding would be very minor or clinically insignificant.

Heparin bridging is only for patients with high thromboembolic risk. In a patient on a vitamin K antagonist, start LMWH or unfractionated heparin when the INR falls below 2, or after two to three doses have been omitted.

Bridging is never needed for DOACs, because their half-lives are short and the anticoagulant-free interval is brief.

Restart anticoagulation about 24 hours after the procedure. Delay to 48–72 hours only when the risk of post-operative bleeding is high.

Mechanical prosthetic valves: do not stop the VKA for minor surgical, superficial, dental or ophthalmic procedures — use local haemostasis and check that the INR on the day is not more than 0.5 above target. Major surgery needs an INR below 1.5.

For mechanical valves, stop warfarin 3–5 days before surgery and bridge once the INR falls more than 0.5 below target. Intravenous unfractionated heparin is preferred because the effect of LMWH cannot be fully reversed. Restart oral anticoagulation the day after surgery.

Target INR for a mechanical prosthesis is 2.5–4.0 depending on prosthesis thrombogenicity and patient factors; mitral or tricuspid position needs a higher target of 3.0. DOACs are contraindicated with mechanical valves.

For a surgical aortic bioprosthesis, low-dose aspirin 75–100 mg daily for three months is now favoured over oral anticoagulation, provided the patient is in sinus rhythm.

Duration of DAPT after PCI: aspirin 75–100 mg plus clopidogrel 75 mg — one month after a bare-metal stent, at least six months after a drug-eluting stent, and 12 months after ACS irrespective of revascularisation strategy. Thereafter lifelong single antiplatelet therapy.

In older people bleeding is commoner than recurrent thrombosis, so a short DAPT course is appropriate — 6 months for stable IHD and 12 months for ACS, and as short as 1 and 6 months respectively with newer drug-eluting stents. The evidence no longer supports bare-metal stents in the elderly.

Prasugrel is not recommended in patients aged 75 or above — it was not superior to clopidogrel and increased major and fatal bleeding. Ticagrelor may be used; its bleeding risk is similar to clopidogrel.

Add a proton pump inhibitor to reduce gastrointestinal bleeding in older patients on DAPT, particularly with a previous GI bleed.

Use the trans-radial approach for PCI. Bleeding is the commonest non-cardiac complication of PCI and predicts death, MI, stroke, longer stay and higher cost in the elderly.

After intracranial bleeding, restarting anticoagulation is associated with fewer thromboembolic events and a similar risk of recurrent haemorrhage; the optimal timing is not established and the type of bleed matters (recurrence risk is higher after subarachnoid than intraparenchymal haemorrhage).

Renal protection: estimate creatinine clearance, hydrate before contrast, withhold nephrotoxics and metformin, and dose-adjust all renally excreted drugs. Acute heparin dosing must be adjusted to renal function.

Medication reconciliation and deprescribing: stop or reduce anticholinergics, benzodiazepines and sedating antihistamines before the procedure; continue essential cardiac and antiepileptic drugs; plan insulin and oral hypoglycaemic adjustment; avoid prolonged fasting.

Bowel preparation in elderly patients: avoid sodium phosphate preparations (hyperphosphataemia, acute phosphate nephropathy) and avoid phosphate enemas in renal impairment; use PEG-based split-dose preparation with careful attention to volume status.

Screen for and address frailty, cognitive impairment and delirium risk, falls, malnutrition, pressure-injury risk, sensory impairment (hearing aids, spectacles, dentures returned promptly), and continence. Minimise sedation depth and duration.

Provide VTE prophylaxis and antimicrobial prophylaxis where indicated, ensure normothermia, and use short-acting anaesthetic and sedative agents.

After the procedure: early mobilisation, early oral intake, removal of catheters and lines, multimodal opioid-sparing analgesia, delirium screening (4AT or CAM), and a clear plan for restarting antithrombotics.

2024 AHA/ACC Perioperative Guideline — antiplatelet recommendations: continue aspirin perioperatively where possible in all patients with stents, regardless of stent type or timing. Continue DAPT if surgery is required within 30 days of a bare-metal stent or 3 months of a drug-eluting stent.

Elective non-cardiac surgery requiring interruption of antiplatelet therapy within 30 days of stent placement is classified as harmful (risk of stent thrombosis).

Stop times before surgery (2024): prasugrel 7 days, clopidogrel 5 days, ticagrelor 3 days, aspirin 4–5 days. Ticagrelor is the only reversible platelet inhibitor of this group.

Timing of surgery after PCI: at least 14 days after balloon angioplasty; at least 12 months after a drug-eluting stent placed for ACS or complex PCI; at least 6 months after a drug-eluting stent for chronic coronary disease; time-sensitive surgery may proceed at 3 months (ESC allows 1 month).

Aspirin for primary prevention should be stopped before surgery (except carotid surgery), and should not be newly started pre-operatively. Aspirin for secondary prevention may reasonably be continued if the cardiac risk outweighs bleeding risk (based on POISE-2).

If a patient after PCI is on oral anticoagulant monotherapy that must be stopped, substitute aspirin until the anticoagulant can be resumed.

Bridging: the BRIDGE trial and the PAUSE study established that routine bridging is not indicated — a standardised, interval-based DOAC interruption without bridging or routine coagulation testing gives low rates of both thromboembolism and major bleeding. Bridging is reserved for high thrombotic risk on a vitamin K antagonist.

Endoscopy-specific guidance (ASGE/ESGE/BSG): for low-risk endoscopic procedures (diagnostic endoscopy ± biopsy, ERCP with stent placement without sphincterotomy) antiplatelets and anticoagulants are continued. For high-risk procedures (polypectomy, EMR/ESD, sphincterotomy, PEG insertion, EUS-FNA) they are interrupted; aspirin is usually continued throughout.

GLP-1 receptor agonists: the 2024 multisociety guidance (AGA/ASMBS/ASA/ISPCOP/SAGES) replaced blanket withholding with a risk-stratified approach — continue in most patients, use a 24-hour clear-liquid diet, and consider gastric point-of-care ultrasound or rapid-sequence induction if there are GI symptoms or high aspiration risk.

SGLT2 inhibitors should be withheld 3–4 days before an elective procedure (4 days for ertugliflozin) to prevent euglycaemic ketoacidosis.

Left atrial appendage occlusion is an accepted alternative for patients with non-valvular AF who cannot tolerate long-term anticoagulation, and increasingly allows procedures without antithrombotic interruption.

Indian practice point: generic clopidogrel and ticagrelor are widely used; warfarin remains common because of cost, so INR-based planning, patient literacy and reliable follow-up must be built into the checklist. Andexanet alfa and idarucizumab availability is limited outside large centres, which favours interval-based DOAC interruption over reliance on reversal agents.