Home > Interventional Cardiology > Journal Club 9 October 2013

Journal Club 9 October 2013

Paper

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

Presenter

PJS

Summary

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-dayMACE 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 12-24 months, 3.5%; P < .001). MACE rate by stent type was 5.1%for BMS and 4.3%for DES
(P < .001). After adjustment, the 3 factors most strongly associated with MACE were
nonelective surgical admission (adjusted odds ratio [AOR], 4.77; 95%CI, 4.07-5.59), history
of myocardial infarction in the 6 months preceding surgery (AOR, 2.63; 95%CI, 2.32-2.98),
and revised cardiac risk index greater than 2 (AOR, 2.13; 95%CI, 1.85-2.44). Of the 12
variables in the model, timing of surgery ranked fifth in explanatory importance measured by
partial effects analysis. Stent type ranked last, and DES was not significantly associated with
MACE (AOR, 0.91; 95%CI, 0.83-1.01). After both BMS and DES placement, the risk of MACE
was stable at 6 months. A case-control analysis of 284 matched pairs found no association
between antiplatelet cessation and MACE (OR, 0.86; 95%CI, 0.57-1.29).

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

Supplementary Material

The editorial is available here.

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