We read with interest the article by van Kuijk et al recently published in the Journal that raises important questions regarding the best intervals between coronary stenting and noncardiac surgery. The authors suggest that instead of waiting 4 to 6 weeks after bare metal stenting, as currently recommended in the American Heart Association/American College of Cardiology guidelines, we should ideally postpone surgery for 90 days, when the risk of major cardiac events are expected to be lower. However, prolonging by 45 to 60 days the interval between procedures might not be harmless, even for elective procedures. The prognosis of the underlying disease that requires surgical treatment could be affected in some circumstances, such as in oncologic patients, when waiting has more than psychological consequences.

Nuttall et al were the first to suggest that we should wait 90 days between BMS and noncardiac surgery. They found 47 cardiac events in 899 patients who underwent surgery after BMS, and the greater incidence occurred when the interval was <30 days (26 events; 10.5%). When the interval was 31 to 90 days or >90 days, the incidence was substantially lower: 3.8% (10 events) and 2.8% (11 events), respectively. Even if the difference between these 2 last groups was statistically significant, the clinical effect would be questionable. In the present study, the authors performed the same analysis in 174 patients who had undergone noncardiac surgery after BMS. Despite the smaller sample size and number of events compared to the study by Nuttall et al, the conclusion was quite similar. When the interval was <30 days, the incidence of events was 50%, and when it was >90 days, it was 4%. Nonetheless, the careful analysis of the 14% incidence of events in the 31- to 90-day interval group shows us that only one event occurred in a group of 7 patients. Actually, probably because of this issue, the authors repeated the statistical analysis and found a 33% incidence of events when the interval between procedures was <90 days versus 4% for intervals >90 days (p <0.001). They also performed another analysis of the incidence of cardiac events with a cutoff in 30 days: 50% × 4% (p <0.001). When grouping the original intermediate interval with either the <30-day or the >90-day intervals, they were not substantially affected. Why did the authors decide to choose the 90-day cutoff for their recommendation? We believe that neither the findings from Nuttall et al nor van Kuijk et al (just 1 event in the 30- to 90-day interval) are strong enough to support such an important change in the previous guidelines recommendation.