The clinical delimma comes when we are faced with patients who present with hip fracture and had undergone BMS implantation <4 weeks or DES implantation <12 months ago. There are three options that can be considered for the anti-platelet regimen. Firstly, one GS-4997 can choose to continue dual anti-platelet therapy [22] throughout the peri-operative period if possible. Secondly, since anti-thrombotic agents (e.g., low-molecular-weight heparin) are often used as thromboembolic prophylaxis in hip fracture, one can implement it as bridging therapy [21] to substitute for dual anti-platelet therapy. Although success with bridging therapy has been reported, prospective studies are necessary to validate it

as a viable management strategy. Recent studies [23] have recommended bridging therapy with glycoprotein IIb/IIIa inhibitors primarily for those who have not completed dual anti-platelet therapy and in patients whose stent complexities and comorbidities significantly increase their risk for developing catastrophic stent thrombosis. The final option is discontinue thienopyridine preoperatively and following the hip fracture surgery, the

thienopyridine should be restarted [24], with or without a loading dose, as soon as it is deemed safe. Primary percutaneous coronary intervention is the definitive treatment for peri-operative stent thrombosis as administration of thrombolytic is contraindicated A-1210477 cell line in patients with recent surgery. Hence, for patients with previous coronary stenting, hip fracture surgery should ideally be performed in institutions where 24 h interventional cardiology next services are available to provide emergent intervention if the need arises. Anti-thrombotic agents for thromboembolic prophylaxis Venous thromboembolism is one of the leading causes of peri-operative morbidity and mortality in patients with hip fracture. In the absence of thromboembolic prophylaxis, the prevalence of venography-detected proximal deep venous thrombosis was 27% in patients who had undergone hip fracture surgery [25]. The incidence of fatal pulmonary embolism ranges from 0.4% to 7.5% of

patients within 3 months of hip fracture surgery. Although thromboembolic prophylaxis is a routine aspect of care in patients with hip fracture, there is no clear-cut guideline regarding the optimal agent, the timing and duration of prophylaxis. Whether to initiate thromboembolic prophylaxis before or immediately after surgery is still unclear. Deep venous thrombosis may begin as early as the time of hip fracture. Until more definitive data is available, it is reasonable to initiate anti-thrombotic therapy as soon as patient is admitted into hospital. The American College of Chest Physicians (ACCP)guidelines [26] recommend the use of three agents for thromboembolic prophylaxis namely fondaparinux, unfractionated Alvocidib order heparin (UFH) and low-molecular-weight heparin (LMWH).