Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Noncardiac Surgery

Cruden, Nicholas L.; Harding, Scott; Flapan, Andrew D.; Graham, Cat; Wild, Sarah H.; Slack, Rachel D.; Pell, Jill P.; Newby, David E.

doi:10.1161/circinterventions.109.934703

Cited by 141 publications

(90 citation statements)

References 32 publications

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“…Importantly, there was no excess in the incidence of adverse events between bare metal stents and drug-eluting stents. 6 …”

Section: Discussionmentioning

confidence: 99%

Circulation: Cardiovascular Interventions Editors' Picks

2011

Circ: Cardiovascular Interventions

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The EditorsThe following are highlights from the new series, Circulation: Cardiovascular Interventions Topic Review. This series will summarize the most important manuscripts, as selected by the editors, that have published in the Circulation portfolio. The objective of this new series is to provide a concise review of significant papers that are relevant to interventional cardiology. The studies included in this article represent the most noteworthy research in the area of coronary stent placement. (Circ Cardiovasc Interv. 2011;4:e24 -e30.)

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“…Importantly, there was no excess in the incidence of adverse events between bare metal stents and drug-eluting stents. 6 …”

Section: Discussionmentioning

confidence: 99%

Circulation: Cardiovascular Interventions Editors' Picks

2011

Circ: Cardiovascular Interventions

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“…They again disproved the general opinion that BMS are safer and documented beyond reasonable doubt and once and for all that, indeed, DES are safer [22][23][24][25].…”

Section: Bms Desmentioning

confidence: 91%

The infamous coronary stent saga

2014

Cardiovasc Med

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SummaryAgainst all odds, as a foreign body in a coronary artery was considered too thrombogenic, coronary artery stents have become a standard feature of percutaneous coronary intervention (PCI). After initial reluctance to employ coronary stents based on misinterpretation of thrombosis rates when stents were exclusively used for bail-out procedures, stent overuse took over quickly. Balloon angioplasty results indicated that only 25% of lesions can possibly benefit from a stent. A stent implanted in the remaining 75% of lesions is without any chance to help but carries some risk to harm. However, the risk of harm has become so small with ever improving stents that default stenting has become acceptable. Avid stent implanters argue that only 100% stenting assures that the 25% of lesions needing a stent indeed get a stent. Shortly after drug-eluting stents (DES) had been introduced, they were falsely accused of being dangerous on the ground of their higher propensity for stent thrombosis after the first year compared to bare metal stents (BMS). In fact, they had significantly fewer early stent thromboses during the first year irrespective of the extent of antiplatelet therapy. This advantage was admittedly progressively lost over the years. Subsequent generations of DES enhanced this early reduction of stent thrombosis but no longer showed that late catch-up phenomenon. T hese facts are ignored or misinterpreted to the present date by most physicians and all guidelines and textbooks. It was always preferable to implant a DES rather than a BMS when there was concern about stent thrombosis, be it because of need of early surgery or another impossibility to maintain double antiplatelet therapy. The respective advantage of current generation DES is overwhelming so that using a BMS is close to unethical. The most recent misconception, i.e., the need to have an absorbable stent, is also principally based on the myth of DES to be overly thrombogenic. The current absorbable stents disappear at best after a few years when the risk of a late stent thrombosis with a modern DES is virtually nil. Other reasons for absorbable stents, such as restitution of normal histology and vasomotion, easy accessibility of the stented segment for later bypass graft insertion, less stent malapposition to the vessel wall, and reduced need for antiplatelet therapy are either wrong or clinically trivial.

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“…Observational data indicate that between 5% and 35% of patients receiving a drug eluting stent (DES) undergo non-cardiac surgery within 1-2 years of their index percutaneous coronary intervention (PCI). Within this cohort, retrospective observational studies report an overall incidence of peri-operative death or major adverse cardiac events of 2-9%, with the greatest risk when surgery is performed early after stent implantation (1)(2)(3)(4). Based on these data, the American College of Cardiology and American Heart Association focused update on duration of dual antiplatelet therapy in patients with coronary artery disease (5) recommends that non-cardiac surgery should be delayed for at least three (class IIb recommendation), but ideally for 6 months (class IIa recommendation), while the most recent European Society of Cardiology guidelines recommend delaying surgery for 6 months following DES implantation (6).…”

Section: "Dear Colleague This 68 Year Old Diabetic Lady Recently Undmentioning

confidence: 99%

Non-cardiac surgery following drug-eluting coronary stent implantation—a question of timing?

2017

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"Dear colleague, this 68 year old diabetic lady recently underwent percutaneous coronary intervention with drug eluting stents. Unfortunately, she now requires hip replacement surgery. I would be grateful for your advice regarding the optimal timing of surgery …"This clinical scenario will be familiar to many involved in the management of patients undergoing non-cardiac surgery. Observational data indicate that between 5% and 35% of patients receiving a drug eluting stent (DES) undergo non-cardiac surgery within 1-2 years of their index percutaneous coronary intervention (PCI). Within this cohort, retrospective observational studies report an overall incidence of peri-operative death or major adverse cardiac events of 2-9%, with the greatest risk when surgery is performed early after stent implantation (1-4). Based on these data, the American College of Cardiology and American Heart Association focused update on duration of dual antiplatelet therapy in patients with coronary artery disease (5) recommends that non-cardiac surgery should be delayed for at least three (class IIb recommendation), but ideally for 6 months (class IIa recommendation), while the most recent European Society of Cardiology guidelines recommend delaying surgery for 6 months following DES implantation (6).Besides their retrospective observational design, major limitations of previous studies have been the lack of a meaningful comparator or control population and the absence of detailed data on peri-operative antiplatelet use. Without these, it remains unclear to what degree the observed rate of peri-operative cardiac events is attributable to the presence of a DES, existing ischaemic heart disease, premature interruption of dual antiplatelet therapy, or surgical factors such as the urgency, type or magnitude of surgery undertaken. A recent study published in the Journal of the American College of Cardiology goes some way towards addressing these limitations and provides further insight into the relationship between the timing of surgery and peri-operative cardiac risk.Egholm and colleagues undertook a retrospective data linkage study using the Western Denmark Heart and Danish National Patient Registries between 2005 and 2012 to identify 4,303 patients who underwent surgery within 12 months of DES implantation, and 20,032 patients without known ischaemic heart disease who underwent similar surgical procedures (7). Clinical outcomes at 30 days (myocardial infarction, cardiac death and all cause mortality) for each DES-PCI patient were compared with up to five control patients matched for age, sex and type of operation. Within the PCI cohort, use of first generation DES was high (60%) with just over half of the patients (56%) undergoing stent implantation for an acute coronary syndrome.Consistent with previous studies (2,4), surgery performed within 1 month of DES implantation, emergency surgery, Editorial

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Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Noncardiac Surgery

Cited by 141 publications

References 32 publications

Circulation: Cardiovascular Interventions Editors' Picks

Circulation: Cardiovascular Interventions Editors' Picks

The infamous coronary stent saga

Non-cardiac surgery following drug-eluting coronary stent implantation—a question of timing?

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