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Timing of stent implantation may not impact noncardiac-surgery-related MACE
The time between coronary stent implantation and noncardiac surgical procedures failed to explain MACE in a large cohort of individuals in the United States, according to results published in JAMA.
Clinical guidelines recommend that noncardiac surgery should be delayed for 1 year in patients who have received a drug-eluting stent and 6 weeks in those with a bare-metal stent implantation. The researchers in the current study suggested that evidence supporting this recommendation may contain conflicts or limitations, and they sought to evaluate risk factors for coronary events in this population in a national retrospective cohort study.
The outcome measure was a composite 30-day MACE rate of all-cause mortality, MI and cardiac revascularization. This was evaluated for possible associations between timing of surgery and stent type. The analysis involved adjustments for patient, surgery and cardiac risk factors and included a nested case-control study examining the association between perioperative antiplatelet cessation and MACE.
Eligible participants were culled from Veterans Affairs and non-Veterans Affairs operations between 2000 and 2010. Outcomes 24 months after implantation underwent analysis.
There were 124,844 coronary stent implantations — 47.6% DES and 52.4% bare-metal stents —included in the study. Of this cohort, noncardiac operations were performed in 28,029 patients (22.5%; 95% CI, 22.2%-22.7%). The MACE rate in the noncardiac operations group was 4.7% (n=1,980; 95% CI, 4.5%-4.9%).
An association was observed for the duration between implantation and surgery for the primary outcome of MACE. When the time was less than 6 weeks after implantation, the rate was 11.6%. For 6 weeks to less than 6 months, the rate was 6.4%; for 6 to 12 months, the rate was 4.2%; and for greater than 12 months to 24 months, it was 3.5% (P<.001).
Adjusted analysis results indicated that nonelective surgical admission (OR=4.77; 95% CI, 4.07-5.59), history of MI in the 6 months before surgery (OR=2.63; 95% CI, 2.32-2.98) and revised cardiac risk index greater than 2 (OR=2.13; 95% CI, 1.85-2.44) were the three factors demonstrating the strongest association with the primary outcome.
Time of surgery was fifth of the 12 variables explored in the model with regard to explanatory importance for MACE. Stent type was the least important of these variables. No association was observed between DES and MACE (OR=0.91; 95% CI, 0.83-1.01).
MACE rates were stable at 6 months after implantation of either stent type.
Emmanouil S. Brilakis
Results of the case-control study demonstrated no association between cessation of antiplatelet therapy and MACE (OR=0.86; 95% CI, 0.57-1.29).
“Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated,” the researchers concluded.
In an accompanying editorial, Emmanouil S. Brilakis, MD, PhD, and Subhash Banerjee, MD, with the VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, explained how they believe these and other recent findings on the subject should impact practice.
Subhash Banerjee
“The approach for patients with BMS should not change; these patients usually can undergo surgery within 6 weeks after coronary stent implantation with very low risk of stent thrombosis,” Brilakis and Banerjee, who are both Editorial Board members of Cardiology Today’s Intervention, wrote. “For patients with DES, surgery performed at least 6 months after DES implantation appears to carry low risk for stent thrombosis, especially with contemporary, second-generation DES, which have more biocompatible, durable-polymer coatings. Hence, nonurgent operations should be postponed until 6 months after stent implantation.”
They concluded that the study by Hawn and colleagues provides good scientific evidence to a field and a common clinical question that have been, and continue to be, dominated by expert opinion.
For more information:
Brilakis ES. JAMA. 2013;1451-1452.
Hawn MD. JAMA. 2013;310:1462-1472.
Disclosure: One researcher reported receiving research support from Merck and Cubist. All other researchers reported no relevant financial disclosures. See the editorial for a full list of relevant financial disclosures for Banerjee and Brilakis.
Perspective
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The current guidelines stating that patients with DES continue dual antiplatelet therapy for 1 year have discouraged surgeons from proceeding with elective procedures during that timeframe. In this retrospective study, the authors provocatively observed that increased MACE was not noted 6 months after insertion. However, as the authors state, it does require more strict study in a randomized fashion moving forward. For me, the results will not immediately affect timing of surgery until the findings are corroborated. Patients who need urgent, emergent surgery will proceed with accepted risks of bleeding, transfusions and their sequelae, and those who can wait will wait.
More interesting to me surgically would be a closer look at the non-MACE morbidity data. All-cause mortality, MI and cardiac revascularization are well-defined endpoints to evaluate.
Collaborative decision-making between the patient’s physicians will ensure the best options for stent choice, surgical timing and antiplatelet therapy approach. The findings of the study will assist us in moving toward more evidenced-based decision-making for timing our patients’ surgeries.