We thank the authors for their comments on our research paper about the timing of noncardiac surgery (NCS) after bare metal stenting (BMS). In daily practice, a clinical decision is determined from the balance between benefits and harms, according to the historical adagio: “Primum non nocere.” The importance of a continuous evaluation of the double-edged sword on the timing of NCS and the antiplatelet regimen must be accentuated. From the results of our study, we have recommended postponing surgery, preferably until 90 days after BMS, instead of waiting 4 to 6 weeks as recommended in the American Heart Association/American College of Cardiology guidelines.

In 2007, the American Heart Association/American College of Cardiology guidelines recommended an interval of 4 to 6 weeks from BMS to NCS. Subsequently, Nuttall et al performed the largest study in patients with NCS after BMS and proposed an ideal interval of 90 days from BMS to NCS. They found a substantially lower incidence of cardiac events when the interval was 31 to 90 days or >90 days. However, because these were only small differences, we performed the present study and observed a gradual decrease in the risk of adverse cardiac events with stabilization after an interval of 90 days. Of note, the risk of delaying the surgical procedure (eg, total hip replacement vs cancer therapy) also plays a pivotal role in the decision process.

Dual antiplatelet therapy has been proved to prevent thrombotic events, with a mild to moderate increased risk of bleeding. Our study and the study by Nutall et al have demonstrated that the discontinuation of dual antiplatelet therapy within this period is associated with an increased incidence of stent thrombosis. Importantly, in our study, we observed that even with the continuation of dual antiplatelet therapy, early NCS after BMS was associated with an increased risk of cardiac events. In specific patient groups with an increased risk of atherothrombotic events, the need for prolonged dual antiplatelet therapy after BMS needs special attention. The recent guidelines for preoperative cardiac risk assessment and perioperative cardiac management during NCS have recommended postponing elective NCS for ≥6 weeks and optimally for ≤3 months after BMS and that dual antiplatelet therapy should be continued. After 3 months, patients can be referred for NCS, with continuation of at least aspirin therapy.

In conclusion, we observed a gradual decrease between the risk of cardiac events and the interval between BMS and NCS. After 30 days, a strong decrease in the risk of cardiac events was observed that continued to decrease and stabilized after 90 days. As mentioned by the authors, in specific groups, such as oncologic patients, prolonging the interval for 90 days might not be harmless, even for elective procedures. Therefore, we recommend an individualized patient approach in which the treating physician balances the benefits of dual antiplatelet therapy and optimal re-endothelization of the coronary stent versus the risks of bleeding complications and acute stent thrombosis.