Risk of Adverse Cardiac and Bleeding Events Following Cardiac and Noncardiac Surgery in Patients With Coronary Stent

Abstract

P ercutaneous coronary intervention (PCI) is the most common strategy for myocardial revascularization and in the vast majority of the cases is accomplished with coronary stenting. To prevent the occurrence of stent thrombosis and its serious clinical consequences, dual antiplatelet therapy is recommended for at least 1 month after bare-metal stent (BMS) implantation and for 6 to 12 months after drug-eluting stent (DES) implantation. [1][2][3] This different therapeutic approach is because of delayed endothelialization associated with DES, a phenomenon that extends the time window for the risk of stent thrombosis.Among patients who receive coronary stents, a considerable proportion subsequently need surgery, 4,5 and this represents a risk factor for both ischemic and bleeding events, Background-Epidemiology and consequences of surgery in patients with coronary stents are not clearly defined, as well as the impact of different stent types in relationship with timing of surgery. Methods and Results-Among 39 362 patients with previous coronary stenting enrolled in a multicenter prospective registry and followed for 5 years, 13 128 patients underwent 17 226 surgical procedures. The cumulative incidence of surgery at 30 days, 6 months, 1 year, and 5 years was 3.6%, 9.4%, 14.3%, and 40.0%, respectively, and of cardiac and noncardiac surgery was 0.8%, 2.1%, 2.6%, and 4.0% and 1.3%, 5.1%, 9.1%, and 31.7%, respectively. We assessed the incidence and the predictors of cardiac death, myocardial infarction, and serious bleeding event within 30 days from surgery. Cardiac death occurred in 438 patients (2.5%), myocardial infarction in 256 (1.5%), and serious bleeding event in 1099 (6.4%). Surgery increased 1.58× the risk of cardiac death during follow-up. Along with other risk factors, the interplay between stent type and time from percutaneous coronary intervention to surgery was independently associated with cardiac death/ myocardial infarction. In comparison with bare-metal stent implanted >12 months before surgery, old-generation drugeluting stent was associated with higher risk of events at any time point. Conversely, new-generation drug-eluting stent showed similar safety as bare-metal stent >12 months and between 6 and 12 months and appeared trendly safer between 0 and 6 months. with an inverse relationship with time. 6 Indeed, premature cessation of dual antiplatelet therapy is a strong predictor of stent thrombosis, and surgery is a common reason for premature discontinuation of either single or dual antiplatelet therapy (DAPT) antiplatelet therapy. 7 The hypercoagulable state associated with surgery can further contribute to increase the overall ischemic risk. On the opposite front, continuation of antiplatelet therapy may increase the risk of perioperative bleeding. 8 The risk of perioperative complications, however, depends also on other factors, including patient status, type, and magnitude of surgery and prevalence of comorbidities. Conclusions-Surgery 3Cardiac risk, therefore, extends well beyond the recommende...

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

“…Recent data including more comprehensive identification of surgical procedures, however, changed these figures to around 15-23% within the first year (5,6,10), and up to 40% within 5 years (6). Considering that DES should be preferred over BMS to accomplish coronary revascularization (4), in clinical practice risk stratification must take into account that most of those patients do have a DES in the coronary tree (5).…”

“…Time from index PCI to surgery is significantly associated with the risk of perioperative cardiac events (5,6,8,18,19). This risk is partially, but not entirely, related to the risk of stent thrombosis.…”

“…Another registry study from Ontario, suggested that the earliest optimal time for elective surgery is >180 days after DES implantation, reaching a plateau afterwards (21). Data from the Italian REAL registry (6,22), showed that the interplay between stent type and time from PCI to surgery was independently associated with perioperative cardiac death or MI. In that study, new-generation DES showed similar safety as BMS at any time interval between PCI and surgery, and were trendly safer when surgery occurred between 0 and 6 months after stenting, with all the benefit over BMS apparently gained when surgery occurred between 2 and 6 months after stenting (6).…”

“…In the PARIS (Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients) registry, interruption of DAPT based on physician judgment in patients undergoing surgery at any time point after PCI was not associated with a significantly higher risk of MACE nor of stent thrombosis (23). Taking into account these data, the increased safety of new-generation DES, the reduced minimally recommended duration of DAPT after DES implantation and the most recent data about stent and surgery (5,6,18), the latest ACC/AHA guidelines reduced the recommended delay from DES implantation to surgery from >1 year into "optimally at least 6 months", suggesting that even >3 months can be considered in selected cases (15).…”

“…Accordingly, previous guidelines provided a general recommendation that elective surgery be delayed until 30 to 45 days after bare metal stent (BMS) implantation and 1 year after DES (3,4). Recently, new evidence has accrued suggesting that the safety window for surgery after implant of new-generation DES could be safely shortened to <6 months (5,6). The aim of this brief commentary is to critically review available data about cardiac risk associated with surgery in patients with coronary drug-eluting stents.…”