Optimal Timing of Noncardiac Surgery After Stents

Abstract

The planning of noncardiac surgery in patients with a history of coronary artery disease and previous percutaneous coronary intervention with stent implantation is a topic that elicits clinical concern and discussion. These patients face risks related to their underlying coronary heart disease, as well as potential problems related to the coronary stent or associated antiplatelet medications. Some surgical procedures that confer a significant risk of surgical bleeding may require consideration of interrupting dual antiplatelet therapy. This is particularly challenging within the first year after coronary stenting, for which there are only limited data to guide practice.1–5 Article see p 1355 In this issue of Circulation , Wijeysundera and colleagues6 examine cardiovascular outcomes during the 30 days after elective noncardiac surgery among patients who were previously treated with stents. Using province-wide data from Ontario, including 8116 patients undergoing surgical procedures from 2003 to 2009, they assessed the impact of various time intervals between stent and surgery on outcome. They included subjects undergoing orthopedic, vascular, and oncological surgical procedures. The authors concluded that the risk of the composite outcome of 30-day mortality, readmission for acute coronary syndrome, or repeat revascularization after bare metal stent (BMS) implantation was lowest at 46 to 180 days and, after drug-eluting stent (DES), was lowest more 180 days after the procedure. There are limitations to the data that were available for analysis that the authors acknowledge—no data are available on some key in-hospital outcomes such as perioperative bleeding, myocardial infarction, congestive heart failure, and stent thrombosis. The management of antiplatelet therapy around the time of surgery, and clinical factors such that might determine the urgency of surgery, could not be discriminated finely in this administrative database study. Adverse cardiac events after surgery were fairly infrequent (2.1% at 30 …