Delaying Noncardiac Surgery for 6 Months After Coronary Stenting May Reduce Complications

Patients who require noncardiac surgery after receiving stents have lower rates of acute MI and/or coronary revascularization when the surgery is delayed at least 6 months, according to a study published in the December 30, 2014, issue of the Journal of the American College of Cardiology.

Mary T. Hawn, MD, MPH, of the University of Alabama at Birmingham (Birmingham, AL), and colleagues retrospectively assessed patients who underwent stenting at VA medical centers in the United States between October 1999 and September 2009. Patients who underwent noncardiac surgery within 24 months of receiving a stent (n = 20,590) were matched 1:2 with patients who did not have surgery (n = 41,180).

The majority of stents were first-generation DES (58.4% sirolimus-eluting and 42.9% paclitaxel-eluting in the surgical group vs 55.9% and 44.8%, respectively, in the nonsurgical group).

Types of surgery were:

• Integumentary (17.2%)
• Genital/urinary (16.5%)
• Eye/ear (16.4%)
• Musculoskeletal (15.3%)
• Digestive (12.2%)
• Vascular (9.6%)
• Nervous System (6.0%)
• Respiratory (5.4%)
• Other (1.4%)

Early Risk Levels Out by 6 Months

During the 30 days following surgery and the same poststent period for the matched controls, the surgical group had higher rates of the composite cardiac endpoint (acute MI and/or revascularization), MI, and all-cause mortality but a similar rate of revascularization compared with the nonsurgical group (table 1).

 

In terms of temporal trends, the cardiac risk difference between the surgical and nonsurgical cohorts was highest when surgery was performed in the first 6 weeks after stent placement and decreased as time increased after stenting. No difference was seen for revascularization during any interval (table 2).

When the researchers looked at procedural characteristics, elective inpatient cases and those involving DES—but not BMS—were associated with reductions in incremental risk when surgery was performed after 6 months rather than earlier (P = .01 for both).

“Underlying patient conditions inherent to decision making for BMS placement, not necessarily stent characteristics, likely explain this,” Dr. Hawn and colleagues note. “These results further refine the incremental risk of noncardiac surgery in patients with coronary stents and how the risk is modulated over time.”

Furthermore, the researchers say the results suggest “focus should be shifted away from stent type and toward a patient’s cardiac and surgical risk factors when considering the optimal timing of surgery following coronary stent placement.”

They acknowledge, however, that since they did not look at antiplatelet management, including duration or interruptions, there is no way to know if it played any role in the occurrence of adverse cardiac events over the study period.

Helpful for Challenging Patients

In an editorial accompanying the study, Emmanouil S. Brilakis, MD, PhD, of the University of Texas Southwestern Medical Center at Dallas (Dallas, TX), and George D. Dangas, MD, PhD, of the Mount Sinai Medical Center (New York, NY), say the study provides confirmatory data that the first 6 weeks after coronary artery stenting is the highest risk period for perioperative complications and that the risk remains elevated over a 6-month period.

They suggest it “may… be best to perform noncardiac surgery in patients with coronary stents (regardless of when the stents were implanted) at centers with coronary intervention capability to allow for prompt treatment if perioperative myocardial infarction and stent thrombosis occur.”

Additionally, Drs. Brilakis and Dangas say the findings indicate that BMS may not be a good choice in patients requiring surgery soon after stenting. They add that “meticulous stent implantation technique with the avoidance of edge dissection/trauma, underexpansion, or malapposition; careful consideration of all factors that may lead to unwanted disruption of dual antiplatelet therapy; and utilization of stent types that offer advantages with respect to stent thrombosis are all necessary steps for clinical success.” The decision on surgical timing also should include input from all medical and surgical colleagues, they say.

Note: Dr. Dangas is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD.

 

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Sources:
1. Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64: 2730-2739.

2. Brilakis ES, Dangas GD. What to do when a patient with coronary stents needs surgery [editorial]? J Am Coll Cardiol. 2014;64:2740-2742.

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