Bridging Therapy in Patients at High Risk for Stent Thrombosis Undergoing Surgery

A. D/C clopidogrel 5 days prior to surgery B. Continue ASA (Increase dose to 325 mg until prohibitive bleeding risk) C. Check baseline IIb/IIIa and P2Y12 via the Verify Now device prior to initiating tirofiban D. Start Tirofiban 2 days prior to the procedure (Patient MUST be on a monitored bed) * Load Tirofiban ONLY if P2Y12 (Verify Now Assay) platelet inhibition is \< 20% OTHERWISE initiate only the continuous infusion dose * Creatinine clearance \> 30mL/min: Tirofiban 0.4 mcg/kg/min for 30 minutes, followed by continuous infusion at 0.1 mcg/kg/min * Creatinine clearance \< 30mL/min: Tirofiban 0.2 mcg/kg/min for 30 minutes, followed by continuous infusion of 0.05 mcg/kg/min E. Check steady state IIb/IIIa inhibitor verify now assay (\>8 hour after initiation) F. Hold Tirofiban 12 hours prior to procedure G. Check IIb/IIIa inhibitor verify now assay (10-12 hours after Tirofiban is discontinued) H. CBC pre and post op I. Reload clopidogrel\> 24 hours post op (300 mg X 1 then 75 mg daily) unless prohibitive bleeding risk J. Reduce ASA to pre-procedure dose. Restart ASA, 24 hours port-op if it was D/C prior to procedure K. Check P2Y12 via the Verify Now device post-loading dose of clopidogrel (test cannot be performed w/in 48 hours of the D/C of IIb/IIIa inhibitor (tirofiban)