Coronary Stents and Noncardiac Surgery

Abstract

Case Presentation: A 55-year-old man was admitted for investigation of a persistent cough. Chest x-ray revealed an opacity near the right upper-lobe bronchus. He was an ex-smoker, and his only previous medical history was of an acute coronary syndrome leading to the implantation of a drug-eluting stent (DES) in his proximal left anterior descending artery 3 months before this admission. A transbronchial biopsy was required, so a discussion ensued between the cardiology and the respiratory teams about whether to stop his oral antiplatelet agents (OAAs), in this case, a combination of clopidogrel and aspirin. Interruption of OAA therapy, as often happens for noncardiac surgery, has been shown to be an important factor in stent thrombosis.1 The consequences of stent thrombosis are severe, with a 64% rate of death or myocardial infarction and a mortality rate of between 9% and 45%.1,2 In recent years, there has been an explosion in the use of DES, for which the risk of stent thrombosis, although likely to be similar to the standard bare-metal stent in the early phase, is less well defined owing to the longer, potentially indefinite period of time over which it may occur.3 Concern about the possible increased incidence of stent thrombosis with DES led to the publication of a consensus statement that highlighted the importance of not prematurely discontinuing dual OAA therapy and increasing its recommended duration in the case of DES to 1 year.4 The timing and definition of stent thrombosis vary between studies, which has led to a call for standardizing definitions.5 In addition, although most of the trials have included low-risk patients and coronary lesions, the use of DES in the real world is much less controlled, potentially increasing the risk of stent thrombosis.6,7 It has been well established that patients …