Abstract
Background
We sought to assess contemporary approaches of interventional cardiologists to preoperative evaluation and perioperative management of coronary stents.
Methods
Online survey sent in December 2008 to 3771 US interventional cardiologists (10% completion rate).
Results
Patients with coronary stents needing noncardiac surgery are frequently encountered: 49% and 30% of the cardiologists saw two to four and five or more such patients, respectively, every month. The majority of participants recommended (a) ≥6 weeks delay as optimal for surgery after bare metal stent implantation; (b) continuing dual antiplatelet therapy in stent patients undergoing minor bleeding risk procedure; (c) avoiding drug-eluting stent implantation in patients known to need noncardiac surgery within 12 months from percutaneous coronary intervention; (d) treating perioperative stent thrombosis with primary percutaneous coronary intervention; and (e) performing nuclear stress testing in stable patients who need major noncardiac surgery. There was equipoise in the need for “bridging” with glycoprotein IIb/IIIa inhibitors in patients needing early surgery after drug-eluting stent implantation.
Conclusion
Interventional cardiologists frequently treat patients who require surgery after stent implantation. Although agreement exists on the optimum delay for surgery after stenting, on the need for bare metal stents or balloon angioplasty alone if early noncardiac surgery is needed, and on the treatment of perioperative stent thrombosis, there is divergence of opinion on the need for preoperative stress testing and on the “bridging” therapy for patients who need surgery early after stent implantation.
With widespread use of drug-eluting stents in percutaneous coronary interventions (PCI), a large and increasing number of stent patients is anticipated to require noncardiac surgery. Those patients are at risk of perioperative stent thrombosis, a catastrophic complication with high morbidity and mortality . Although significant progress has recently been made on the optimum perioperative management of bare metal stent and, to a lesser extent, drug-eluting stent (DES) patients, several areas of controversy remain . In the present study, we sought to determine the contemporary opinions of interventional cardiologists on the perioperative management of coronary stent patients and on preoperative coronary revascularization.
1
Methods
A link to a 10-item online questionnaire ( Appendix A ) was sent in December 2008 and January 2009 to 3771 US interventional cardiologists, 374 (10%) of whom completed the questionnaire. Ninety-seven percent of the responders treated patients with coronary stents who needed to undergo surgery: 30% saw ≥5 patients per month, 49% of the saw two to four such patients per month, and 21% saw 0 to one such patient per month.
2
Results
The study results are summarized in Table 1 .
| Concept | Guideline recommendation | Survey findings |
|---|---|---|
| 1. Perioperative management of coronary stents | ||
| 1.1. Delay to noncardiac surgery | ||
| a. Minimum delay from bare metal stent implantation to elective noncardiac surgery | 4–6 weeks delay of surgery based on: 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | 98% recommended a delay of 6 weeks before noncardiac surgery (question 4) |
| 1.2 Perioperative management of antiplatelet therapy after DES implantation | ||
| a. Major noncardiac surgery 12 months post DES implantation | Delay surgery at least 12 months post DES implantation. No guidelines provided on antiplatelet treatment after 12 months based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 41% recommended continuing aspirin and clopidogrel during surgery, 48% recommended continuing aspirin only, and 11% recommended discontinuation of both |
| b. low bleeding risk surgery | Continue dual antiplatelet therapy based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 76% would continue aspirin and clopidogrel; 18% would continue aspirin alone; 5% would stop both aspirin and clopidogrel |
| c. urgent noncardiac surgery days after DES implantation | Continue dual antiplatelet therapy, or at least aspirin if possible. “Bridging” therapy with glycoprotein IIb/IIIa inhibitor is unproven. based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 50% would administer perioperative “bridging: with a glycoprotein IIb/IIIa inhibitor; 49% would try to identify a surgeon that would operate on aspirin and clopidogrel |
| 1.3. Management of perioperative stent thrombosis | ||
| a. Bleeding would likely not be catastrophic | Primary percutaneous coronary intervention based on: expert opinion | 99% would perform primary percutaneous coronary intervention |
| b. Bleeding would likely be catastrophic (such as in neurosurgery) | No consensus due to lack of data | 66% would perform primary percutaneous coronary intervention and 33% medical therapy only |
| 2. Preoperative coronary revascularization | ||
| 2.1. Choice of percutaneous revascularization strategy in patients in need of noncardiac surgery | Bare metal stent implantation or balloon angioplasty only for patients who need percutaneous coronary intervention and are likely to require invasive or surgical procedures within the next 12 months, based on 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | 97% recommended bare metal stent implantation or balloon angioplasty only |
| 2.2. Need for pre-operative stress testing before major noncardiac surgery | Proceeding to surgery with heart rate control (class IIa recommendation) or consider noninvasive testing (class IIb recommendation) in patients without an active cardiac condition with low or unknown functional capacity with 1–2 clinical risk factors (ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease) if testing would change management, based on 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | For patients needing aortobifemoral bypass for intermittent claudication within 5 years from coronary bypass graft surgery, 70% recommended nuclear stress testing and 25% recommended proceeding with surgery. |
2.1
Perioperative management of coronary stents
Ninety-eight percent recommended a delay of 6 weeks before noncardiac surgery is performed after bare metal stent implantation (Question 4).
