Increased incidence of cardiovascular disorders and heart disease has resulted in the fact that more and more patients have to take antithrombotic drugs. Often continued further in life, the therapy is based on oral anticoagulants from the coumarin group (acenocoumarol, warfarin), new generation of oral thrombin as well as factor Xa inhibitors and antiplatelet agents [1–6]. Antiaggregants most commonly applied in both primary and secondary prevention of cardiovascular diseases include acetylsalicylic acid (ASA), clopidogrel, prasugrel, and ticagrelor [7, 8]. Acetylsalicylic acid (aspirin) inactivates cyclooxygenase, which inhibits physiological aggregation of blood platelets and development of blood clots by impairing extrinsic pathways of coagulation and clotting for the life spam of the platelet, ranging from 7 to 10 days[5, 9–11]. Antiplatelet drugs may be used in the course of single antiplatelet therapy (SAPT), or dual antiplatelet therapy (DAPT). In recent years there has been a significant increase in the number of patients requiring DAPT, i.e. aspirin (acetylsalicylic acid) as well as oral antagonists of the antiplatelet P2Y12 receptor for adenosine 5′-diphosphate. Data related to the year 2017, published by the European Society of Cardiology, show that annually about 1-2 million patients require DAPT due to myocardial infarction, acute coronary syndrome (ACS), following endovascular therapy on coronary vessels, i.e. angioplasty as well as angioplasty with stent implantation. Implantation of Bare Metal Stents (BMS) or Drug Eluting Stents (DES) releasing the drug for a specified duration of time requires uninterrupted antithrombotic therapy, particularly DAPT, to be continued for a period from one to 12 months. Discontinuation of antiplatelet therapy earlier than one year after stent implantation poses a risk of stent thrombosis, and the risk of death in such cases amounts to approximately 40% [5, 12–16].
Patients using both SAPT and DAPT pose a significant clinical problem if it is necessary to perform surgery, including a dental surgery.
It is assumed that approximately 5% of patients starting DAPT, during the first year or later, will require an operative intervention other than cardiac surgery. This also applies to dental surgery and dental patients. Surgical procedures, involving disruption of body tissues and integument, are associated with the need to stop bleeding and achieve haemostatic balance, which is difficult in the case of patients using DAPT due to defective clotting[17–20].
Despite the guidelines for perioperative care provided to patients using antithrombotic therapy, the related issues pose constitute a significant challenge in the daily practice of dental medicine and cardiology. Of particular importance is the qualification for dental surgeries if the patient reports earlier than 12 months after the strict therapy was started. Some medical practitioners (dentists, cardiologists, family doctors), in fear of prolonged post-extraction bleeding and haemorrhagic complications, recommend that medication be discontinued, which may lead to serious thromboembolic complications [6, 7]. The choice between a risk of clots and thromboembolic complications caused by DAPT interruption and a risk of haemorrhagic complications resulting from continued antiplatelet therapy is always difficult. Most commonly it is necessary to make the decision tailored to the specific case, and to make sure the process will be the least threatening to the patient’s well-being and life [15, 21].
It is always necessary to consider whether or not it is possible to delay or postpone an intervention so that it is not performed earlier than 6-12 months after acute coronary syndrome, myocardial infarction or implantation of drug eluting stent [2, 22]. However, dental procedures often cannot be delayed because of the painfulness of the condition, acute purulent inflammation, or such random incidents as injuries, or traumatic dental injuries where it is necessary to remove the effected teeth. In such cases the procedures are performed without interruption to antithrombotic therapy, even more so because there are no standardised methods assessing platelet function and its return to the normal state in patients taking antiplatelet drugs. It is not possible to apply bridging anticoagulation in patients using antiplatelet therapy [6].
The research project was designed to investigate whether a tooth extraction procedure in which TachoSil fibrin-collagen patches are applied to the wound can safely be performed, without a need to discontinue antiaggregation therapy, and leading to normal local haemostasis, in patients requiring DAPT due to myocardial infarction, acute coronary syndrome or other cardiovascular diseases