Guidelines recommend delaying elective surgery in patients with drug eluting stent (DES) for one year after stent implantation to allow completion of 1 year of dual anti-platelet therapy (DAPT) without interruption. This recommendation is based on expert consensus and results in several clinical questions, including whether it is preferable to use a bare metal stent (BMS) in patients with a potential for future surgery and whether this delay is excessive for patients considering surgery with other potential benefits (i.e. knee replacement in patients with life-limiting osteoarthritis). Accordingly, the authors sought to understand the risk of major adverse cardiovascular events (MACE) following non-cardiac surgery among patients with coronary stents as a function of time since coronary stenting, stent type, and antiplatelet therapy during surgery.
This study was a retrospective cohort of patients undergoing non-cardiac surgery within 2 years of a percutaneous coronary stent procedure. The authors identified 28,029 patients undergoing non-cardiac surgery within 2 years of coronary stenting. In this cohort, the 30-day MACE after non-cardiac surgery was 4.7%. Factors most strongly associated with MACE included non-elective surgery, myocardial infarction in the preceding 6 months, and a revised cardiac risk index of greater than 2. Timing of surgery in relation to coronary stenting was also associated with MACE, with surgery closer to the time of stenting being associated with increased risk. In contrast, stent type and antiplatelet cessation was not associated with MACE.
Emphasis on stent type and antiplatelet therapy in relation to perioperative cardiac risk may be overblown relative to the risk conferred by the type of surgery and other measures of clinical risk captured in guidelines and risk calculators. Although this study cannot inform best practices in surgical timing and antiplatelet therapy among patients with coronary stents, it does suggest current guidelines on this issue may inhibit a reasoned and patient-centered approach in conferring the risk-benefit tradeoffs of these clinical decisions.
- Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462-1472