Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents

• Autores: Mary T. Hawn, Laura A. Graham, Joshua S. Richman, Kamal M. F. Itani, William G. Henderson
• Localización: JAMA: the journal of the American Medical Association, ISSN 0098-7484, Vol. 310, Nº. 14, 2013, págs. 1462-1472
• Idioma: inglés
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• Resumen

  • Importance Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 1 year after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). The evidence underlying these recommendations is limited and conflicting.

    Objective To determine risk factors for adverse cardiac events in patients undergoing noncardiac surgery following coronary stent implantation.

    Design, Setting, and Participants A national, retrospective cohort study of 41?989 Veterans Affairs (VA) and non-VA operations occurring in the 24 months after a coronary stent implantation between 2000 and 2010. Nonlinear generalized additive models examined the association between timing of surgery and stent type with major adverse cardiac events (MACE) adjusting for patient, surgery, and cardiac risk factors. A nested case-control study assessed the association between perioperative antiplatelet cessation and MACE.

    Main Outcomes and Measures A composite 30-day MACE rate of all-cause mortality, myocardial infarction, and cardiac revascularization.

    Results Within 24 months of 124?844 coronary stent implantations (47.6% DES, 52.4% BMS), 28?029 patients (22.5%; 95% CI, 22.2%-22.7%) underwent noncardiac operations resulting in 1980 MACE (4.7%; 95% CI, 4.5%-4.9%). Time between stent and surgery was associated with MACE (<6 weeks, 11.6%; 6 weeks to <6 months, 6.4%; 6-12 months, 4.2%; >12-24 months, 3.5%; P?

    Conclusions and Relevance Among patients undergoing noncardiac surgery within 2 years of coronary stent placement, MACE were associated with emergency surgery and advanced cardiac disease but not stent type or timing of surgery beyond 6 months after stent implantation. Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated.

    Noncardiac surgery after recent coronary stent placement is associated with increased risk of adverse cardiac events. Consequently, it is desirable to delay elective surgery as long as possible after coronary stent placement. In 2004, drug-eluting stents (DES) were approved and overtook bare metal stents (BMS) as the preferred revascularization strategy.1 Reports of unanticipated late stent thrombosis after cessation of dual antiplatelet therapy (APT) and case reports of stent thrombosis in patients with DES undergoing noncardiac surgery led to a revision of the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines in 2007.1- 8 The revised guidelines recommend continuing dual APT for all patients at least 1 year after DES implantation.9 For patients with DES undergoing noncardiac surgery, class IIa recommendations, based on level C evidence, state the following: (1) elective surgery after DES implantation should be delayed until completion of 1 year of dual APT, or (2) if the surgery is urgent, the surgery should be performed without cessation of APT. The guidelines for DES differ from those for BMS, which recommend a delay in surgery and temporary cessation of APT after 4 to 6 weeks from stent placement.10 Approximately 600?000 percutaneous coronary stent procedures are performed annually in the United States.11,12 Twelve percent to 23% of these patients undergo noncardiac surgery within 2 years of coronary stent placement.13- 17 Delaying necessary noncardiac surgery can pose a significant clinical dilemma for a large number of patients. The delays in surgery recommended by the guidelines are based on a limited and conflicting evidence base. Case series early in the DES experience suggested high rates of major adverse cardiac events (MACE) after noncardiac surgery. However, subsequent, larger multicenter cohort studies reported MACE rates similar to BMS MACE rates.13,14,18 Small series assessing perioperative APT management found no evidence that continued perioperative APT mitigates the risk of MACE. It is not clear whether the lower observed MACE rates in more recent studies are attributable to the effectiveness of guideline-driven delays of elective surgery together with continuing perioperative APT or reflect more reliable estimates of perioperative MACE rates in populations with stents, or both.

    To better understand the relationship between stent type, APT, and MACE associated with noncardiac surgery after coronary stent placement, we evaluated a national cohort of Veterans Affairs (VA) patients who had either coronary BMS or DES placed between 2000 and 2010. We hypothesized that early surgery is associated with higher MACE rates after coronary stent placement, particularly in patients with DES, and that continued APT reduces the risk of postoperative MACE.