The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following Coronary Stenting

Abstract

The incremental risk of noncardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilizes at 1.0% after 6 months. Elective, high-risk, inpatient surgery, and patients with DES may benefit most from delay from a 6-month delay after stent placement.

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Di

“…[101][102][103]149 Data from more recent large observational studies suggest that the time frame of increased risk of stent thrombosis is on the order of 6 months, irrespective of stent type (BMS or DES) . [151][152][153] In a large cohort of patients from the Veterans Health Administration hospitals, the increased risk of surgery for the 6 months after stent placement was most pronounced in those patients in whom the indication for PCI was an MI . 146 An additional consideration, irrespective of the timing of surgery, is that surgery is associated with proinflammatory and prothrombotic effects that may increase the risk of coronary thrombosis at the level of the stented vascular segment as well as throughout the coronary vasculature .…”

The significance of underlying cardiac comorbidity on major adverse cardiac events after major liver resection

“…1,[16][17][18][19] More recently, however, Holcomb and colleagues demonstrated that the incremental risk of cardiac complications significantly decreases when surgery is performed more than 6 months following coronary stenting: the incremental risk of cardiac complications stabilizes at 1% beyond 6 months following coronary stenting. 20 Although NSQIP excludes those with prior percutaneous coronary intervention within 6 months of hepatectomy, we still found that those with history prior PCI (>6 months before the liver resection) had a cardiac complication rate of 6.4% as well as a three-fold increase risk of cardiac arrest. One can infer that underlying coronary disease, the complexity of liver surgery, and a fluid restrictive strategy maintaining a low CVP and perhaps necessitating vasopressors are all synergistic drivers of major adverse cardiac complications in patients undergoing major liver resection.…”

Perioperative management of anticoagulant and antiplatelet therapy

“…A key predictor of major adverse cardiac and cerebrovascular events (MACCE) appears to be the time elapsed between coronary stent implantation and surgery. In a linked administrative database study involving 20 590 patients with coronary stents and 41 180 control patients without stents who had non-cardiac surgery, the incidence of MACCE was highest in the initial 6 weeks after surgery but remained significantly higher than in the control group until 6 months postsurgery 42. These results are expanded by those of a Danish cohort of 22 590 patients with drug-eluting coronary stents in which 4303 patients with surgery within 1 year were frequency matched by surgery type with 20 232 controls.…”