For patients requiring urgent noncardiac surgery for cancer diagnosis and treatment within days after DES implantation, 50% of the physicians would administer perioperative bridging with a glycoprotein IIb/IIIa inhibitor and 49% would try to identify a surgeon that could operate while the patient continues to receive aspirin and clopidogrel (Question 10).
In a DES patient requiring major noncardiac surgery 12 months after DES implantation, 41% recommended continuing aspirin and clopidogrel during surgery; 48%, recommended continuing aspirin only; and 11%, discontinuation of both aspirin and clopidogrel (Question 3).
For cataract surgery within 12 months after DES implantation, 76% of the cardiologists would continue aspirin and clopidogrel, 18% would continue aspirin only, and 5% would stop both aspirin and clopidogrel before surgery (Question 5).
For patients developing stent thrombosis after lower extremity noncardiac surgery, 99% recommended primary PCI (Question 8), whereas for patients developing stent thrombosis after neurosurgery, 66% recommended primary PCI, and 33%, medical therapy (Question 9).
2.2
Preoperative cardiac evaluation and coronary revascularization
For acute coronary syndrome patients in whom the need for early noncardiac surgery was known, 97% of physicians recommended either balloon angioplasty or bare metal stent implantation (Question 6).
For patients needing aortobifemoral bypass for intermittent claudication within 5 years from coronary bypass graft surgery, 70% recommended nuclear stress testing and 25% recommended proceeding with surgery without further testing (Question 7).
2
Results
The study results are summarized in Table 1 .
| Concept | Guideline recommendation | Survey findings |
|---|---|---|
| 1. Perioperative management of coronary stents | ||
| 1.1. Delay to noncardiac surgery | ||
| a. Minimum delay from bare metal stent implantation to elective noncardiac surgery | 4–6 weeks delay of surgery based on: 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | 98% recommended a delay of 6 weeks before noncardiac surgery (question 4) |
| 1.2 Perioperative management of antiplatelet therapy after DES implantation | ||
| a. Major noncardiac surgery 12 months post DES implantation | Delay surgery at least 12 months post DES implantation. No guidelines provided on antiplatelet treatment after 12 months based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 41% recommended continuing aspirin and clopidogrel during surgery, 48% recommended continuing aspirin only, and 11% recommended discontinuation of both |
| b. low bleeding risk surgery | Continue dual antiplatelet therapy based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 76% would continue aspirin and clopidogrel; 18% would continue aspirin alone; 5% would stop both aspirin and clopidogrel |
| c. urgent noncardiac surgery days after DES implantation | Continue dual antiplatelet therapy, or at least aspirin if possible. “Bridging” therapy with glycoprotein IIb/IIIa inhibitor is unproven. based on: 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory on the Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents | 50% would administer perioperative “bridging: with a glycoprotein IIb/IIIa inhibitor; 49% would try to identify a surgeon that would operate on aspirin and clopidogrel |
| 1.3. Management of perioperative stent thrombosis | ||
| a. Bleeding would likely not be catastrophic | Primary percutaneous coronary intervention based on: expert opinion | 99% would perform primary percutaneous coronary intervention |
| b. Bleeding would likely be catastrophic (such as in neurosurgery) | No consensus due to lack of data | 66% would perform primary percutaneous coronary intervention and 33% medical therapy only |
| 2. Preoperative coronary revascularization | ||
| 2.1. Choice of percutaneous revascularization strategy in patients in need of noncardiac surgery | Bare metal stent implantation or balloon angioplasty only for patients who need percutaneous coronary intervention and are likely to require invasive or surgical procedures within the next 12 months, based on 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | 97% recommended bare metal stent implantation or balloon angioplasty only |
| 2.2. Need for pre-operative stress testing before major noncardiac surgery | Proceeding to surgery with heart rate control (class IIa recommendation) or consider noninvasive testing (class IIb recommendation) in patients without an active cardiac condition with low or unknown functional capacity with 1–2 clinical risk factors (ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease) if testing would change management, based on 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery | For patients needing aortobifemoral bypass for intermittent claudication within 5 years from coronary bypass graft surgery, 70% recommended nuclear stress testing and 25% recommended proceeding with surgery. |
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