Dual anti-platelet therapy after coronary drug-eluting stent implantation and surgery-associated major adverse events

Abstract

Surgery may necessitate interruption of dual antiplatelet therapy (DAPT) within the first year after coronary drug-eluting stent (DES) implantation. We conducted a population-based cohort study to assess the rate of surgery within the first year after DES implantation, surgery-associated major adverse cardiac events (MACE), reoperation for bleeding within 30 days after surgery, and two nested case-control analyses to explore any association between preoperative antiplatelet therapy, MACE, and reoperation for bleeding. In the cohort of 22,654 patients treated with DES, 1,944 patients (8.6 %) underwent moderate- to high-risk surgery within 12 months. Of these, 62 (3.2 %) experienced MACE and 54 (2.8 %) needed reoperation for bleeding within 30 days. In the nested case-control analyses of 458 cases and controls, where 70 % (n=324) had a first generation DES, absence of preoperative antiplatelet therapy was associated with an increased MACE rate (OR 2.36, 95 % CI 1.02-5.48) compared to single antiplatelet therapy (SAPT) or DAPT. Preoperative SAPT versus DAPT showed no difference in MACE rates (OR 0.85, 95 % CI 0.30-2.40). Surgery within the first month was associated with increased MACE rate (OR 4.67, 95 % CI 2.22-9.83) compared to surgery 2-12 months after DES implantation. Absence of preoperative antiplatelet therapy did not reduce reoperation for bleeding as compared to patients on SAPT or DAPT (OR 1.32, 95 % CI 0.56-3.12). In conclusion, absence of preoperative antiplatelet therapy and surgery within the first month after DES implantation were associated with increased MACE rates.

Risk of Myocardial Infarction and Death After Noncardiac Surgery Performed Within the First Year After Coronary Drug-Eluting Stent Implantation for Acute Coronary Syndrome or Stable Angina Pectoris

“…Because stent thrombosis was very rare and is expected to be even rarer with newer-generation DES, the conclusions are unlikely to be different in a cohort restricted to newer-generation stents. 19 In conclusion, patients with ACS requiring surgery between 1 and 12 months after DES implantation had a risk of MI and death that was comparable with the risk observed in the general population cohort without known coronary artery disease. This suggests that noncardiac surgery can be 6…”

Perioperative management of patients who are receiving antiplatelet therapy: a case-based, evidence-informed approach

“…It confirmed a higher rate of MI among patients who underwent surgery within 1 month (OR, 14.3; 95% CI, 7.5-27.4), but there was a strong effect modification if the surgery was emergent rather than elective (OR, 26.6; 95% CI, 11.2-62.8). 45 Together, these Clinical guidance In patients who are receiving ASA and are at risk for cardiovascular events, we suggest interrupting ASA for ~7 days before noncardiac surgery and to resume ASA with caution postoperatively, especially if patients are receiving thromboprophylaxis with low -dose heparin. In patients not at risk for cardiovascular events, we suggest not initiating ASA in the perioperative period.…”

Coronary stent implantation and adverse cardiac events after surgery

“…As the current study was registry‐based, we did not have individual‐level information on antiplatelet therapy in relation to surgery. This is a limitation since the perioperative handling of antiplatelet therapy in relation to surgery has impact on ischaemic events . It is also a limitation that we were not able to include data on stroke, repeat revascularization or bleeding after surgery.…”

“…This is a limitation since the perioperative handling of antiplatelet therapy in relation to surgery has impact on ischaemic events. 18 It is also a limitation that we were not able to include data on stroke, repeat revascularization or bleeding after surgery. Since we used the Danish National Patient Registry for event detection, we were unable to account for stent thrombosis specifically; however, any stent thromboses should be detected as either myocardial infarction or death.…”